Are Opiates Futile in Low Back Pain?

There is no shortage of evidence regarding the harms of opiate use and misuse. With this in mind, prescriptions for opiates have been dropping in the United States, but were still dispensed at a rate of 43.4 prescriptions annually per 100 persons in 2020.1 The emergency department remains an important frontier for work in judicious prescribing, but opiate analgesia remains a valuable tool for the initial treatment of a variety of presentations.

Which brings us to acute back pain, a frustrating and challenging condition to manage for patients and physicians alike.

Recently, substantial media coverage summarized the OPAL trial published in The Lancet, concerning the use of opiates for acute “spinal” pain—inclusive of both back and neck pain.2 The lay media spin on the article fell onto side of universally negative against the use of opiates. While this reporting is superficially true, it tells only part of the story, and little regarding its relevance to emergency-department practice.

Patients included in this Australian trial were recruited in both the emergency department and in general practice, and were eligible if the current episode of pain began within the past 12 weeks. The authors define this as “acute” pain, and while we certainly see a share of patients in the emergency department suffering from months of pain, we consider these patients as a distinct presentation from those whose pain has rapidly escalated in the preceding 24 to 48 hours. In fact, the original trial protocol required patients to have had pain for at least two weeks prior to recruitment, further limiting generalizability to the scope of patients presenting to the emergency department.

After enrollment, patients were randomized either to a modified-release oxycodone-naloxone combination opiate, starting with an initial dose containing 5 mg of oxycodone, or placebo. Patients were prescribed a schedule of twice-daily analgesia, and were allowed to increase the dose from 5 mg to 10 mg if pain was not initially well-controlled. This may contrast from typical practice using immediate-release preparations to manage severe pain, or from use of oxycodone-acetaminophen or hydrocodone-acetaminophen combination products. The addition of naloxone to the tablets may also provide a confounder in terms of the analgesia provided.

The trial analgesia protocol also differs from typical prescribing in which acute pain is managed by starting from a maximal dose, determined by the clinically necessary analgesic effect, then rapidly decreased as pain improves. Rather, the research protocol describes a prolonged six-week program of follow-up and repeated prescribing. From an emergency department perspective, the scope of initial treatment is rarely, if ever, intended to involve a six-week period of treatment. The treatment response for any six-week program is of limited relevance to the acute treatment provided in the emergency department.