: Opioids don’t work to relieve acute back or neck pain.

Norman Swan A large proportion of Australians suffering from neck or back pain are prescribed opioids and morphine-like narcotics despite the risk of addiction. These risks may be manageable, if the benefits are significant. This is not the case, according to the world’s most recent and best-known trial on opioids for acute neck and back pain. According to the authors of the study, this means that doctors’ clinical guidelines which guide them to evidence-based treatments need to be revised. For you and I, it means that we need to consider non-drug ways to control pain and get better. Professor Christine Lin is the senior author of the paper. Christine is at the Institute for Muscular Skeletal Health, University of Sydney. Christine, welcome to the Health Report.

Christine Lin Thanks for having me. Norman

Norman Swan What is the statistic of people…the extent of people who are treated with opioids for acute neck and back pain in Australia?

Christine Lin We know that approximately 40% of patients who visit their general practitioner and up to 70% of those who come to the emergency department for back and neck pain are prescribed opioids. It’s a high percentage of people.

Norman Swan : Please describe your trial.

Christine Lin : Yeah, in this trial, we recruited 347 patients with acute neck and low back pain from general practice or people who presented to the emergency department. We randomly assigned them to either receive an opioid or a placebo. It was a placebo, which looked like an opioid but had no active ingredients. Both groups receive what is called guideline care. This means that they are reassured by their doctor that the pain will improve and advised to remain active.

Norman Swan : And what opioid did you use?

Christine Lin We used a modified-release opioid called oxycodone. It’s oxycodone mixed with naloxone. Naloxone is a non-active ingredient that helps to counteract some of the side effects associated with opioids.

Norman Swan I don’t have a brand name but wouldn’t GPs, and others, use something more like Panadeine Forte which contains codeine and Panadol?

Christine Lin

Norman Swan : What were your findings?

Christine Lin We followed people up to a year after they began the study. Our main interest was how their pain felt at six weeks. That’s the maximum treatment period. We found that there was no difference between the pain intensity of people taking opioids and those who took placebo.

Norman Swan : What about quality of life, rehabilitation and other things?

Christine Lin : Yeah, the main outcome we were interested in was pain intensity. In most outcomes, we found that the opioids did not confer any benefit. In a few outcomes such as mental quality of life, we did see a slight advantage for those in the placebo group.

Norman Swan Did you receive any signals about misuse?

Christine Lin We asked them, in a questionnaire at one year, if they had used opioids differently than prescribed by their doctor. We found that the opioid group had a higher rate of opioid misuse compared to the placebo group.

Norman Swan : Some people may say that this study is fine because you are measuring it over a period of six weeks. Sometimes, however, the GP or the person suffering from acute back pain may say that oxycodone is the best way to get them through the first week. Then they will switch to paracetamol, ibuprofen, etc.

Christine Lin : And as I said, our primary result was pain after six weeks. We also measured pain at other times, and asked people to record pain every day since they started taking opioids. We found that even on the first day, there was no evidence to suggest that the opioid group had a lower pain score. This was evident even in the first seven-day period.

Norman Swan : If you don’t take care of acute back pain…this was what some pain specialists taught…if you do not take care of it straight away, you risk chronic pain. So you have to act fast. Many GPs have heard this from those who taught them about pain, and they’ve told their patients to control the pain or else they will develop chronic pain. Is there evidence that chronic pain is a different path than acute pain?

Christine Lin Well, we’re seeing that this study and other studies we have done as well as other groups that have done shows that taking medicines in general does not relieve the pain like we thought it would.

Norman Swan : This is chronic pain.

Christine Lin In acute lower back pain we found that, through other studies we conducted, including this one on opioids, that taking medication didn’t really add any benefit to what you could do to treat your pain. If you can move around and stay active, you’ll be able to manage your pain better.

Norman Swan : We’ve talked to you and your colleagues about these other research studies, which show that paracetamol, nonsteroidals, are not very effective. I mean, patients want to get something from their GP. They’ll feel disappointed or unsure if they leave the GP without anything. Is there any medication that can help?

Christine Lin : In regards to medicines, yeah, the majority of them are not very effective in treating acute neck or lower back pain. You mentioned nonsteroidals. They actually…outside of all the medications you mentioned, there has been a modest effect on managing acute low back. If pain medication is an option, that’s the medicine you should consider.

Norman Swan : In the end, why do you believe there is a non-response? Does it go beyond low-back pain? You’d assume that if it’s called a “pain killer”, it will work.

Christine Lin : Yes, we have looked at opioids as well for other acute pain conditions. We’re beginning to realize that opioids may not be as effective as we thought. We’ve also done a systematic review of the use opioids in acute musculoskeletal ache management for people who present to the emergency department. This study showed that opioids are no better than non opioid medicines. In the next few decades, I think we’ll see more research showing that opioids are not better than non-opioids and placebos in these conditions.

Norman Swan : Interesting and important research. Thank you so much for being with us, Christine.

Christine Lin Thanks for having me. Norman

Norman Swan Professor Christine Lin is at the Institute for Musculoskeletal Health, University of Sydney. We’ll link to this study on the Health Report website.

This week’s Health Report is now available.

Tegan Tegan Taylor

Norman Swan : See you later.