Opioids for low back pain

Richard A Deyo, Michael Von Korff, David Duhrkoop, Richard A Deyo, Michael Von Korff, David Duhrkoop

Abstract

Back pain affects most adults, causes disability for some, and is a common reason for seeking healthcare. In the United States, opioid prescription for low back pain has increased, and opioids are now the most commonly prescribed drug class. More than half of regular opioid users report back pain. Rates of opioid prescribing in the US and Canada are two to three times higher than in most European countries. The analgesic efficacy of opioids for acute back pain is inferred from evidence in other acute pain conditions. Opioids do not seem to expedite return to work in injured workers or improve functional outcomes of acute back pain in primary care. For chronic back pain, systematic reviews find scant evidence of efficacy. Randomized controlled trials have high dropout rates, brief duration (four months or less), and highly selected patients. Opioids seem to have short term analgesic efficacy for chronic back pain, but benefits for function are less clear. The magnitude of pain relief across chronic non-cancer pain conditions is about 30%. Given the brevity of randomized controlled trials, the long term effectiveness and safety of opioids are unknown. Loss of long term efficacy could result from drug tolerance and emergence of hyperalgesia. Complications of opioid use include addiction and overdose related mortality, which have risen in parallel with prescription rates. Common short term side effects are constipation, nausea, sedation, and increased risk of falls and fractures. Longer term side effects may include depression and sexual dysfunction. Screening for high risk patients, treatment agreements, and urine testing have not reduced overall rates of opioid prescribing, misuse, or overdose. Newer strategies for reducing risks include more selective prescription of opioids and lower doses; use of prescription monitoring programs; avoidance of co-prescription with sedative hypnotics; and reformulations that make drugs more difficult to snort, smoke, or inject.

Conflict of interest statement

Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following interests: RAD receives honorariums from UpToDate for authoring topics on low back pain. He benefits from an endowment to his university from Kaiser Permanente. He has been a member of the board of directors for the Informed Medical Decisions Foundation, a non-profit organization. MVK has several research grants from Pfizer awarded to the Group Health Research Institute. He is also a co-investigator on Food and Drug Administration mandated post-marketing surveillance studies of opioid safety funded by a consortium of drug companies.

© BMJ Publishing Group Ltd 2015.

Figures

Fig 1
Fig 1
Use our interactive graphic as a guide to prescribing opioids for low back pain. See www.bmj.com/content/350/bmj.g6380/infographic
Fig 2
Fig 2
International use of six powerful opioids—fentanyl, hydromorphone, methadone, morphine, oxycodone, and pethidine (meperidine)—during 2010 (www.painpolicy.wisc.edu)
Fig 3
Fig 3
Per capita consumption of fentanyl, hydromorphone, methadone, morphine, oxycodone, pethidine (meperidine) in the United States. This figure does not include all opioids, and hydrocodone, in particular, is not included. Data from the US Centers for Disease Control indicate that total opioid sales in the US continued to rise consistently at least through 2010
Fig 4
Fig 4
Randomized trials of strong opioids versus placebo for chronic low back pain or sciatica included in a systematic review. ER=extended release; FU=follow-up; LBP=lower back pain; MEQ=morphine equivalents; VAS=visual analogue scale

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Source: PubMed

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