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Opioid drugs are one of the most commonly prescribed treatments for the global problem of lower back pain — but they may not work, a new study finds.
Experiencing pain in the neck and lower back is common. According to an analysis of data from the 2021 Global Burden of Disease Study, low back pain is the leading cause of years of disability worldwide, and neck pain is fourth.
Low back pain is defined as acute when symptoms persist for up to six weeks, and chronic when pain persists for more than 12 weeks, according to the North American Spine Society (PDF).
When it comes to managing this pain, doctors should carefully limit patients’ use of opioids and limit them to a short period of time, according to the association’s clinical guidelines. Opioids for pain relief are recommended only when other pharmacological treatments have not worked or when a person cannot use them for personal reasons.
Despite these guidelines and “there is no evidence of their efficacy in reducing pain, opioid pain relievers are still widely prescribed in many countries for people with low back and neck pain,” said Christine Lin, a professor at the Institute for Musculoskeletal Health at the University of Sydney in Australia, in a press release. Lin is senior author of the latest study, published Wednesday in the journal The Lancet.
Due to scarce research, the scientists studied the effectiveness and safety of using opioids to treat a small cohort of 310 people. The patients had sought help for neck or low back pain from primary care clinics or hospitals in Sydney between February 2016 and March 2022. back pain or both for 12 weeks or less.
The study participants were then randomly divided into two groups: One group took a combination of naloxone and up to 20 milligrams of the opioid oxycodone per day for six weeks. Naloxone was used to prevent constipation, a common side effect of opioids, and thus prevent participants from finding out which group they were in. The other group was instructed to take a placebo pill.
Both groups also received care tips from a doctor they had to see weekly. The concern involved the doctor reassuring them and advising them to stay active, avoid bed rest and, if necessary, avoid other treatments, including non-opioids.
The authors found that opioids were no more helpful than the placebo in terms of effects on back and neck pain. Six weeks after treatment, the mean pain score was 2.78 in the opioid group and 2.25 in the placebo group, a difference that increased over time. More people in the opioid group had persistent pain at weeks 26 and 52 than in the placebo group.
The authors also found that not only are opioids unlikely to relieve back and neck pain, but they can also cause harm even after short-term, prudent use.
The opioid group had worse mental health scores and more reports of nausea, dizziness and constipation than the placebo group. “We also know that being prescribed opioid pain medications, even for a short period of time, increases the risk of long-term opioid abuse,” Lin said in a press release.
Opioids and pain
The study authors and experts not involved in the new study have theories about why opioids didn’t appear to be more helpful than the placebo.
One possibility is that the opioid group’s back or neck pain could have had more underlying factors than the authors considered — factors known to respond poorly to opioid treatment, experts said.
The pain treated could be more chronic, recurrent pain than the type caused by acute injury, according to a commentary on the study by Dr. Mark D. Sullivan and Dr. Jane C. Ballantyne, who were not involved in the investigation. Sullivan is a professor of psychiatry and behavioral sciences, and Ballantyne is a retired professor of anesthesiology and pain medicine at the University of Washington.
“Participants only had to be pain-free for 1 month for their current episode of back pain,” Sullivan and Ballantyne wrote. “If many of these participants had recurrent pain, this could explain the non-response to opioid therapy. Low back pain has been reported to transform over a year.”
Dr. John Finkenberg, a San Diego-based specialist in orthopedic spine surgery, said areas of pain in the neck and back sometimes need to be treated separately. He was not involved in the investigation.
“If someone has had both of these, frankly, they’re going to have a systemic problem, whether it’s generalized arthritis or rheumatism. So we have to be careful with the patients who come in with both,” added Finkenberg, who is also president of the North American Spine Society.
The authors did not collect data on the care the doctors provided at follow-up appointments, so they had no details on whether the patients followed any advice or the impact it had. In addition, only 57% of participants reported their adherence to taking the medication as prescribed. Of those, just over half took more than 80% of their prescriptions.
Dealing with back and neck pain
Given the findings that opioids have no benefits but carry a risk of harm, the authors believe that opioids should not be recommended for the treatment of acute neck or low back pain.
“Instead, physicians should be encouraged to focus on patient-centered approaches, including advice to stay active and simple pain relievers,” Lin said in the press release. “The good news is that most people with acute low back pain and neck pain recover naturally within 6 weeks.”
The authors studied non-specific back or neck pain, pain of unknown cause. When doctors don’t know the origin, Finkenberg argued that opioids shouldn’t be used as a first choice or quick fix.
Useful alternatives to opioids include nonsteroidal anti-inflammatory drugs, also known as NSAIDs, such as ibuprofen, naproxen, and celecoxib. A combination of an NSAID and a prescription muscle relaxant was found to reduce pain and disability within a week, according to a February study.
Range-of-motion exercises can also help. These include stretches to maintain or improve mobility.
People with these pains should also “use their bodies as a barometer,” Finkenberg said. If you’re doing an activity and your body feels uncomfortable, don’t force the pain. Doing so can cause the area to become increasingly inflamed, causing more pain and damage.
If your pain and any weakness persists after three to four weeks, “you really need to see a specialist, because it’s hard to pick up on these subtleties of why people have discomfort,” Finkenberg said. “If proper, advanced diagnostic tests are needed, it’s better to get them sooner.”
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