Opioids not superior in chronic back pain

A US clinical trial has found that non-opioid pain medicines are just as good as opioids in chronic back, hip or knee pain

The small, year-long study, which focused on 240 veterans with chronic back pain or hip or knee osteoarthritis, aimed to compare opioid versus non-opioid medications on pain-related function, pain intensity and adverse effects.

The patients were randomised and both interventions – opioid and non-opioid medications – followed a treat-to-target strategy aiming for improved pain and function.

“Each intervention had its own prescribing strategy that included multiple medication options in 3 steps. In the opioid group, the first step was immediate-release morphine, oxycodone, or hydrocodone/acetaminophen,” the authors write.

“For the nonopioid group, the first step was acetaminophen (paracetamol) or a nonsteroidal anti-inflammatory drug. Medications were changed, added, or adjusted within the assigned treatment group according to individual patient response.”

The primary outcome was pain-related function (Brief Pain Inventory interference scale) over 12 months, while the main secondary outcome was pain intensity (BPI severity scale).

For both BPI scales, a one-point improvement was clinically important. The scales ranged from 0-10 and higher scores meant worse function or pain intensity.

Among 240 randomised patients (mean age, 58.3 years; women, 32 [13.0%]), 234 completed the trial.

The groups did not significantly differ on pain-related function over 12 months (overall P = .58); mean 12-month BPI interference was 3.4 for the opioid group and 3.3 for the nonopioid group (difference, 0.1 [95%CI, −0.5 to 0.7]).

Pain intensity was significantly better in the nonopioid group over 12 months (overall P = .03); mean 12-month BPI severity was 4.0 for the opioid group and 3.5 for the nonopioid group (difference, 0.5 [95%CI, 0.0 to 1.0]).

Adverse medication-related symptoms were significantly more common in the opioid group over 12 months (overall P = .03); mean medication-related symptoms at 12 months were 1.8 in the opioid group and 0.9 in the nonopioid group (difference, 0.9 [95%CI, 0.3 to 1.5]).

The authors write that overall, opioids did not demonstrate any advantage over non-opioid medications that could potentially outweigh the risk of harms.

“Among the secondary outcomes, only anxiety symptoms were statistically better in the opioid group,” they write.

“This finding is consistent with the role of the endogenous opioid system in stress and emotional suffering. The importance of this finding is uncertain because the magnitude of the difference in anxiety was small and the overall level of anxiety was low (9% of patients had moderate severity anxiety symptoms at baseline).

“Results do not support initiation of opioid therapy for moderate to severe chronic back pain or hip or knee osteoarthritis pain,” they write.

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