The results of a 12-month study show that opioids provided no benefit over non-opioid medications for improving pain-related function in people with chronic back pain or hip or knee osteoarthritis.
The study in JAMA involved 240 patients with moderate-to-severe pain, despite analgesic use, who were randomly assigned to receive treatment with an opioid or non-opioid prescribing strategy.
At 12 months, the researchers found no significant difference between the two groups in the primary outcome, pain-related function, as measured on the 10-point brief pain inventory interference scale (3.3 and 3.5, respectively). There was also no significant difference in health-related quality of life between the groups.
Pain intensity was significantly better in the non-opioid group compared with the opioid group over the course of 12 months; however, the researchers note this was unlikely to be clinically meaningful (4.0 vs 3.5, respectively, at 12 months).
Those assigned to opioid prescribing strategy also had significantly more adverse medication-related symptoms compared with those assigned to non-opioids.
The opioid group received immediate-release opioids beginning with morphine, hydrocodone/paracetamol and oxycodone. Doses could be increased or patients could be switched to morphine sustained action (SA) and oxycodone SA, followed by transdermal fentanyl.
The non-opioid medication group began with paracetamol and NSAIDs. Treatment could then be replaced or extended with adjuvant oral medications such as nortriptyline and gabapentin, and topical analgesics like lidocaine. The final step included treatments such as pregabalin, duloxetine and tramadol.
The researchers conclude that their results do not support the initiation of opioids for these indications.
“There is substantial evidence that opioids are effective for acute pain after surgery and trauma, and for pain at the end of life,” said Roger Knaggs, Royal Pharmaceutical Society spokesperson on pain management. However, he noted there is very limited evidence available to inform their use beyond 3 months, and even less beyond 12 months.
“Over the last few years there has been a large increase in opioid prescribing in many developed countries, including the UK,” he said.
“In 2016, the cost of prescribed opioids was almost £300m. There is ongoing research to investigate strategies to support patients in tapering their opioid dose; however, the results from this study suggest that alternative approaches may be more effective in the longer term.”