Written by Nickolas Srica
Spoon Feed
Patients who received opioids in the ED for low back pain were significantly more likely to return to the ED within 30 days for the same complaint when compared to those who received only NSAIDs, acetaminophen, or a combination of the two.
Why does this matter?
The data continue to pile up against the use of opioids for both acute and chronic low back pain, as well as other general musculoskeletal complaints, not only because they do not seem to improve pain levels compared to other non-opioid strategies, but also because the risk for harm and long-term use or misuse is high. This study gives us yet another reason to avoid the use of opioids for low back pain.
Treating back pain can be such a pain in the…backside
This was a retrospective multicenter observational study performed across 21 community and academic EDs within a single health system that included data from 836 adult patients who were ultimately discharged from the ED after a diagnosis of low back pain. Admitted patients with low back pain were excluded. 299 (36%) of the patients received opioids during their ED visit. Patients who received any opioid (32%, OR 1.78, 95% CI 1.21-2.64), IV opioids (33%, OR 1.83, 95% CI 1.18-2.86), or IM opioids (39%, OR 2.38, 95% CI 1.35-4.12) had significantly higher rates of return ED visits within 30 days than those who received NSAIDs (19%), acetaminophen (20%), or a combination of the two (8%). Those who received oral opioids, benzodiazepines, or antispasmodics had no statistically significant difference compared to the NSAID/acetaminophen groups. Though this study alone can’t answer for us why those who received opioids seemed more likely to return to the ED, the habit-forming nature and lack of benefit of opioids certainly may be playing a role, and we should all continue to try to avoid their use for low back pain.
Source
Relationship Between Pain Management Modality and Return Rates for Lower Back Pain in the Emergency Department. The Journal of Emergency Medicine. 2021 Feb 23. doi: 10.1016/j.jemermed.2021.01.022
I agree with the conclusion made by Srica in this review that "the habit-forming nature" may be playing a role, but what about the possibility that the opioid-treated patients return to the ED because the medications help them feel better? I know that isn’t a popular thing to say right now, but I think that it is a reasonable explanation to consider. I understand the critique from studies that show no difference in patient reported improvement in pain with opioids versus other medications, but I would consider that peoples’ behavior may be a better indicator of the benefit they derive from certain treatments as opposed to a pain scale. Maybe they return to the ED because they perceive that the treatment they received there was more beneficial.
This is a fair point.
Is it possible that the reason they received opioids was partly due to a severe level of pain due to a legitimate low back injury / arthritic stenosis, etc. This would explain them coming back to ER if their back condition was indeed more deteriorated than those that only received NSAIDS.