Are opioids more effective for chronic musculoskeletal pain?
Thursday, April 26, 2018
In the last 20 years, physicians have been prescribing opioids for chronic pain with the rationale that chronic pain patients legitimately need some relief. Physicians felt the side effects of these opioids were not too severe and that when opioids were used as prescribed, there was little chance for addiction.
However, as we now know, overdoses from opioids are at an epidemic level today. Opioids have proven to be more dangerous than other treatment options because they put people at risk for accidental death and addiction.
In fact, opioids have never been proven to be better than standard pain medications or nonmedication treatments for most common pain problems, including chronic back pain and arthritis pain. Patients and doctors need to be considering whether an opioid really is the best choice for common pain problems, including back and arthritis pain.
To address whether moderate to severe chronic back pain or hip or knee osteoarthritis pain responds better to opioid medication compared with nonopioid medication, researchers conducted a pragmatic, 12-month, randomized trial with masked outcome assessment.
Patients from 62 Minnesota Veteran's Affairs (VA) primary care clinicians were randomized to receive opioid or nonopioid treatment for chronic pain due to back or knee osteoarthritis for 12 months in the Strategies for Prescribing Analgesics Comparative Effectiveness (SPACE) trial. Patients were excluded if they were already on long-term opioid therapy, had contraindications to either treatment (including substance use disorder) or had conditions that could interfere with a 12-month assessment, such as life expectancy less than 12 months.
Both opioid and nonopioid medication interventions 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 three steps.
In the opioid group, the first step was immediate-release morphine, oxycodone or hydrocodone/acetaminophen. 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
A total of 240 patients (98 percent follow-up rate) completed the trial. Using the Brief Pain Inventory scores, patients who received nonopioid treatment had better BPI pain severity ratings than those who received opioids. The two groups were comparable for pain-related function, physical health-related quality of life and mental health-related quality of life.
Opioids were associated with a higher rate of adverse events, but no significant differences in adverse events or misuse measures. Post-hoc tests for interaction of pain location and treatment were not significant, and adjusting for baseline smoking status as a sensitivity analysis did not change the associations.
Despite the study limitation that VA patients are not always representative of other populations, especially in terms of gender, the high retention rate of patients and strong design support the assertion that opioid therapy may not be suitable for patients with moderate to severe back pain or hip or knee osteoarthritis pain.
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