It is time for someone to say this out loud. “We should not use opioids for back pain.”
Back pain is a common and sometimes disabling condition that affects more than 80% of people sometime in their lifetime. Over 20% of people have back pain at any given time and about 11% of the population are disabled by it.(1) That is a lot of back pain.
There are many treatments for back pain. These include NSAIDs (ibuprofen, etc.), acetaminophen (Tylenol®), physical therapy, chiropractic or osteopathic manipulation, exercise, acupuncture, counseling, stretching, yoga, and TENS (transcutaneous electrical nerve stimulation) units. A systematic review in 2010 looked at all treatments for nonspecific low back pain and found all to have similar effectiveness and none were much better than placebo.(2) Behavioral therapy may be one of the most underutilized and most effective treatments for chronic pain.(3)
There is, however, one treatment that science shows is worse than the others: opioids. Opioids are no better at treating pain than other modalities and in all types of back pain they result in worse outcomes.
When used for acute episodes of back pain they result in higher medical costs, increased risk of surgery and delayed recovery.(4) They also double the risk of future disability.(5)
When used for acute exacerbations of chronic low back pain they dramatically increase the risk of future abuse and addiction.(6)
When used prior to back surgery, they result in worse outcomes from surgery.(7)
When used for chronic low back pain the effect on pain is felt to be clinically insignificant(8) and they result in worse outcomes and worse quality of life.(9) In fact, the American Academy of Neurology recommends against using opioids for chronic back pain.(10)
In summary, there is no study that shows that opioids are effective for any type of back pain in any situation and their use will almost always result in worse outcomes. Back pain is the most common diagnosis in which opioids are used. Simply by stopping opioid use for back pain, we can greatly decrease the number of opioids prescribed, reduce abuse and addiction, reduce overdose deaths, and improve pain and quality of life for those with back pain.
Opioids should not be used for back pain. Period.
1. Balague F, Mannion AF, Pellise F, Cedraschi C. Non-specific low back pain. Lancet. 2012;379(9814):482-491. doi:10.1016/S0140-6736(11)60610-7.
2. Artus M, van der Windt DA, Jordan KP, Hay EM. Low back pain symptoms show a similar pattern of improvement following a wide range of primary care treatments: A systematic review of randomized clinical trials. Rheumatology. 2010;49(12):2346-2356. doi:10.1093/rheumatology/keq245.
3. Cherkin DC, Sherman KJ, Balderson BH, et al. Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain. JAMA. 2016;315(12):1240. doi:10.1001/jama.2016.2323.
4. Webster BS, Verma SK, Gatchel RJ. Relationship between early opioid prescribing for acute occupational low back pain and disability duration, medical costs, subsequent surgery and late opioid use. Spine (Phila Pa 1976). 2007;32(19):2127-2132. doi:10.1097/BRS.0b013e318145a731.
5. Franklin GM, Stover BD, Turner J a, Fulton-Kehoe D, Wickizer TM. Early opioid prescription and subsequent disability among workers with back injuries: the Disability Risk Identification Study Cohort. Spine (Phila Pa 1976). 2008;33(2):199-204. doi:10.1097/BRS.0b013e318160455c.
6. Edlund MJ, Martin BC, Russo JE, Devries A, Braden JB, Sullivan MD. The Role of Opioid Prescription in Incident Opioid Abuse and Dependence Among Individuals With Chronic Noncancer Pain. Clin J Pain. 2014;30(7):557-564.
7. Lee D, Armaghani S, Archer KR, et al. Preoperative Opioid Use as a Predictor of Adverse Postoperative Self-Reported Outcomes in Patients Undergoing Spine Surgery. J Bone Jt Surg. 2014;96(11):e89-e89. doi:10.2106/JBJS.M.00865.
8. Shaheed CA, Maher CG, Williams KA, Day R, Mclachlan AJ. Efficacy, Tolerability, and Dose-Dependent Effects of Opioid Analgesics for Low Back Pain A Systematic Review and Meta-analysis. JAMA Intern Med. 2016;176(7):958-968. doi:10.1001/jamainternmed.2016.1251.
9. Eriksen J, Sjøgren P, Bruera E, Ekholm O, Rasmussen NK. Critical issues on opioids in chronic non-cancer pain: an epidemiological study. Pain. 2006;125(1-2):172-179. doi:10.1016/j.pain.2006.06.009.
10. Franklin GM. Opioids for chronic noncancer pain: a position paper of the American Academy of Neurology. Neurology. 2014;83(14):1277-1284. doi:10.1212/WNL.0000000000000839.