Opioids for Chronic Lower Back Pain
Scope of the guidance
This item is based on the Cochrane revew of opioids for chronic
low back pain (LBP). It reflects the best available evidence to
determine whether opioids are effective in relieving chronic
LBP.
Source:
Deshpande A, Furlan A, Mailis-Gagnon A, Atlas S, Turk, D.
Opioids for chronic low-back pain. Cochrane Database of
Systematic Reviews 2007, Issue 3
http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004959/pdf_fs.html
Key Points
1. Background
- LBP is a significant cause of morbidity and
social cost.
- Approximately 80% of the population in the UK
will have LBP at some point in their live.
- Risk factors for LBP are:
o
heavy physical work
o
lifting and handling of loads
o
awkward postures and movements (e.g. bending, twisting, static
postures)
o
whole body vibration (e.g. truck driving)
- In most cases LBP will ease over a number of
weeks but in up to one third of people, LBP will persist for over a
year.
- Most therapies for LBP are directed towards
symptom control and improving function:
o
physical methods: physiotherapy, transcutaneous electrical nerve
stimulation (TENS) machine, massage
therapy
o
invasive methods: epidural, facet joint block, trigger point
injection
o
surgery: suitable for very few people - high ‘failure’ rates
- Medication is important in the management of
LBP. There are three categories:
o
non-steroidal anti-inflammatory drugs (NSAIDs)
o
sedatives and muscle relaxants such as diazepam
o
analgesics including opioids
2. Opioid analgesics
- Opioids are classified as being either weak or
strong
- Weak opioids have a limit to their analgesic
effect which is mainly due to side-effects
- Use of opioids for controlling chronic
non-cancer pain is controversial, but there is a growing trend
towards prescribing opioids for chronic pain, particularly LBP
- Reasons for a GP not to prescribe an opioid
for LBP include fear of or actual addiction to the opioid,
sleepiness and other side effects.
- Common side effects of opioids include:
o
headaches
o
nausea
o
sleepiness
o
constipation
o
dry mouth
o
dizziness
3. Results of the Cochrane review
- Conclusions were limited as there were very
few good quality trials of opioids for LBP to review.
- Trials showed that tramadol (an atypical weak
opioid) was more effective than placebo for pain relief and for
improving function.
- The most common side effects of tramadol were
headaches and nausea.
- Opioids were no better at relieving pain than
naproxen (a non steroidal anti-inflammatory). There was no
difference between opioids and naproxen in terms of improvement in
patients’ function.
4. Conclusions
- The use of opioids for the long-term
management of LBP is questionable.
- More research needs to be done to
definitively establish whether opioids are useful in LBP or whether
patients should be prescribed only NSAIDs.
- More research is needed to see whether
different groups of patients (e.g. those where spinal surgery has
failed or those with LBP with radicular symptoms) respond in
different ways to opioids.
EGP 1. May 2008