What is the role of opioids in the treatment of chronic low back pain (cLBP)?

Updated: Aug 22, 2018
  • Author: Jasvinder Chawla, MD, MBA; Chief Editor: Stephen A Berman, MD, PhD, MBA  more...
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Answer

Answer

The authors of a 2008 summary and analysis of the best available evidence concluded that all the high-quality studies involving opioid analgesics demonstrated improvements in pain compared with a placebo that were clinically and statistically significant enough to support the their use as a treatment adjunct for patients with cLBP. [113] Although evidence-informed data show stronger support for short- than long-term use, there is still sufficient support for prolonged use as an adjunct treatment for chronic spinal pain.

Randomized controlled trials showed a relatively high dropout rate (20-40%) of patients due to adverse side effects. On average, a third were excellent responders, a third were fair responders, and the remainder tended to be nonresponders. Generally, the evidence for improvements in function is less impressive than reports of a reduction in pain. Opioids appear to be generally safe when used appropriately, and serious side effects are relatively infrequent. Despite contrary opinions among experts, an analysis of the literature also demonstrates that aberrant behaviors in a controlled medical environment, such as recreational abuse and drug divergence, have remained at acceptably low levels. [113]

In another evidence-based review, the author cites his findings with more skepticism regarding the long-term use of opioids for chronic back pain. [106, 57, 58] A review of 6 trials compared opioids with placebo or nonopioid analgesics and showed that opioids performed better than the controls in pain reduction; however, in a meta-analysis of the 4 studies that used the best methodology for analysis, this difference was not statistically significant. [114] The conclusions from this systematic review were consistent in demonstrating that opioids are useful for short-term pain relief, but that long-term efficacy or benefit with respect to cLBP is yet to be demonstrated. Furthermore, a review of studies investigating deviant medication-taking behaviors found a wider variation of aberrancy ranging from 5-24%. [114]


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