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Opioids for chronic low‐back pain

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Abstract

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Background

The use of opioids in the long‐term management of chronic low‐back pain (LBP) appears to be increasing. Despite this trend, the benefits and risks of these medications remain unclear.

Objectives

To determine the efficacy of opioids in adults with chronic LBP.

Search methods

We electronically searched CENTRAL, CINAHL and PsycINFO to May 2006; MEDLINE and EMBASE to May 2007. We supplemented our search by reviewing references in relevant systematic reviews and identified trials.

Selection criteria

We included randomised or quasi‐randomised controlled trials assessing the use of opioids (as monotherapy or in combination with other therapies) for four weeks or longer, in adults with chronic LBP. Studies were included if they compared non‐injectable opioids to other treatments. Comparisons between opioids were excluded.

Data collection and analysis

Two authors independently assessed methodological quality and extracted data onto a pre‐designed form. Results were statistically pooled using RevMan 4.2. We reported on pain and function using standardized mean difference (SMD) with 95% confidence interval (95% CI) and on side effects using absolute risk difference (RD) with 95% CI.

Main results

We included four trials. Three compared tramadol to placebo. Pooled results revealed that tramadol was more effective than placebo for pain relief, SMD 0.71 (95% CI 0.39 to 1.02), and improving function, SMD 0.17 (95% CI 0.04 to 0.30). The two most common side effects of tramadol were headaches, RD 9% (95% CI 6% to 12%) and nausea, RD 3% (95% CI 0% to 6%). One trial comparing opioids to another analgesic (naproxen) found opioids were statistically significant for relieving pain but not improving function. When re‐calculated, the results were not statistically significant for either pain relief (SMD ‐0.58; 95% CI ‐1.42 to 0.26) or improving function (SMD ‐0.06; 95% CI ‐0.88 to 0.76) .

Authors' conclusions

Despite concerns surrounding the use of opioids for long‐term management of chronic LBP, there remain few high‐quality trials assessing their efficacy. The trials in this review, although achieving high internal validity scores, were characterized by a lack of generalizability, inadequate description of study populations, poor intention‐to treat analyses, and limited interpretation of functional improvement. Based on our results, the benefits of opioids in clinical practice for the long‐term management of chronic LBP remain questionable. Therefore, further high‐quality studies that more closely simulate clinical practice are needed to assess the usefulness, and potential risks, of opioids for individuals with chronic LBP.

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Plain language summary

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Opioids for the treatment of chronic low‐back pain

Low‐back pain is a major cause of pain, disability and cost to individuals, their families and society in general. Up to 85% of the general population will experience low‐back pain at some point in their lives. In most cases, the pain eases within four to six weeks and individuals are able to return to their normal activities. However, by some estimates, in up to 30% of the cases, the pain will persist for up to a year or longer.

Opioids are pain relievers that act on the central nervous system. If used over a long period of time, they may become habit‐forming. Opioids are used to relieve pain in a growing number of conditions, including the treatment of chronic low‐back pain (LBP).

We included three studies (908 participants) that compared opioids against a placebo (fake medication). On average, those receiving tramadol, an atypical weak opioid, reported more pain relief and less difficulty performing their daily activities in the short‐term than those who received a placebo. In a fourth study (36 participants), on average, those receiving an opioid, either morphine or a morphine‐derivative, reported little or no difference in terms of pain relief in the short‐term compared with those who received a non‐steroidal anti‐inflammatory medication (naproxen). In general, there was little or no difference between the two groups in their ability to perform daily activities.

There still remains little evidence in the medical literature to address the concerns of physicians and patients regarding the effect of opioids on pain intensity, improved function and risk of drug abuse. The trials that do exist suggest that a weak opioid reduces pain but has minimal effect on function. Side effects were more common with opioids but not life‐threatening. The results of these trials should be regarded with caution and may not be appropriate in all clinical settings. More high quality studies are needed to address the benefits and risks of long‐term opioid use in chronic LBP, their relative effectiveness compared with other treatments and to better understand which patients may be most suitable for this type of intervention.