Written by Thomas Davis
Opioids were no better than non-opioid medicines for chronic back, hip, or knee pain. However, undesirable medication-related symptoms occurred more commonly among those taking opioids.
Why does this matter?
It’s 3 A.M. and your patient with 8 months of back pain decides tonight is the night to come to the emergency department. When you ask to clarify why he checked in tonight, he looks at you surprised by your stupid question. “Doc,” he says with glaring eyes, “I’m in pain. I just can’t take it any more.” We know that opioids do not improve pain for acute low back pain. But what are the data behind opioid use for chronic back, hip, or knee pain? Finally, we have RCT data to guide our decisions.
How to treat chronic emergencies.
This was a pragmatic RCT that randomized 240 patients with chronic hip, back, or knee pain to opioid versus non-opioid medications. Patients already on long-term opioid therapy and those with substance use disorders were excluded. Patients were managed in primary care clinics within the Veterans Affairs system and were primarily men (87%). Pain was managed using an open-label, protocolized “treat-to-target” approach that escalated therapy intensity as needed during regular clinic visits. For example, opioid patients were initially prescribed immediate-release opioids before escalation to sustained-action and transdermal therapy. Non-opioid patients began with acetaminophen and NSAIDs before escalating to other therapies such as TCAs, gabapentinoids, capsaicin, and lidocaine. The primary outcome was pain-related function at 12 months using a Brief Pain Inventory scale (range 0-10, higher score = worse). Despite an open label bias that would presumably favor the opioid treatment group, there was no difference between treatment groups (opioid group 3.4, nonopioid group 3.3, p = 0.58). Pain intensity favored non-opioid therapy (p = 0.03) but was felt to be clinically insignificant (4.0 vs 3.5). There was a mild increase in medication-related symptoms among opioid patients (1.8 vs 0.9, p = 0.03).
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 Mar 6;319(9):872-882. doi: 10.1001/jama.2018.0899.
Peer reviewed by Clay Smith