Long-term opioid therapy for chronic low back pain

Study key points

In a 12-month trial involving 402 matched participants with low back pain (LBP), participants who took opioids continuously did not fare better than those who did not with regard to pain intensity, disability, pain impact, or the likelihood of minimally important changes in any outcome.

Relevance

Long-term opioid therapy (LTOT) continues to be a common scenario in the management of chronic LBP in spite of current guidelines. Previous trials we have covered have demonstrated a lack of benefit of opioid vs non-opioid therapy¹ as well as association with potential harm. Unfortunately, these trials were for a shorter term or data were not collected from a generalized population. This study attempted to evaluate this question with a longer (12-month) evaluation period, using data from a national registry.

Details

Trial design: Retrospective cohort study

Setting: Participants selected from the Pain Registry for Epidemiological, Clinical, and Interventional Studies and Innovation (PRECISION)

Participants: 402 adults (73.9% female; 55.4 years [SD, 11.9 years]) with chronic LBP identified through a national registry from April 2016 through August 2022. Participants reporting LTOT (>90 days) were matched to opioid nonusers with propensity scores. The mean daily morphine milligram equivalent dosage at baseline was 36.7 (95% CI, 32.8–40.7).

Outcomes

Primary outcomes:

• LBP intensity
• Back-related disability
• Pain impact measured with a numerical rating scale (the Roland-Morris Disability Questionnaire) and the Patient-Reported Outcomes Measurement Information System (PROMIS)

Secondary outcomes involved minimally important changes in primary outcomes.

Findings

There were no differences between LTOT and control groups in:

• Mean pain intensity (6.06; 95% CI, 5.80–6.32 vs 5.92; 95% CI, 5.68–6.17)
• Back-related disability (15.32; 95% CI, 14.55–16.09 vs 14.81; 95% CI, 13.99–15.62)
• Pain impact (32.51; 95% CI, 31.33–33.70 vs 31.22; 95% CI, 30.00–32.43)
• Greater likelihood of minimally important changes in any outcome

Author’s conclusions

Using LTOT for up to 12 months is no more effective in improving chronic LBP outcomes than treatment without opioids. Clinicians should consider tapering opioid dosage among LTOT users in accordance with clinical practice guidelines.

Clinical bottom line

These findings reiterate, with longer-term data, what previous studies and clinical guidelines have emphasized. The use of LTOT does not provide advantages over non-opioid treatment in the setting of chronic LBP. In addition, realizing the potential harms of initiation or ongoing therapy in this setting, the authors have recommended appropriate discussion and potential tapering based on current standards.

Reference

1. Bonakdar R. Opioids Not Superior to Nonopioid Medications for Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain [abstract of Krebs EE, Gravely A, Nugent S, et al. Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain; The SPACE Randomized Clinical Trial. JAMA. 2018;319(9);872-882]. PracticeUpdate Primary Care. Accessed March 26, 2024. https://www.practiceupdate.com/content/opioids-not-superior-to-nonopioid-medications-for-pain-related-function-in-patients-with-chronic-back-pain-or-hip-or-knee-osteoarthritis-pain/65085

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