Opioids: No better than placebo for acute back and neck pain
Acute back and neck pain are common and very uncomfortable health problems. Worldwide, 577 million people are affected, seven percent of the world‘s population. “It’s not easy pain. Back pain can be bad enough that it makes life pretty miserable,” says Chris Maher of the University of Sydney. From work to leisure activities, everything is more difficult. Maher and colleagues investigated how well oxycodone-type opioid pain relievers provide relief. They published the result of the Australian study in the journal Lancet: Oxycodone is no better than a placebo for acute back and neck pain, so it is ineffective.
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Against back and neck pain: First, heat or simple painkillers
The trigger for the study was the statistic that up to two thirds of Australian patients with acute back and neck pain are given prescription opioids first – although according to medical guidelines this should only be done if neither heat nor a simple painkiller with an anti-inflammatory effect helped have. There are important reasons for the restriction: Oxycodone has a high potential for addiction, and according to Maher, the risk increases after just three days of use. In addition, up to a third of those treated cannot tolerate it because it causes side effects such as nausea, constipation, dizziness and confusion. Above all, the risk of an accidental fatal overdose is high.
“In Australia there are two to three deaths a day from prescription opioids,” says Maher. “Unfortunately, you hear little about it, because all of these people are mostly unknown.” It’s sad that only the famous cases of musicians like Prince and Tom Petty, or actors like Heath Ledger briefly highlight the problem. “This study is particularly important because we were able to show that this commonly used opioid is ineffective in this medical context,” Maher said.
Randomly assigned to the opioid group of the study
The researchers recruited 347 subjects with acute back or neck pain between 2016 and 2021. 174 subjects were randomly assigned to the opioid group and 173 to the control group. The study was thus randomized and triple-blinded: neither doctors nor subjects, and the independent statistician who used the randomization method knew which subjects were in which group.
To further ensure blinding, the real oxycodone tablets also contained naloxone to prevent constipation. “Not only would this side effect be uncomfortable for patients, it would also unblind them to their group,” says Maher.
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Before treatment, the average pain severity in the opioid group was 5.7 on a pain scale from one to ten (Brief Pain Inventory). For the placebo group, the mean score was 5.6. The test subjects were to take two tablets daily until they were largely pain-free (zero to one on the pain scale) for three days in a row – but for a maximum of six weeks. Both groups were also recommended to be as active as possible and not to rest in bed.
“Opioid Completely Ineffective”
After six weeks of treatment, pain scores had dropped to 2.78 in the opioid group and 2.25 in the control group. Statistically, there was no significant difference between the two groups. “It’s pretty clear that the opioid is completely ineffective for these patients,” says Maher.
A final check-up one year after the start of treatment revealed a higher quality of life and lower pain levels in the control group. A quarter of the subjects were not there until the end of the study. However, they were evenly distributed between the two groups, so the results were still correct, Maher’s colleague Christine Lin told New Scientist magazine.
Another important finding of the study was that one year after the start of treatment, every fifth subject in the final opioid group had a significantly increased risk of addiction. In the final control group, this only affected one in ten. When determining the risk, the subjects are not only asked whether they have taken the painkiller differently than prescribed (abuse), but also whether they have noticed cognitive impairment and mood swings.
Overall, it is time to question the use of opioid painkillers as a last resort for acute back and neck pain and to adjust medical guidelines accordingly, researchers from the University of Washington write in a commentary in the same issue of the Lancet.
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