Nonopioid Medications and Acute Low Back Pain

Highlight from the North American Spine Society 32nd Annual Meeting

Alternatives to opioids, such as acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, and corticosteroids, have shown little evidence for efficacy in acute low back pain or pose a high risk for adverse events, explained Jerome Schofferman, MD, at a session titled, The Opioid Predicament: Implications for Spine Physicians and Surgeons, presented at the North American Spine Society (NASS) 32nd Annual Meeting.
Man holding his back in severe pain, with medication on a tableSome spine physicians believe opioids may play a role in treatment for select patients with acute low back pain that are at low risk for abuse.After reviewing the recent literature on pharmacotherapy for acute low back pain, Dr. Schofferman believes that opioids may play a role in treatment for select patients at low risk for abuse and with careful patient education on use.

“The goals of medication use for acute low back pain are to improve the patient’s pain and, perhaps more importantly, to maintain function and avoid adverse effects for the patient, public health, and even the physician prescriber,” explained Dr. Schofferman, who serves on the NASS Board of Directors as the Committee on Ethics and Professionalism Chair, and is Founder and Member of the Rehabilitation, Interventional, and Medical Spine (RIMS) Section of NASS.

Acetaminophen
Findings from a randomized controlled trial involving more than 1,500 patients as well as two recent systematic reviews by Chou et al and Qaseem et al suggest that acetaminophen is not effective or has insufficient evidence of efficacy in acute low back pain.1-3

Non-Steroidal Anti-Inflammatory Drugs
A 2017 systematic review of 35 randomized placebo-controlled trials found that while NSAIDs are statistically more effective than placebo in reducing pain and disability, the magnitude of the difference was not clinically relevant, Dr. Schofferman said.4 He suggested that NSAIDs are probably effective in some patients, but many patients do not respond to these agents.

The systematic review by Chou et al found mixed results, with slight to no benefit of NSAIDs with respect to pain reduction, and an increased frequency of adverse effects even with short-term use.3 The efficacy findings were confirmed in the review by Qaseem et al, which also indicated no evidence of difference in the degree of pain relief among various NSAIDs.

Use of NSAIDS should consider the 33% increased risk of major cardiovascular events, Dr. Schofferman said.5 In the past 2 years, the FDA strengthened its warning for NSAIDs to include an increased risk for heart attack or stroke even as early as the first weeks of NSAID use.6 In addition, dyspepsia can occur early after NSAID use, and gastrointestinal hemorrhage may occur later in the treatment course, Dr. Schofferman said.7

Thus, while NSAIDs might be better than placebo for acute low back pain, they pose a high risk for adverse events, Dr. Schofferman summarized. However, NSAIDs might be used short-term for mild to low-moderate acute low back pain in younger patients with no risk factors for cardiovascular disease, he said.

Skeletal Muscle Relaxants
While systematic reviews of skeletal muscle relaxants do show efficacy in the treatment of acute low back pain compared to placebo in almost every study, these agents are linked to a high frequency of adverse events, Dr. Schofferman said.2,3

“Although under-discussed in the press, these drugs produce dependence and are especially dangerous when combined with opioids,” Dr. Schofferman told the audience.8

Corticosteroids
Current evidence does not support use of corticosteroids for acute low back pain regardless of whether these agents are injected, given intravenously, or taken orally. “In my personal experience … there are some patients with flares of chronic low back pain who seem to respond dramatically and quickly to oral steroids,” Dr. Schofferman said.

Opioids
Opioids have not been studied specifically for acute low back pain, and evidence of effectiveness is based on extrapolation from the short-term benefits seen when treating chronic low back pain and other acute pain states, expert opinion, and clinical experience, Dr. Schofferman explained.9

Many of the risks linked to prescription opioid use are associated with long-term use, Dr. Schofferman said, adding that it is unclear how often short-term use of opioids for acute pain leads to long-term use.

A recent study by the Centers for Disease Control and Prevention (CDC) examined this question using data from nearly 1.3 million commercially insured opioid-naïve patients who were prescribed at least 1 day of opioid use for a variety of pain conditions.10 The probability of continued opioid use at 1 year was 6% and at 3 years was 2.9%.10

“Now some would say this number is terribly high, and others would say it seems pretty reasonable,” because it is unclear whether opioids were purposely used long-term in this data set, Dr. Schofferman said. Data regarding pain intensity or the etiology of the pain was either not available or was not considered in this analysis.

“If the prescription was greater than 8 days, there was a 13.5% chance that the patient would still be on opioids at one year, and if the initial use was greater than 31 days it was almost a 30% chance,” he added.10

The highest probability of opioid use at 1 year was found among patients initiated on long-acting opioids (27.3%) followed by tramadol (13.7%), hydrocodone short-acting (5.1%) and oxycodone short-acting (4.7%).10

A study by Jeffery et al found that opioid prescriptions initiated in emergency departments were associated with a lower probability of long-term use than those started in primary care offices, and were more likely to adhere to CDC guidelines, Dr. Schofferman noted.11 Probability of long-term opioid use also was linked to type of insurance, with people who received Medicare insurance because of disability being more likely to transition to long-term use compared with patients on Medicare because of age or patients with commercial insurance (13.4% vs 6.2% and 1.8%, respectively).11

“In my opinion, there is a role for opioids in moderate to severe acute low back pain in patients who do not have a history of substance abuse disorder,” Dr. Schofferman concluded. “It is important to use short-acting opioids only. The first prescription should be for a maximum of 7 days, should not be refilled without seeing the patient, and each refill should be considered very carefully.”

Dr. Schofferman stressed the importance of instructing patients about care of opioid pills at home, including keeping the medication in a safe place, proper discarding or returning of unused pills, and not loaning or selling pills. In addition, he said patients should begin early rehabilitation in conjunction with opioid use to help reduce pain, maintain function, and limit fear avoidance. Early rehabilitation is particularly important for patients who may be at risk for long-term opioid use, he advised.

View the other presentations in this symposium:

Disclosure
Dr. Schofferman serves on the NASS Board of Directors as the Committee on Ethics and Professionalism Chair, and is Founder and Member of the Rehabilitation, Interventional, and Medical Spine (RIMS) Section of NASS.

Updated on: 01/02/18
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