Medical News Today Quotes Dr. Williams: Opioids about as effective as placebo for lower back and neck pain, study finds

Posted By Vernon B. Williams, MD || 7-Jul-2023

Lower back pain is the single leading cause of disability worldwide. In 2020, 619 million people globally were affected by the condition. By 2050, this figure is expected to increase to 843 million.

Neck pain is also a leading contributor to disability worldwide and is estimated to be the fourth leading cause of disability in terms of “years lived with disability.”

Clinical guidelines recommend opioid painkillers for people with lower back pain or neck pain when other treatments have not worked. Studies, however, show that opioids may be a first-line treatment for many with the conditions, including two-thirds of those in Australia.

Despite this, little evidence exists to suggest that opioids are an effective way to manage lower back pain and neck pain. The use of opioids as a treatment is also known to increase the risk of adverse events, such as opioid dependency, misuse, and overdose.

Further research on the efficacy of opioids for treating lower back pain and neck pain could inform treatment options.

Recently, researchers from the University of Sydney, Australia investigated the efficacy and safety of short courses of opioids for managing lower back pain and neck pain.

They found that opioids did not outperform the placebo in pain relief and that treatment with opioids increased the risk of misuse later on.

Their study appears in The Lance.

Medical News Today spoke with Charles De Mesa, a doctor of osteopathic medicine and chief of Interventional Pain, Physical Medicine & Rehabilitation at Hoag Spine & Specialty Clinic in California, who was not involved in the study, about this research.

He told us:

“A high-quality study gives evidence that opioids are no better than a placebo for acute lower back and neck pain. There are simply too many risks such as opioid misuse and no benefit. Even short-term judicious use has the potential to lead to long-term harms including intoxication, addiction, and overdose.”

No significant difference between opioids and placebo

For the study, the researchers recruited 347 participants with an average age of 44,7 years. All of the participants had lower back pain, neck pain, or both for 12 weeks or less, and around half were female.

The participants were randomly split into two groups in which they received guideline-recommended care and opioid oxycodone-naloxone or guideline-recommended care, and an identical placebo for up to 6 weeks.

Guideline-recommended care included reassurance and advice to stay active. After 6 weeks, participants could seek other care if required.

The researchers also measured the patients’ pain intensity before and after treatment according to the Brief Pain Inventory Pain Severity Subscale, which assesses pain on a scale of 0–10.

Ultimately, the opioid and placebo groups experienced no significant difference in pain scores after 6 weeks of treatment. The results remained after adjusting for the site of pain and the number of days since pain onset.

The researchers noted that pain scores in the placebo and opioid did not differ much after 12 weeks but that by week 52, those in the placebo group had slightly lower pain scores.

Pain scores at week 6 for the opioids and placebo groups averaged at 2.78 and 2.25. At 52 weeks, the pain score for the opioids group was 2.37, while that for the placebo group was 1.81.

They further found no difference between the groups in terms of the physical component of quality of life. However, the placebo group experienced a small yet significant improvement in mental health at 6 and 12 weeks.

While there was no difference in the proportion of participants reporting adverse events, the opioid group was more likely to develop opioid misuse.

After 52 weeks, 20% of the opioid group compared to 10% of the placebo were classified as “at risk” on the Current Opioid Misuse Measure Scale.

What are the study limitations?

When asked about the study’s limitations, Dr. Joel Frank, a licensed psychologist at Duality Psychological Services in California, not involved in the study, told MNT: “Firstly, the treatment protocol was medication-focused, but 42% of the sample was non-compliant. Secondly, their ‘guideline care’ included physical activity recommendations, but they stated the care was ‘not monitored’.”

“Thirdly, their primary measure for pain severity was the BPI, a self-report measure,” said Dr Frank. “Self-report measures are inherently subjective. When utilizing self-report measures for pain, it is advisable to include additional measures that evaluate pain catastrophization to derive a fuller picture of the subjective experienced pain level.”

MNT also spoke with Dr. Vernon Williams, a sports neurologist, pain management specialist, and founding director of the Center for Sports Neurology and Pain Medicine at Cedars-Sinai Kerlan-Jobe Institute in California, not involved in the study.

Dr. Williams noted that the results are limited as rather than comparing opioid use to no treatment, they compared it to a placebo, which is capable of inducing a physical response.

“There are physiologic effects related to your body responding to the expectation of the active treatment and your body’s response to the potential benefit — or expectation — of the placebo. So rather than the opioid not being effective, the study showed that the opioid did not outperform [the] placebo. It’s a subtle, but significant distinction,” he noted.

MNT also asked Dr. Gustavo De Carvalho Machado, senior research fellow at the University of Sydney, Australia, not involved in the study, about its limitations. He cautioned that:

“The findings are not directly applicable to pre-hospital — patients who require an ambulance — and emergency department settings. Patients who present to these settings have more severe pain and disability and the outcomes of this trial were measured weeks after recruitment and in emergency settings timely analgesia within hours is crucial for management and discharge planning.”

Alternative treatments for chronic back pain

MNT also spoke with De Mesa about alternatives for treating lower back and neck pain.

“More effective alternatives for lower back and neck pain address the underlying causes of pain. For example, a physician may help determine which specific muscles and/ or accompanying structures such as tendons and ligaments are precisely implicated. Physical therapy, improved ergonomics and exercise may be prescribed,” he noted.

“Often spinal pain is multifactorial therefore a holistic treatment approach can help the individual achieve long-term recovery. In addition to physical conditioning, nutrition, acupuncture, cognitive behavioral, and education programs are beneficial. Over-the-counter anti-inflammatory medications may be used as needed. The best treatment plan will vary depending on the individual’s needs and circumstances,” he advised.

De Mesa noted that board-certified physiatrists, pain specialists, and spine surgeons may be recommended for chronic spinal pain.

“Chronic pain may be caused by arthritis of spinal joints or inflammation of the vertebral endplates. Injections to pinpoint the pain generator and treat the source of pain may be recommended,” he explained.

“Radiofrequency ablation [destruction] of the spinal medial branch nerves and basivertebral nerve ablation are two examples of interventional procedures which may reduce pain and improve quality of life. Surgical options are performed if deemed medically necessary and typically reserved as a last resort,” he noted.

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