Steering patients to relief from chronic low back pain: Opioids’ role

,

Medical Education Library

Steering patients to relief from chronic low back pain: Opioids’ role

March 2013 · Vol. 62, No. 03 Suppl: S8-S13

By

Roger Chou, MD

When and how to initiate opioids is challenging—to say the least—given their potential for abuse and worrisome adverse effects. Here’s how to integrate opioids into an overall approach to your patient’s chronic low back pain.

References

1. Koes BW, van Tulder MW, Thomas S. Diagnosis and treatment of low back pain. BMJ. 2006;332:1430-1434.

2. Bair MJ, Robinson RL, Katon W, et al. Depression and pain comorbidity. Arch Intern Med. 2003;163:2433-2445.

3. Martin BI, Deyo RA, Mirza SK, et al. Expenditures and health status among adults with back and neck problems. JAMA. 2008;299:656-664.

4. Cherkin DC, Wheeler KJ, Barlow W, et al. Medication use for low back pain in primary care. Spine. 1998;23:607-614.

5. Pengel LHM, Herbert RD, Maher CG, et al. Acute low back pain: systematic review of its prognosis. BMJ. 2003;327:323-327.

6. Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147:478-491.

7. Deyo RA, Smith DH, Johnson ES, et al. Opioids for back pain patients: primary care prescribing patterns and use of services. J Am Board Fam Med. 2011;24:717-727.

8. Von Korff M, Kolodny A, Deyo RA, Chou R. Long-term opioid therapy reconsidered. Ann Intern Med. 2011;155:325-328.

9. Deshpande A, Furlan A, Mailis-Gagnon A, et al. Opioids for chronic low-back pain. Cochrane Database of Systematic Reviews. 2007(3):CD004959.-

10. Martell BA, O’Connor PG, Kerns RD, et al. Systematic review: Opioid treatment for chronic back pain: prevalence, efficacy, and association with addiction. Ann Intern Med. 2007;146:116-127.

11. Hale ME, Ahdieh H, Ma T, Rauck R. Efficacy and safety of Opana ER (oxymorphone extended release) for relief of moderate to severe chronic low back pain in opioid-experienced patients: a 12-week, randomized, double-blind, placebo-controlled study. J Pain. 2007;8:175-184.

12. Katz N, Richard R, Harry A, et al. A 12-week, randomized, placebo-controlled trial assessing the safety and efficacy of oxymorphone extended release for opioid-naive patients with chronic low back pain. Curr Med Res Opin. 2007;23:117-128.

13. Franklin GM, Enass R, Turner JA, et al. Opioid use for chronic low back pain: a prospective, population-based study among injured workers in Washington state, 2002-2005. Clin J Pain. 2009;25:743-751.

14. Furlan AD, Sandoval JA, Mailis-Gagnon A, et al. Opioids for chronic noncancer pain: a meta-analysis of effectiveness and side effects. CMAJ. 2006;174:1589-1594.

15. Chou R, Huffman LH. Medications for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med. 2007;147:505-514.

16. Chou R, Huffman LH. Non-pharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med. 2007;147:492-504.

17. Hayden JA, van Tulder MW, Malmivaara AV, et al. Meta-analysis: exercise therapy for nonspecific low back pain. Ann Intern Med. 2005;142:765-775.

18. Hayden JA, van Tulder MW, Tomlinson G. Systematic review: strategies for using exercise therapy to improve outcomes in chronic low back pain. Ann Intern Med. 2005;142:776-785.

19. FDA clears Cymbalta to treat chronic musculoskeletal pain. Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm232708.htm. Accessed October 7, 2012.

20. Chou R, Loeser JD, Owens DK, et al. Interventional therapies, surgery and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine. 2009;34:1066-1077.

21. Waddell G. Biopsychosocial analysis of low back pain. Baillieres Clin Rheumatol. 1992;6:523-557.

22. Chou R, McCarberg B. Managing acute back pain patients to avoid the transition to chronic pain. Pain Management. 2011;1:69-79.

23. Turner JA, Aaron LA. Pain-related catastrophizing: what is it? Clin J Pain. 2001;17:65-71.

24. Vlaeyen JW, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain. 2000;85:317-332.

25. Chou R, Fanciullo G, Fine P, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10:113-130.

26. Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the Opioid Risk Tool. Pain Med. 2005;6:432-442.

27. Peppin JF, Passik SD, Couto JE, et al. Recommendations for urine drug monitoring as a component of opioid therapy in the treatment of chronic pain. Pain Med. 2012;13:886-896.

28. Bohnert AS, Valenstein M, Bair MJ, et al. Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA. 2011;305:1315-1321.

29. Dunn KM, Saunders KW, Rutter CM, et al. Opioid prescriptions for chronic pain and overdose: a cohort study. Ann Intern Med. 2010;152:85-92.

30. Gomes T, Mamdani MM, Dhalla IA, et al. Opioid dose and drug-related mortality in patients with nonmalignant pain. Arch Intern Med. 2011;171:686-691.

Table of Contents

How to avoid opioid misuse

Steering patients to relief from chronic low back pain: Opioids’ role

Disclosure

The author reported no potential conflict of interest relevant to this article.

Mr. S, age 57, recalls no specific event that triggered his lower back pain, which began 2 years ago and has been gradually worsening. His pain improves at times and varies in severity day to day. At this visit, he rates the pain as a 7 on a 10-point scale. The pain now interferes with his ability to walk more than 2 to 3 blocks, and when he golfs on weekends, he must now ride in the golf cart. Mr. S describes himself as fortunate, as his back pain has not interfered with his job as an engineer.

Mr. S has no associated leg pain or other neurologic symptoms. Radiography of the lumbosacral spine shows degenerative disc disease and facet joint arthritis. He has tried acetaminophen, then prescription-strength nonsteroidal anti-inflammatory drugs (NSAIDs) and supervised exercise therapy. He asks you about an opioid prescription.

Is it time to prescribe opioids?

Up to 70% of people experience a low back pain episode at least once in their lifetime, making low back pain among the most common conditions encountered in clinical practice.¹ Low back pain can impair function, ability to work, and quality of life, and it frequently is associated with depression or anxiety.^2,3

Physicians prescribe medications more than any other treatments for low back pain.⁴ The analgesic arsenal includes acetaminophen, NSAIDs, opioids, antidepressants, skeletal muscle relaxants, benzodiazepines, anticonvulsants, and others.

The good news for people with acute low back pain is that the natural history is quite favorable: most improve within the first 4 weeks.⁵ The key components of early treatment are self-care education, advice to stay active, and simple analgesics (acetaminophen and NSAIDs). Opioids may be appropriate for time-limited symptomatic relief for selected patients with severe pain,⁶ but no randomized trials have examined opioids for acute low back pain.

The treatment approach is less definitive for individuals such as Mr. S with chronic low back pain (generally defined as >12 weeks’ duration). Opioids are commonly prescribed and are the most potent analgesics,⁷ but they are associated with abuse potential and other adverse effects, such as constipation, nausea, and sedation. Furthermore, opioids’ clinical benefits for low back pain may be limited, particularly when prescribed for long-term use.⁸

Few studies inform opioid use in low back pain

Two systematic reviews published in 2007 found few placebo-controlled randomized trials of opioids for chronic low back pain, with some trials showing no analgesic benefit of opioids over placebo and no clear evidence of improved function.^9,10 Two subsequent trials showed moderate benefits of opioids for chronic low back pain—1.5 to 2 points on a 10-point pain scale—compared with placebo.^11,12

Observational studies from workers’ compensation settings suggest that opioid use by people with low back pain may worsen outcomes. A cohort study using a Washington State administrative database found poorer function associated with higher opioid doses over time.¹³ Although these investigators applied statistical adjustments for potential confounders, residual confounding probably remained because individuals who were more likely to have poor outcomes may also have been more likely to receive higher opioid doses.

A greater body of evidence exists on the use of opioids for other types of chronic pain, such as osteoarthritis or rheumatoid arthritis. A systematic review found approximately 20% to 30% greater pain relief for noncancer chronic pain from opioids compared with placebo during short-term treatment (average 5 weeks).¹⁴ These results may reasonably extrapolate to estimated benefits from opioids for chronic low back pain, which probably wouldn’t respond differently than other types of chronic pain.

Guidelines call for a multifaceted approach

Given the limited evidence and potential for adverse effects, guidelines from the American College of Physicians and American Pain Society (ACP/APS) recommend opioids as part of an overall approach to managing low back pain.⁶

First-line therapy. The ACP/APS guidelines recommend using acetaminophen and NSAIDs as first-line pharmacologic treatment for low back pain.⁶ Although less potent than opioids, these analgesics offer a more favorable balance of benefits to harms.¹⁵ Acetaminophen is associated with liver toxicity and NSAIDs with gastrointestinal bleeding and cardiovascular events, but we can mitigate these risks by avoiding use in people with contraindications and prescribing lower doses for the shortest duration necessary.

The guidelines also recommend an emphasis on self-care, in particular advising people to remain active.⁶ This message has been shown to be more effective than prescribed bed rest in helping individuals with low back pain return to normal function.¹⁶ For chronic low back pain, exercise therapy remains a key intervention with added health benefits. Effective programs focus on core strengthening, flexion/extension movements, directional preference, aerobic fitness, mind-body exercises (such as yoga and Pilates), and other techniques.¹⁷ Some evidence suggests that >20 hours of intervention time is more effective than less intensive exercise therapy.¹⁸