OPAL RCT – No More Opioids for Back Pain
August 11, 2023
Written by Vivian Lei
Spoon Feed
Opioid pain medications offer no benefit compared to placebo for patients with acute back or neck pain.
Stone-cold data on opioids: The OPAL trial
Acute neck and back pain are extremely common reasons for visits to emergency departments and primary care clinics. Prescribing an opioid medication for pain control is still widely practiced despite lack of evidence supporting its use.
The OPAL trial was a multicenter, triple-blinded RCT conducted in 157 primary care clinics and emergency departments in Sydney, Australia, enrolling patients with 12 weeks or less of at least moderate-severity low back pain and/or neck pain. The 347 participants were randomized to receive an opioid (extended-release combination of oxycodone and naloxone) or placebo for a maximum of 6 weeks. Both groups also received guideline-recommended care, including advice to stay active and use of NSAIDs. Pain scores at 6 weeks were not significantly different between the two groups: 2.78 in the opioid group versus 2.25 in the placebo group on a 10-point scale. Taking opioids also did not improve other clinical outcomes, such as physical functioning, quality of life, recovery time, work absenteeism, or healthcare utilization. At 52 weeks of follow-up, those in the opioid group had slightly worse pain scores as well as a greater risk of opioid misuse compared to placebo. Non-severe adverse events were similar between groups, although nausea, constipation, and dizziness were more common in the opioid group.
How will this change my practice?
This study supports my practice of avoiding opioid prescriptions for acute neck and back pain and provides strong evidence toward their lack of efficacy for pain and quality of life outcomes in addition to an increased risk of short and long-term harms.
Source
Opioid analgesia for acute low back pain and neck pain (the OPAL trial): a randomised placebo-controlled trial. Lancet. 2023 Jun 27:S0140-6736(23)00404-X. doi: 10.1016/S0140-6736(23)00404-X. Epub ahead of print.
While I firmly support avoidance of opioids for honestly just about everything I kind of question this trials end point of 6 weeks in terms of usefulness…to the best of my knowledge the vast majority of back pain is self limiting and would resolve by 6 weeks. I’d be more interested in the short term data: day 1, day 3, day 5…and a measurement of how quickly pt. is able to return to normal ADLs (with hopes that the short term data also supports no narcs).