Opioids have really fallen out of favour as a chronic pain relief option.
Even for patients with severe chronic back pain, or severe pain from their osteoarthritis in their hip or knee, opioids will not offer any better relief in terms of pain-restricted function that non-opioid medication, a recent study published in JAMA has shown.
The US clinical trial involved 240 US adults with moderate to severe chronic back pain or hip or knee osteoarthritis pain despite analgesic. Researchers compared whether treatment with opioids such as morphine, oxycodone or hydrocodone/paracetamol improved pain-related function over a 12-month period over treatment with nonopioid such as paracetamol or an NSAID.
Surprisingly, the results showed no significant difference in terms of pain related function over the course of the study. In fact, the pain intensity was significantly better in the nonopioid group over the 12-month period, however the study authors said the clinical importance of this finding was unclear.
As was perhaps more expected, the group that took opioids had more side effects.
“Overall, opioids did not demonstrate any advantage over nonopioid medication that could potentially outweigh their greater risk of harms,” the researchers said.
When looking at all the results – even including secondary outcomes, the only area where opioids were found to be superior to nonopioids in this study of chronic pain patients was in the area of anxiety. The opioid group had fewer anxiety symptoms – so they had just as little function, and even more intense pain but they worried about it less.
The study authors said their findings added to the growing body of evidence that opioids offer little benefit over other medications and even placebo in the management of chronic pain conditions, especially when their side effect profile is taken into consideration.
“Results do not support initiation of opioid therapy for moderate to severe chronic back pain or hip or knee osteoarthritis pain”, they concluded.
Ref: JAMA 2018;319(9) 872-882. doi:10.1001/jama.2018.0899
There has been a lot of noise around opioid use lately. In particular, in the States where it’s been declared a public health emergency.
While concerted efforts are being made to ensure that patients who are experiencing chronic pain are not also in a position where they also have to deal with opioid addiction, in the cases of severe, acute pain most doctors would consider pain relief the priority and opioids the gold standard.
Well it seems that too may need a rethink.
According to a new randomised controlled trial just published in JAMA, an oral ibuprofen/paracetamol combination works just as well at reducing pain, such as that felt with a suspected fractured arm as a range of other oral opioid combinations including oxycodone and paracetamol.
The US researchers randomly selected over 400 patients who presented to emergency with moderate to severe arm or leg pain, severe enough to warrant investigation by imaging to receive an oral paracetamol/ibuprofen combination pain relief or one of three other opioid combination analgesics including oxycodone/paracetamol, hydrocodone/paracetamol or codeine/paracetamol.
Two hours after ingestion there were no statistically significant or clinically important difference in pain reduction between the four groups.
A limitation of the study was that it didn’t compare adverse effects, however the study authors said their findings support the use of the paracetamol/ibuprofen combination as an alternative to oral opioid analgesics, at least in cases of severe arm or leg pain.
Their findings also contradict the long-held idea that non-opioid pain killers are less effective than opioids, an idea that has been underpinned by the WHO pain ladder that has guided clinicians managing both cancer and non-cancer pain since 1986.
Even though most scripts for opioids are written out in the community, previous research has showed that long-term opiate use is higher among those patients who were initially treated in hospital.
“Typically, treatment regimens that provide adequate pain reduction in the ED setting are used for pain management at home,” an accompanying editorial stated.
“[This trial] provides important evidence that nonopioid analgesia can provide similar pain reduction as opioid analgesia for selected patients in the ED setting.”
What’s more, the effectiveness of this paracetamol and ibuprofen combination for moderate to severe pain may also translate to its more widespread use for acute pain in other clinical conditions traditionally treated with opioid medication, however this would need further investigation, the editorial author concluded.
Ref:
JAMA 2017; 318(17): 1661-1667. Doi:10.1001/jama.2017.16190
JAMA 2017; 318(17) 1655-1656
Clinical Articles
Monographs
