Placebo proves better than opioids at treating acute back and neck pain
Despite the risks associated with opioid use, they’re commonly prescribed as a first-line treatment for acute lower back and neck pain. Researchers have found that, compared to opioids, a placebo is more effective in reducing acute – short-term – back and neck pain and are calling for a change to current prescribing guidelines.
Globally, lower back and neck pain are prevalent. Clinical guidelines recommend that opioids, a class of medications that mimic the analgesic properties of opium derived from the poppy plant, be prescribed when other forms of analgesia are contraindicated or haven’t worked.
Despite these guidelines, as many as two-thirds of Australians are prescribed opioids as a first-line treatment after presenting with lower back and neck pain. According to the Centers for Disease Control and Prevention (CDC), in the US in 2020, opioids were dispensed at a rate of 43.3 prescriptions per 100 people. The CDC, National Institute for Health and Care Excellence in the UK, and the Australian Commission on Safety and Quality in Healthcare have all called for a reduction in opioid prescriptions.
While they’re effective at reducing pain, opioids can produce adverse side effects such as dependency, misuse, and overdose. Moreover, there’s no robust evidence to suggest that they’re effective at managing acute back and neck pain. A study led by researchers at the University of Sydney, Australia, has looked at the short- and long-term effectiveness and safety of using opioids to treat acute lower back and neck pain. It’s the first study to do so.
The researchers recruited 347 participants with a primary complaint of acute lower back pain, acute neck pain, or both. For the study, "acute" was defined as at least moderate pain for 12 weeks or less. After being randomly assigned to receive either a placebo or the opioid oxycodone, up to 20 mg daily, for six weeks. Participants were followed for 12 months. Both groups received standard care, which included avoiding bed rest and staying active, and pain severity was measured at six weeks.
Oxycodone – sold as OxyContin or Endone and commonly referred to as “oxy” – is a potent analgesic for treating moderate to severe pain. It works directly in opioid receptors in the central nervous system, reducing feelings of pain by interrupting the way the nerves signal pain between the body and the brain.
The study found that, at six weeks, participants who received opioids didn’t have better pain relief than those taking a placebo. Even short-term use of an opioid provided no benefits in pain reduction and led to a small increase in pain in the medium and long term, compared to the placebo. More people in the placebo group recovered in the first 14 days than those in the opioid group.
In the long term, quality of life and pain were better for the placebo group. And the researchers found that, at 12 months, the participants taking opioids had a “small but significantly higher” risk of misusing the drug.
“We have clearly shown that there is no benefit to prescribing an opioid for pain management in people with acute back or neck pain, and in fact, it could cause harm in the long term even with only a short course of treatment,” said Christine Lin, corresponding author of the study.
The researchers say the findings demonstrate no benefit to prescribing opioids for acute back and neck pain, in keeping with a 2016 study of opioid use for chronic – long-term – lower back pain, which found only a small treatment benefit but increased risk of harm.
“Opioids should not be recommended for acute back and neck pain full stop,” Lin said. “Not even when other drug treatments are not able to be prescribed or have not been effective for a patient.”
Rather than relying on opioids, the researchers say treatment should focus on physical and psychological interventions and non-opioid analgesics.
“This study is further evidence that the first line management of acute low back pain and neck pain should rely on reassurance and advice to stay active, and simple analgesics like non-steroidal anti-inflammatory drugs if necessary,” said Chris Maher, one of the study’s co-authors.
They say the study’s findings ought to influence the prescription of opioids, which is especially important in light of global concerns about the risks of opioid use.
“The possible harmful effects of opioids are well known,” said Andrew McLachlan, another of the study’s co-authors. “They range from minor harms such as constipation and drowsiness to major harms such as dependence, addiction, overdose, and even unintentional death.”
The researchers say clinical guidelines should be updated to advise against prescribing opioids for acute neck and lower back pain.
The study was published in the journal The Lancet.
Source: University of Sydney