Efficacy, Tolerability, and Dose-Dependent Effects of Opioid Analgesics for Low Back Pain: A Systematic Review and Meta-analysis
Three articles on PainSci cite Shaheed 2016: 1. The Complete Guide to Low Back Pain 2. The Complete Guide to Neck Pain & Cricks 3. Opioids for Chronic Aches & Pains
PainSci commentary on Shaheed 2016: ?This page is one of thousands in the PainScience.com bibliography. It is not a general article: it is focused on a single scientific paper, and it may provide only just enough context for the summary to make sense. Links to other papers and more general information are provided wherever possible.
A review of 13 placebo-controlled trials of short-term opioids for chronic back pain found that fully half of study subjects withdrew because of side effects or lack of efficacy, and for those who stayed the benefits were short-term and minor, leading to the sad conclusion that opioids are “not likely to be clinically important within guideline recommended doses.” (As of 2015, there wasn’t enough evidence for any conclusions about long-term benefits, or for acute back pain — which is kind of incredible.)
~ Paul Ingraham
original abstract †Abstracts here may not perfectly match originals, for a variety of technical and practical reasons. Some abstacts are truncated for my purposes here, if they are particularly long-winded and unhelpful. I occasionally add clarifying notes. And I make some minor corrections.
IMPORTANCE: Opioid analgesics are commonly used for low back pain, however, to our knowledge there has been no systematic evaluation of the effect of opioid dose and use of enrichment study design on estimates of treatment effect.
OBJECTIVE: To evaluate efficacy and tolerability of opioids in the management of back pain; and investigate the effect of opioid dose and use of an enrichment study design on treatment effect.
DATA SOURCES: Medline, EMBASE, CENTRAL, CINAHL, and PsycINFO (inception to September 2015) with citation tracking from eligible randomized clinical trials (RCTs).
STUDY SELECTION: Placebo-controlled RCTs in any language.
DATA EXTRACTION AND SYNTHESIS: Two authors independently extracted data and assessed risk of bias. Data were pooled using a random effects model with strength of evidence assessed using the grading of recommendations assessment, development, and evaluation (GRADE).
MAIN OUTCOMES AND MEASURES: The primary outcome measure was pain. Pain and disability outcomes were converted to a common 0 to 100 scale, with effects greater than 20 points considered clinically important.
RESULTS: Of 20 included RCTs of opioid analgesics (with a total of 7925 participants), 13 trials (3419 participants) evaluated short-term effects on chronic low back pain, and no placebo-controlled trials enrolled patients with acute low back pain. In half of these 13 trials, at least 50% of participants withdrew owing to adverse events or lack of efficacy. There was moderate-quality evidence that opioid analgesics reduce pain in the short term; mean difference (MD), -10.1 (95% CI, -12.8 to -7.4). Meta-regression revealed a 12.0 point greater pain relief for every 1 log unit increase in morphine equivalent dose (P = .046). Clinically important pain relief was not observed within the dose range evaluated (40.0-240.0-mg morphine equivalents per day). There was no significant effect of enrichment study design.
CONCLUSIONS AND RELEVANCE: For people with chronic low back pain who tolerate the medicine, opioid analgesics provide modest short-term pain relief but the effect is not likely to be clinically important within guideline recommended doses. Evidence on long-term efficacy is lacking. The efficacy of opioid analgesics in acute low back pain is unknown.
- “Strong opioids for noncancer pain due to musculoskeletal diseases: Not more effective than acetaminophen or NSAIDs,” Berthelot et al, Joint Bone Spine, 2015.
- “Who Benefits from Chronic Opioid Therapy? Rethinking the Question of Opioid Misuse Risk,” Huber et al, Healthcare (Basel), 2016.
- “Five Studies: Understanding America’s Opioid Crisis,” Livia Gershon, PSMag.com.
- “Effect of a Single Dose of Oral Opioid and Nonopioid Analgesics on Acute Extremity Pain in the Emergency Department: A Randomized Clinical Trial,” Chang et al, Journal of the American Medical Association, 2017.
- “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,” Krebs et al, Journal of the American Medical Association, 2018.
This page is part of the PainScience BIBLIOGRAPHY, which contains plain language summaries of thousands of scientific papers & others sources. It’s like a highly specialized blog. A few highlights:
- Inciting events associated with lumbar disc herniation. Suri 2010 Spine J.
- Prediction of an extruded fragment in lumbar disc patients from clinical presentations. Pople 1994 Spine (Phila Pa 1976).
- Characteristics of patients with low back and leg pain seeking treatment in primary care: baseline results from the ATLAS cohort study. Konstantinou 2015 BMC Musculoskelet Disord.
- Effectiveness and cost-effectiveness of universal school-based mindfulness training compared with normal school provision in reducing risk of mental health problems and promoting well-being in adolescence: the MYRIAD cluster randomised controlled trial. Kuyken 2022 Evid Based Ment Health.
- Is there a relationship between throbbing pain and arterial pulsations? Mirza 2012 J Neurosci.