Opioid Treatment for Chronic Low Back Pain and the Impact of Mood Symptoms

Opioids are frequently prescribed for chronic low back pain (CLBP). Psychiatric illness, such as high levels of depression and anxiety symptoms, is a common co-occurrence in chronic pain patients (and is termed comorbid negative affect [NA]). The purpose of the study is to determine whether CLBP patients with either a high vs. a low or moderate degree of NA have different pain relief responses to oral opioids.

Study Overview

• Status: Completed
• Conditions: Depression; Anxiety; Degenerative Disc Disease; Chronic Low Back Pain
• Intervention / Treatment: Drug: Oxycodone; Drug: Morphine; Drug: Placebo

Detailed Description

The level of high, moderate or low NA was determined based on the participant's score on the Hospital Anxiety and Depression Scale (HADS). The HADS is a self-reported questionnaire that has 14 questions related to 2 domains: Anxiety subscale (7 questions) and Depression subscale (7 questions). Each item on the questionnaire is scored from 0 (least amount of anxiety/depression) to 3 (greatest amount of anxiety/depression), with total score between 0 and 21 for either anxiety or depression. Participants were assigned to high, moderate or low NA groups using the following HADS score criteria:

• High NA = HADS score ≥9 on each subscale
• Moderate NA = HADS score ≥6 to ≤8 on each subscale
• Low NA = HADS score ≤5 on each subscale

• Study Type: Interventional
• Enrollment (Actual): 81
• Phase: Phase 4

Contacts and Locations

Study Locations

• United States
  • Massachusetts
    • Chestnut Hill, Massachusetts, United States, 02467
      • Brigham and Women's Hospital

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 21 years to 75 years (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Low Back Pain > 3/10
• Pain > 1 year
• Degenerative disc disease as seen on magnetic resonance imaging (MRI), which must meet minimum disc grading criteria: at least a grade III disc degeneration, a hyperintense zone, or abnormal disc morphology.
• Patients who may have had back surgery will be included.
• No epidural steroids or other nerve blocks for back pain either two weeks before or during the study period.
• No opioids or on short-acting opioids only (max. daily amount=120 mg morphine equivalents). It is not feasible to recruit only opioid naive patients.
• Must agree to 2-week washout for those on opioids.
• No active substance abuse.
• No intention to take new pain or psychiatric treatments during the study, including chiropractic, physical therapy, or complementary or alternative treatments (CAM). It is not feasible to take participants off of any other pain medications, such as nonsteroidal anti-inflammatory drugs (NSAIDS).
• No pregnancy or the intent to become pregnant during the study, and no nursing mothers.
• Women, who are able to bear children, must agree to use contraceptives throughout the study.
• In men, normal baseline testosterone levels.

Exclusion Criteria:

• Patients with pain due to disorders not including a component of disc degeneration, or those with unknown causes of pain will be excluded.
• Patients with the intent to undergo back surgery will be excluded.
• Patients with a history of recent or ongoing alcohol or other drug addiction disorders will be excluded.
• Patients with any history of substance abuse of opioids will be excluded.
• Patients whose diagnosis cannot be firmly established according to criteria described above would not be included.
• Patients whose medical and psychiatric comorbidities are not well controlled, or who are currently experiencing an acute exacerbation of the medical comorbidity, will be excluded.
• Males with abnormal testosterone levels will be excluded (normal range is 1800-6650 pg/ml).
• Female patients who nursing will be excluded.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Non-Randomized
• Interventional Model: Parallel Assignment
• Masking: Double

Number of Arms

3

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: Low Negative Affect (NA); Participants with low NA (HADS score ≤5 on each subscale) received placebo or active opioid drug (immediate-release morphine 15 to 30 mg or oxycodone 5 to 10 mg) up to three times a day as needed for 1 week each in random order, followed by morphine or oxycodone titrated to a maximum allowable daily dose in morphine equivalents of 30 mg for short-acting medication and 60 mg for long-acting medication, respectively, three times a day for up to 20 weeks, followed by morphine or oxycodone tapering (individualized opioid dose was decreased by approximately 25% each week) for 4 weeks.	Drug: Oxycodone; Daily dosage up to 120 mg; Drug: Morphine; Daily dosage up to 90 mg immediate release or 180 mg extended release; Other Names: Morphine sulfate (MS) Contin; Morphine sulfate instant release (MSIR); Morphine sulfate extended release (MSER); Drug: Placebo; Placebo-matching oxycodone, placebo-matching morphine
Active Comparator: Moderate NA; Participants with moderate NA (HADS score ≥6 to ≤8 on each subscale) received placebo or active opioid drug (immediate-release morphine 15 to 30 mg or oxycodone 5 to 10 mg) up to three times a day as needed for 1 week each in random order, followed by morphine or oxycodone titrated to a maximum allowable daily dose in morphine equivalents of 30 mg for short-acting medication and 60 mg for long-acting medication, respectively, three times a day for up to 20 weeks, followed by morphine or oxycodone tapering (individualized opioid dose was decreased by approximately 25% each week) for 4 weeks.	Drug: Oxycodone; Daily dosage up to 120 mg; Drug: Morphine; Daily dosage up to 90 mg immediate release or 180 mg extended release; Other Names: Morphine sulfate (MS) Contin; Morphine sulfate instant release (MSIR); Morphine sulfate extended release (MSER); Drug: Placebo; Placebo-matching oxycodone, placebo-matching morphine
Active Comparator: High NA; Participants with high NA (HADS score ≥9 on each subscale) received placebo or active opioid drug (immediate-release morphine 15 to 30 mg or oxycodone 5 to 10 mg) up to three times a day as needed for 1 week each in random order, followed by morphine or oxycodone titrated to a maximum allowable daily dose in morphine equivalents of 30 mg for short-acting medication and 60 mg for long-acting medication, respectively, three times a day for up to 20 weeks, followed by morphine or oxycodone tapering (individualized opioid dose was decreased by approximately 25% each week) for 4 weeks.	Drug: Oxycodone; Daily dosage up to 120 mg; Drug: Morphine; Daily dosage up to 90 mg immediate release or 180 mg extended release; Other Names: Morphine sulfate (MS) Contin; Morphine sulfate instant release (MSIR); Morphine sulfate extended release (MSER); Drug: Placebo; Placebo-matching oxycodone, placebo-matching morphine

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Percent Change in Average Daily Pain Score	Participants rated their average lower back pain over the past 24 hours using an 11-point scale (0=no pain to 10=worst possible pain) and recorded it in an electronic diary. The percent change in pain score from baseline is calculated using weekly averages for up to 20 weeks. Linear mixed modeling (LMM) analysis was used to allow for inclusion in the analysis of the majority of participants with any missing data. For the LMM model, group, group × week, average baseline pain, and opioid use at baseline (yes/no) were entered as fixed effects using an autoregressive covariance structure. Participant, intercept, and week were entered as random effects, using a compound symmetry covariance structure. A positive change from baseline indicates an improvement.	Baseline and Week 20

Collaborators and Investigators

• Sponsor: Brigham and Women's Hospital
• Collaborators: National Institute on Drug Abuse (NIDA); Arthritis Foundation
• Investigators: Principal Investigator: Ajay D Wasan, MD, MSc, Brigham and Women's Hospital

Study record dates

Study Major Dates

• Study Start (Actual): February 1, 2009
• Primary Completion (Actual): January 1, 2013
• Study Completion (Actual): January 1, 2013

Study Registration Dates

• First Submitted: December 28, 2011
• First Submitted That Met QC Criteria: December 29, 2011
• First Posted (Estimate): January 2, 2012

Study Record Updates

• Last Update Posted (Actual): July 11, 2017
• Last Update Submitted That Met QC Criteria: June 14, 2017
• Last Verified: June 1, 2017

More Information

Terms related to this study

• Keywords: low back pain; opioids; mood symptoms
• Additional Relevant MeSH Terms: Pain; Neurologic Manifestations; Musculoskeletal Diseases; Spinal Diseases; Bone Diseases; Back Pain; Low Back Pain; Intervertebral Disc Degeneration; Physiological Effects of Drugs; Central Nervous System Depressants; Peripheral Nervous System Agents; Analgesics; Sensory System Agents; Analgesics, Opioid; Narcotics; Morphine; Oxycodone
• Other Study ID Numbers: 2007P-001047; 5K23DA020681-05 (U.S. NIH Grant/Contract)