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Opioid medications are one of the most typically prescribed treatments for the worldwide problem of low back pain — but they might not work, a new study has found.
Experiencing pain in the neck and lower back is common. In fact, lower back pain is globally the leading contributor to years lived with disability, and neck pain is the fourth, according to an analysis of data from the Global Burden of Disease Study 2021.
Low back pain is defined as acute when symptoms last for up to six weeks, and chronic when the pain lasts for more than 12 weeks, according to the North American Spine Society (PDF).
When it comes to treating this pain, physicians should cautiously limit patient use of opioids and restrict it to a short time period, the society’s clinical guidelines state. Opioids for pain relief are recommended only once other pharmacological treatments haven’t worked or if a person can’t take them for personal reasons.
Despite these guidelines and “there being no evidence of their efficacy in reducing pain, opioid pain relievers are still widely prescribed for people with lower back and neck pain in many countries,” said Christine Lin, a professor at the Institute for Musculoskeletal Health at the University of Sydney in Australia, in a news release. Lin is senior author of the latest study published Wednesday in the journal The Lancet.
Because of scarce research, the scientists studied the effectiveness and safety of using opioids to treat a small cohort of 310 people. The patients had sought help for neck or lower back pain from primary care clinics or hospitals in Sydney between February 2016 and March 2022. At the beginning of the study, participants were about age 44 on average and had experienced at least moderately painful neck or lower back pain or both for 12 weeks or less.
The study participants were then randomly split into two groups: One group took a combination of naloxone and up to 20 micrograms of the opioid oxycodone per day for six weeks. Naloxone was used to prevent constipation, a common side effect of opioids, and therefore keep participants from figuring out which group they were in. The other group was instructed to take a placebo pill.
Both groups were also given care tips from a doctor they were told to see weekly. The care involved the doctor reassuring them and advising them to stay active, avoid bed rest and, if required, avoid other treatments including nonopioids.
The authors found that in terms of effects on back and neck pain, opioids weren’t any more helpful than the placebo. Six weeks into treatment, the average pain score was 2.78 in the opioid group and 2.25 in the placebo group, a difference that increased over time. More people in the opioid group had ongoing pain at weeks 26 and 52 than in the placebo group.
The authors also discovered that not only are opioids unlikely to alleviate back and neck pain, they also might cause harm even after short-term, sensible use.
The opioid group had worse mental health scores and more reports of nausea, dizziness and constipation than the placebo group. “We also know that being prescribed opioid pain relievers even for a short period of time increases the risk of opioid misuse long term,” Lin said in a news release.
The study authors and experts who weren’t involved in the new study have theories on why opioids weren’t found to be more helpful than the placebo.
One possibility is that the back or neck pain of the opioid group could have had more underlying factors than the authors considered — factors that have been known to respond poorly to opioid treatment, experts said.
The pain treated might have been more chronic, recurring pain than the type caused by acute injury, according to a commentary on the study by Dr. Mark D. Sullivan and Dr. Jane C. Ballantyne, who weren’t involved in the study. Sullivan is a professor of psychiatry and behavioral sciences, and Ballantyne is a retired professor of anesthesiology and pain medicine, at the University of Washington.
“Participants were only required to have 1 month pain free before their current episode of spinal pain,” Sullivan and Ballantyne wrote. “If many of these participants had recurrent pain, this might account for the non-response to opioid therapy. Low back pain has been reported to transform over a year.”
Dr. John Finkenberg, a San Diego-based specialist in orthopedic spine surgery, said areas of pain in the neck and back sometimes need to be treated separately. He wasn’t involved in the study.
“If somebody had both of these going on, they, quite frankly, will have a systemic-type issue going on, whether it be general arthritis or rheumatoid. So we have to be careful on the patients that come in with both,” added Finkenberg, who is also president of the North American Spine Society.
The authors didn’t collect data on what care the doctors offered in follow-up appointments, so they didn’t have details on whether the patients followed any advice or its impact. Additionally, only 57% of participants reported the extent to which they complied with taking the medication as prescribed. Of those, just over half took more than 80% of their prescriptions.
Given the findings that opioids have no benefits but do carry risk of harm, the authors think opioids shouldn’t be recommended for treatment of acute neck or lower back pain.
“Instead, doctors should be encouraged to focus on patient-centred approaches that could include advice to stay active, and simple pain relievers,” Lin said in the news release. “The good news is most people with acute low back pain and neck pain recover within 6 weeks naturally.”
The authors studied nonspecific back or neck pain, which is pain with an unknown cause. When doctors don’t know the origin, Finkenberg contended that opioids should not be used as a first choice or a quick fix.
Helpful alternatives to opioids include nonsteroidal anti-inflammatory drugs, also called NSAIDS — such as ibuprofen, naproxen and celecoxib. A combination of an NSAID and a prescription muscle relaxer has been found to reduce pain and disability within a week, according to a February study.
Range of motion exercises can also help. These include stretches to maintain or improve mobility.
People with these pains should also “use their body as the barometer,” Finkenberg said. If you’re doing an activity and your body feels uncomfortable, don’t push through the pain. Doing so could increasingly inflame the area, causing more pain and harm.
If your pain and any weakness persist after three to four weeks, you “really need to go see a specialist because it’s difficult to pick up these subtleties for why people have discomforts,” Finkenberg said. “If the appropriate, advanced diagnostic tests are needed, it’s better to get them earlier.”