Why Opioids Are Not the Answer to Your Back Pain: New Study Calls for Medical Rethink

Hydrocodone Prescription Opioid

A world-first trial led by the University of Sydney found that opioids are not more effective than a placebo for treating acute back and neck pain and may even pose a risk for harm. The researchers argue that treatment guidelines should be updated to advise against using opioids for this type of pain.

The evidence calls for treatment guidelines to be changed.

According to a world-first trial led by the University of Sydney, opioids are no more effective than a placebo for treating acute back and neck pain and could even be harmful.

The research team argues that this evidence calls for an update to treatment guidelines, advising against using opioids for such conditions. It is a significant concern, given that more than 577 million people globally suffer from low back and neck pain at any given moment.

Despite a global push to reduce the use of opioids, in Australia, approximately 40 to 70 percent of those who present with neck and back complaints are prescribed opioids for their pain.

The OPAL trial recruited close to 350 participants from 157 primary care and emergency department sites. Participants with acute-meaning sudden and generally short-term back or neck pain were randomly allocated to a six-week course of a commonly prescribed opioid or a placebo.

Both groups also received standard care including advice to avoid bed rest and stay active. Participants were followed for 52 weeks.

The results of the trial were recently published in The Lancet.

What did the study find?

  • At six weeks, those who received opioids did not have better pain relief than those given the placebo.
  • Quality of life and pain outcomes at long-term follow-up were better in the placebo group.
  • Patients who received opioids were at a small but significantly higher risk of opioid misuse 12 months after their short course of medication.

The research team says that according to current back and neck pain guidelines opioids can be considered as a last resort if all other pharmacological options have failed, however, this study is evidence that opioids should not be recommended at all.

“We have clearly shown 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 lead investigator Professor Christine Lin from Sydney Musculoskeletal Health, an initiative of the University of Sydney, Sydney Local Health District, and Northern Sydney Local Health District

“Opioids should not be recommended for acute back and neck pain full stop.

“Not even when other drug treatments are not able to be prescribed or have not been effective for a patient.”

The study complements previous research into opioid use for chronic (long-term) low back pain which found a small treatment benefit, but increased risk of harm.

Global push to reduce opioid use

Reducing the overuse of opioids is a global health priority. Medical authorities around the world have cautioned that due to the significant risk of harm to individuals and society, opioids should only be used where there is evidence that the benefits outweigh the harms.

Co-author Professor Chris Maher said in recent years there has been a shift in focus from opioid to non-opioid treatments for low back pain, with a focus on physical and psychological therapies and simple analgesics such as anti-inflammatory medicines (called NSAIDs).

“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 Professor Maher, also of Sydney Musculoskeletal Health.

The harm caused by opioid use

Professor Andrew McLachlan, Dean of Sydney Pharmacy School and co-investigator, said the Lancet study is important and should influence prescribing and dispensing of these medicines as Australia faces rising rates of opioid use.
According to Australia’s Therapeutic Goods Administration, every day in Australia nearly 150 hospitalisations and 14 emergency department admissions involve issues relating to opioid use, and three people die from the harm that results from prescription opioid use.

“The possible harmful effects of opioids are well known. They range from minor harms such as constipation and drowsiness to major harms such as dependence, addiction, overdose, and even unintentional death,” said Professor McLachlan.

“The findings from the OPAL trial further reinforce the need to reassess the use of opioid pain-relieving medicines as there is limited evidence of benefit and known significant risk of harm.”

The authors note some study limitations including data gaps due to participant attrition and issues with medication adherence consistent with other back pain drug trials. They suggest neither are likely to have impacted the main outcomes of the study.

Reference: “Opioid analgesia for acute low back pain and neck pain (the OPAL trial): a randomised placebo-controlled trial” by Caitlin M P Jones, Richard O Day, Bart W Koes, Jane Latimer, Chris G Maher, Andrew J McLachlan, Laurent Billot, Sana Shan, and Chung-Wei Christine Lin, 28 June 2023, The Lancet.
DOI: 10.1016/S0140-6736(23)00404-X

The trial is a collaboration between the University of Sydney, The George Institute for Global Health, UNSW, St Vincent’s Hospital Sydney, Sydney Local Health District, and Erasmus University Medical Center in the Netherlands.

The study was funded by the National Health and Medical Research Council, SafeWorkSA, and the Faculty of Medicine and Health, University of Sydney.

2 Comments on "Why Opioids Are Not the Answer to Your Back Pain: New Study Calls for Medical Rethink"

  1. The findings of this University of Sydney study are immensely significant and demand our attention. In a world where opioid misuse and addiction have reached alarming levels, this research highlights a pivotal concern – the ineffectiveness of opioids in managing acute back and neck pain. It is disconcerting to note that despite a global effort to curb opioid use, a substantial portion of individuals with such pain complaints in Australia are still being prescribed opioids. The study’s conclusion that opioids should not be recommended for this type of pain emphasizes the need for a paradigm shift in pain management. Instead, focusing on non-opioid treatments, including physical and psychological therapies, and simple analgesics like NSAIDs, is a logical and safer approach. Furthermore, the study’s reminder of the substantial risks associated with opioids, from addiction to unintentional deaths, underscores the urgent need for a more cautious approach to prescribing and dispensing these medications. Overall, this research serves as a wake-up call for healthcare providers and policymakers to prioritize patient safety and reevaluate their approach to pain management in the face of growing opioid-related challenges.

  2. Kevin Kostielney | October 30, 2023 at 5:49 am | Reply

    After 20 some years of being on opioid use for chronic pain i have not suffered from an overdose. My last back surgery has reached it’s end of longevety, multiple rods are coming apart with no positive outcome for the future, surgery is no longer an option as cost benifit outweigh the risk now that I’m in my mid 70’s
    Opioid use. Is my only option.Your thoughts please.

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