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Opioids No More Effective Than Placebo for Acute Neck and Back Pain: Study

Opioids can cause harm with only a short course of treatment, according to the study's lead researcher.

Henry Jom, The Epoch Times, Oct 24, 2023

Australian researchers have advised acute neck and back pain sufferers to avoid using opioids after finding that these commonly prescribed drugs were no more effective than a placebo in managing acute pain.

According to a paper published in The Lancet, researchers from the University of Sydney led an opioid analgesics trial to investigate the safety and effectiveness of using a short course of opioids for the management of nonspecific low back or neck pain.

The "Opioid Analgesia for Acute Low Back Pain and Neck Pain" (OPAL) trial included 347 adult participants who reported having 12 weeks or less of low back pain, neck pain, or both, with at least moderate pain severity.

The participants were split into two groups:

The primary outcome measured was pain severity at six weeks using the 10-point Brief Pain Inventory scale, a widely used tool for assessing the severity of pain and its impact on functioning.

Additionally, both groups received the same care guidelines, such as reassurance of a positive prognosis, staying active, and avoiding bed rest. Participants were followed for 52 weeks.

According to the researchers, this was the first "blinded, placebo-controlled, multicenter trial" of an opioid that was used to assess the treatment effects of nonspecific low back pain.

Study Findings

Adverse reactions reported by the opioid and placebo groups included nausea, constipation, and dizziness at 35 percent and 31 percent, respectively.

Lead investigator Professor Christine Lin from the Sydney School of Public Health stated in a press release that the study showed no benefit for prescribing opioids in the management of acute back or neck pain.

“In fact, it could cause harm in the long-term even with only a short course of treatment,” she said.

“Opioids should not be recommended for acute back and neck pain full stop. Not even when other drug treatments are not able to be prescribed or have not been effective for a patient,” Ms. Lin said.

This finding calls for a change in the frequent use of opioids for these conditions, the researchers concluded.

The Increase in Opioid Prescriptions

“Since the 1990s, when the amount of opioids prescribed to patients began to grow, the number of overdoses and deaths from prescription opioids has also increased. Even as the amount of opioids prescribed and sold for pain has increased, the amount of pain that Americans report has not similarly changed,” according to the Centers for Disease Control and Prevention (CDC).

In 2021, CDC data shows that 45 people died each day from a prescription opioid overdose, totaling nearly 17,000 deaths.

While overprescribing by clinicians has been found to be a major contributor to prescription opioid overdose, Richard Lawhern, from the American Council of Science and Health argues that this is not the case but says it resulted from the growth of a small number of doctor- and pharmacist-operated “pill mills,” which served walk-in clients who faked their pain in order to purchase opioids for street resale.

Yet the International Association for the Study of Pain (IASP), a global organization that promotes pain research, treatment, and education, supports the use and availability of opioids at all ages for the relief of severe pain during short-lived painful events, and at the end of life.

The IASP states, “Although opioids can be highly addictive, opioid addiction rarely emerges when opioids are used for short-term treatment of pain, except among a few highly susceptible individuals."

The organization added that in some cases, there is no substitute for opioids for achieving satisfactory pain relief, but it does recommend caution when prescribing opioids for chronic pain.

Limiting Prescription Opioids

Dr. Akhil Chhatre, director of spine rehabilitation at Johns Hopkins Medicine, said he completely removed prescription opioids for subacute and chronic pain two years ago.

“The ideal medication to be prescribed depends on the condition or the source of the neck or back pain. For example, if there is an inflammatory source, we would offer steroids or nonsteroidal, anti-inflammatory drugs. If there is a spasm, then we would consider a muscle relaxant,” Dr. Chhatre told The Epoch Times by email.

Dr. Chhatre added that opioids are usually indicated for severe intractable pain, such as cancer-related pain, or immediate postoperative pain.

In Australia, there appears to be consensus about the OPAL study, with the Australian Commission on Safety and Quality in Health Care (ACSQHC) stating that opioid analgesics have a very limited role in treating acute lower back pain.

“If opioids are used to treat people with severe acute pain, their use should be limited to as short a duration as possible, such as a few days, and only if other options are not effective,” a spokesperson for the ACSQHC told The Epoch Times by email.

“It is vital that we review patients to check whether the opioid is having any effect on their pain and to support patients to stop using opioid analgesics as they recover and their pain reduces.”

Chemical Opioids Desensitize Natural Pain Mechanisms

It was previously believed that chemical opioids interacted with the body’s opioid receptors in the same way as naturally-made endogenous opioids, which are proteins produced in the body.

However, researchers have found that chemical opioids induce the activity of deeper cellular structures more rapidly compared to endogenous opioids, which may help explain their undesired side effects. Additionally, chemical or synthetic opioids “hijack” the endogenous opioid receptors that would otherwise be stimulated through the body’s natural pain relief system.

Studies have also shown that chemical opioids desensitize receptors associated with endogenous opioids' enkephalins, dynorphins, and endorphins, which are considered “powerful peptide analgesics.”

Enkephalins and dynorphins act in many different parts of the nervous system by reducing pain sensation, while endorphins stimulate feelings of euphoria.

Furthermore, research has shown that long-term opioid use significantly alters the endogenous opioid system, which plays an important role in drug sensitization and addiction.

An Integrative Approach to Pain Management

Current pain management approaches to acute back and neck pain point to a multidisciplinary approach that is not dependent on pharmacological approaches.

For those who sustain an acute flare-up of pain, Dr. Chhatre recommends avoiding the activity that caused the issue, modifying activities of daily living, and alerting your primary care doctor if the pain persists for more than two to three days.

Avoiding bed rest, staying active, and using simple analgesics such as anti-inflammatories, or a heat pack for acute back pain are recommended.

“Current evidence shows an active approach is more effective and less risky for patients,” the ACSQHC said.

“It is important to recognize that for many people with acute low back pain, the goal of pain medicines is to enable physical activity, not to eliminate pain.”

Moreover, acute back pain usually lasts from several hours to seven days in the majority of cases, Dr. Chhatre said.

At the same time, a small percentage of people (1 percent) who present to their doctor or allied health care professional have a serious cause for their back pain that needs prompt investigation and specific treatment, the ACSQHC said.

Studies have also shown that patients who first seek physical therapy or chiropractic care have better recovery outcomes and shorter episodes of acute care for lower back pain. Additionally, those who received such treatments in the initial stages had decreased dependency on opioid use.

Boosting Our Natural Endorphins

Endorphins are described as the body’s “natural painkillers” and are released by the hypothalamus and pituitary gland in response to pain or stress.

Endorphins, along with dopamine, serotonin, and oxytocin, are nicknamed the “feel-good hormones” due to the euphoric feelings they produce in response to activities that simulate feelings of happiness, such as exercise, meditation, listening to music, and laughter.

Although the feelings from endogenous opioids can be less obvious compared to those from chemical opioids, they are beneficial to health and do not come with the risks of addiction.

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