Neck Pain

Back and neck pain relief – Opioids similar to placebo

Published

2 years ago

July 7, 2023

AmericanChiro

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Design by MNT. Photography by CRISTINA PEDRAZZINI/SCIENCE PHOTOLIBRARY/Getty Images & Lock Stock/Getty Images.

Researchers compared the effectiveness of opioids versus a placebo in treating neck and low back pain.
After 6 weeks, there were no significant differences between the opioids and placebo groups. A year later, the placebo group scored slightly lower in terms of pain.
According to the findings, opioids may not be effective in treating certain types of pain.

Lower back pain is a common complaint.

Single leading cause

Disability worldwide. In 2020, there will be 619 millions people with disabilities in the world. By 2050, the number of people affected by this condition is expected to reach 843 millions.

Neck pain is a major contributor to disability in the world and is estimated as the

Fourth

Leading cause of disability measured in terms of “years of disability”

Clinical guidelines recommend opioids for people with neck or lower back pain when other treatments do not work. Studies show that opioids are a first-line therapy for many people with these conditions, including two thirds of those living in Australia.

Despite this, there is little to no evidence that the symbiotic relationship between humans and animals has been broken.

Evidence of the Usefulness of

There is evidence that suggests opioids are effective in managing lower back and neck pain. It is also known that opioids can increase the risk for a number of serious health problems.

adverse events

Such as opioid dependence, misuse and overdose.

Treatment options could be improved by further research on the effectiveness of opioids in treating neck and lower back pain.

Researchers from the University of Sydney in Australia have recently investigated the efficacy of short courses of opiates for treating lower back pain and cervical pain.

The study found that opioids were not superior to placebos in relieving pain and that opioid treatment increased the risk of abuse later on.

The study is published in

The Lancet

.

Medical News Today spoke to Charles De Mesa, a physician of osteopathic and chief of Interventional Pain, Physical Medicine & Rehabilitation at Hoag Spine & Specialty Clinic, California, who wasn’t involved in the study, regarding this research.

He told us:

“A high-quality research study shows that opioids do not work better than placebo for acute neck and lower back pain. There are too many risks, such as opioid abuse, and no benefit. Even short-term, judicious usage can lead to long-term harms such as intoxication, dependence, and overdose.

Researchers recruited 347 participants, with an average age 44,7 years. The participants were all women and had suffered from lower back pain or neck pain for 12 weeks or less.

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. Participants could seek additional care after 6 weeks if needed.

Researchers also assessed the intensity of pain in patients before and after treatment using the Brief Pain Inventory’s Pain Severity Subscale. This scale measures pain on a 0-10.

After 6 weeks, there was no significant difference between the opioid and placebo groups in terms of pain scores. The results were unchanged after adjusting for both the location of the pain and the number days since the pain began.

Researchers noted that the pain scores of the placebo and opioid groups did not differ much at all after 12 weeks, but that by 52 weeks, the placebo group had slightly reduced pain scores.

The average pain scores for the opioids group and placebo group at week six were 2,78 and 2,25 respectively. The pain score for the placebo group at 52 weeks was 1.81, while the opioid group’s was 2.37.

The researchers also found that there was no difference in the physical component of the quality of life between the two groups. The placebo group did experience a small but significant improvement in mental well-being at 6 and 12-weeks.

The opioid group was more susceptible to developing opioid abuse, even though there was no difference between the proportions of participants reporting adverse effects.

On the Current Opioid Misuse Measure Scale, after 52 weeks, 20% in the opioid group and 10% in the placebo group were classified as being “at risk”.

MNTasked for Dr. Wang Lushun, senior consultant orthopaedic surgeon at Arete Ortho, Singapore, who was not involved in the research, to explain why opioids might be ineffective in treating lower back and neck problems.

“Opioids, which are commonly used to relieve pain, may not be as effective in treating lower back and neck problems. Recent studies have shown this.” This is because opioids are primarily used to treat the perception of pain, and not the cause of the pain,” explained Dr. Wang.

By binding to opioid receptors, the drugs block the sensation of pain. “However, inflammation or physical injury — the common causes for these pains — is not actually alleviated,” explained he.

Over time, the body may also develop a tolerance to opioids. This can lead to the need for higher dosages to achieve the desired level of pain relief. This could lead side effects and possible dependency — one side effect is a phenomena known as opioid-induced Hyperalgesia which can result in even worse pain.

– Dr. Wang Lushun

Dr. Joel Frank, licensed psychologist at Duality Psychological Services, California, who was not involved in the research, responded to MNT when asked about the limitations of the study: “Firstly the treatment protocol was medication focused, but 42% were non-compliant. Second, their guideline care’ included recommendations for physical activity, but they claimed that the care was not monitored.

Dr Frank said, “Thirdly their primary measure of pain severity was the BPI. This is a self report measure.” Self-report measures by their very nature are subjective. It is important to include measures that evaluate pain categorization when using self-report pain measures. This will give a more complete picture of the subjective pain level.

MNT spoke with Dr. Vernon Williams who is a sports neurologist, pain management specialist and founding director of Cedars-Sinai Kerlan-Jobe Institute’s Center for Sports Neurology and Pain Medicine. He was not involved in the research.

Dr. Williams pointed out that the results were limited, as they did not compare opioid use with no treatment but rather compared it with a placebo which can induce a physical reaction.

“There are physiological effects related to your response to the expectation that the active treatment will be effective and your body’s reaction to the potential benefit – or expectation – of the placebo. The study did not show that the opioid was ineffective, but rather that it did not perform better than the placebo. He noted that it’s a subtle but significant difference.

MNT asked Dr. Gustavo De Carvalho Machado of the University of Sydney in Australia, who was not involved in the research, about the limitations of the study. He warned that:

The findings are not directly applicable in pre-hospital settings, such as those who require an ambulance or emergency departments. The results of this trial were not directly applicable to pre-hospital settings, where patients require an ambulance.

MNT and spoke with De Mesa regarding alternative treatments for lower back and neck discomfort.

“More effective alternative treatments for lower back and cervical pain address the underlying cause of pain. A physician can help determine the exact muscles and/or accompanying structures, such as tendons or ligaments, that are involved. He noted that physical therapy, ergonomic improvements and exercise could be prescribed.

“Spinal pain is often multifactorial, so a holistic approach to treatment can help an individual achieve long-term healing. Nutrition, acupuncture and cognitive behavioral programs, as well as physical conditioning, are also beneficial. As needed, anti-inflammatory over-the-counter medications can be used. The best treatment plan depends on the individual and their circumstances.

De Mesa said that spine surgeons, pain specialists and board-certified physiatrists could be recommended to treat chronic spinal pain.

“Chronic Pain may be caused either by arthritis in the spinal joints or by inflammation of the vertebral ends.” He explained that injections may be recommended to treat the source of the pain and pinpoint the pain generator.

“Radiofrequency ablation (destruction) of the spinal medial branches nerves and Basivertebral Nerve Ablation are two example of interventional procedures that may reduce pain and improve your quality of life. He noted that surgical options are only performed if medically necessary. They are usually reserved as a final resort.

AmericanChiro

We understand how important it is to choose a chiropractor that is right for you. It is our belief that educating our patients is a very important part of the success we see in our offices.

Neck Pain

Re: Chronic Pain: Management focuses on the individual, not the pain.

Published

2 years ago

July 17, 2023

AmericanChiro

Dear Editor

Chronic pain management focuses on the individual, not the pain.

I am very pleased with the review by Kang and colleagues [1]. I write as a spinal pain specialist whose patients had an average episode duration of pain pain of 2.5 years [2] for low back pain and 1.3 years for neck pain [3]. These studies confirm that Kang et. al. noted the significant extent of spinal and extraspinal pain, sleep disturbance, and psychological distress. I also recognize the ‘heartsinks’ who have seen many consultants for a variety of complaints, and those with hypersensitivity. I do accept that some patients need further investigations, but it can be done in a way that does not cause further anxiety. To ensure that intensive rehabilitation is not contraindicated. By showing a genuine interest in the family, job and interests of the individual, you can begin to build confidence and hope for the clinical path being recommended.

The review ignores trauma’s effects on some people, causing their pain to begin, and for others, a major factor. Thirteen percent of patients with neck pain who presented to my clinics had a traumatic origin with a missed break and significant psychological comorbidity. Subsequently, it became clear that post-traumatic distress (PTPD), [a term used because post-traumatic stress may require specialist knowledge for diagnosis] can be present in rheumatological practices [4] and with the increasing influx of refugees in the UK [5], more patients are being diagnosed with PTPD. This can have major effects on families [5]. PTPD is commonly seen in medicolegal situations where accidents have caused major destruction to the lives of individuals and their families, including divorce [6]; and is often associated mood disturbances [6].

Kang et. al. correctly mention that sleep disorders are important in the management chronic pain [1], however, two important aspects of a’sleep story’ must be identified. It is important to ask the individual what they are thinking about when they lie awake in bed at night. This may provide clues as to social or family stress. Second, you should ask about their nightmares and dreams, especially if they are unpleasant. These often involve reliving trauma or accidents. When asked about nightmares, people who deny any unpleasant memories during direct questioning may reveal clues. The presence of PTPD can be important because it opens up therapeutic opportunities with psychological support and medications.

My experience in rehabilitation medicine over the years has taught me that to fully assist our disadvantaged clients, social issues must be resolved before psychological issues, and psychological issues must be resolved before physical issues!

References

1. Kang Y et. al., Chronic Pain: Definitions and Diagnosis. BMJ (Clinical Research ed. ), 2023. 381: p. e076036.

2. Frank A. et al. A cross-sectional study of the clinical and psychosocial features of low back injury and the resulting work handicap: Use of the Quebec Task Force Classification. Int J Clin Pract, 2000; 54(10) p. 639-644.

3. Frank A, De Souza L and Frank C. Neck Pain and Disability: A Cross-sectional Survey of the Demographic and Clinical Characteristics of Neck Pain Seen in a Rheumatology Clinic. Int J Clin Pract 2005; 59(doi: 10.1111/j.1742-1241.2004.00237.x): p. 173-182.

4. McCarthy J. and Frank A. Posttraumatic psychological distress can present in rheumatology. BMJ 2002. 325(27 July): p. 221-221.

5. Frank A. Refugee status: a yellow-flag in managing back pain. BMJ 2007;334(13 Jan): p.58-58.

6. Frank A. Psychiatric effects of road traffic accidents: often disabling, and not recognised (letter). BMJ 1993, 307(13th Nov): p.1283.

AmericanChiro

We understand how important it is to choose a chiropractor that is right for you. It is our belief that educating our patients is a very important part of the success we see in our offices.

Neck Pain

Landmark Trial: Opioids No Better Than Placebo for Back Pain

Published

2 years ago

July 16, 2023

AmericanChiro

The first randomized controlled study testing the efficacy of a short course opioids for acute nonspecific neck/low back pain suggests that opioids do not relieve acute neck or low back pain in the short-term and can lead to worse outcomes over the long-term.

After 6 weeks there was no significant difference between the pain scores of patients taking opioids and those who took a placebo. After one year, the pain scores of patients who received placebos were slightly lower. After 1 year, opioid users were also at a higher risk of opioid abuse.

Senior author Christine Lin, Ph.D., from the University of Sydney told Medscape Medical News that this is a “landmark trial” with “practice changing” results.

Lin explained that “we did not have any good evidence before this trial on whether opioids are effective for acute neck or low back pain, but opioids are one of the most commonly prescribed medicines for these conditions.”

Lin stated that based on these results “opioids shouldn’t be recommended at any time for acute neck and low back pain,”

The results of the OPAL study have been published online in The Lancet on June 28.

Rigorous Test

The trial was conducted at 157 primary care and emergency departments in Australia, with 347 adults who experienced low back pain or neck pain for 12 weeks or less.

They were randomly allocated (1:1) to receive guideline-recommended care (reassurance and advice to stay active) plus an opioid (oxycodone up to 20 mg daily) or identical placebo for up to 6 weeks. Naloxone is given to prevent opioid-induced constipation, and to improve blinding.

The primary outcome was the pain severity at six weeks, as measured by the pain severity subscale (10-point scale) of the Brief Pain Inventory.

After 6 weeks of opioid therapy, there was no difference between placebo and opioid therapy in terms of pain relief or functional improvement.

The mean pain score was 2.78 for the opioid group at 6 weeks, compared to 2.25 for the placebo group. (Adjusted median difference, 0.53, 95% CI -0.00 – 1.07, P=.051). At 1 year, the mean pain scores of the placebo group were lower than those of the opioid group (1.8 and 2.4).

The risk of opioid misuse was doubled at 1 year for patients randomly assigned to receive opioid therapy during 6 weeks as compared to those randomly assigned to receive placebo during 6 weeks.

At 1 year, the Current Opioid Use Measure (COMM), a scale that measures current drug-related behavior, indicated that 24 (20%) patients from 123 patients who received opioids, were at risk for misuse. This was compared to 13 (10%) patients from 128 patients in a placebo group ( p =.049). The COMM is a widely-used measure of current aberrant drug related behavior among chronic pain patients who are prescribed opioid therapy.

Results Raise “Serious Questions”

Lin told Medscape Medical News that “I think the findings of the research will need to be distributed to doctors and patients so they receive the latest evidence on opioids.”

“We must reassure doctors and their patients that the majority of people with acute neck and low back pain recover well over time (normally within 6 weeks). Therefore, management is simple – stay active, avoid bed rest and, if needed, use a heat pack to relieve short term pain. Consider anti-inflammatory drugs if drugs are needed,” Lin added.

The authors of the linked comment state that the OPAL trial raises serious questions regarding the use of opioids for acute neck and low back pain.

Mark Sullivan, MD PhD, and Jane Ballantyne MD, from the University of Washington in Seattle, note that clinical guidelines recommend opioids to patients with acute neck and back pain when other drugs fail or are contraindicated.

As many as two thirds of patients may receive an opioid for back or neck pain. Sullivan and Ballantyne say that it is time to reexamine these guidelines.

The National Health and Medical Research Council (NHMRC), the University of Sydney Faculty of Medicine and Health (University of Sydney Faculty of Medicine and Health) and SafeWork SA funded the OPAL study. The authors of the study have not disclosed any relevant financial relationships. Sullivan and Ballantyne have served as board members of Physicians for Responsible Opioid Prescribing (unpaid), and paid consultants for opioid litigation.

Lancet. Online published June 28, 2023. Abstract

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AmericanChiro

We understand how important it is to choose a chiropractor that is right for you. It is our belief that educating our patients is a very important part of the success we see in our offices.

Neck Pain

‘I tried acupuncture for back and neck pain even though I’m afraid of needles–and it’s literally the only thing that’s ever worked’

Published

2 years ago

July 15, 2023

AmericanChiro

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AmericanChiro

We understand how important it is to choose a chiropractor that is right for you. It is our belief that educating our patients is a very important part of the success we see in our offices.