Nonopioids for Chronic Pain Management

Highlight from the North American Spine Society 32nd Annual Meeting

Medication choices for the treatment of moderate to severe chronic pain (>12 weeks) include many of the same options used for acute pain, with a couple of additions, said William Sullivan, MD. Dr. Sullivan spoke during the symposium, The Opioid Predicament: Implications for Spine Physicians and Surgeons, presented at the North American Spine Society (NASS) 32nd Annual Meeting. He is Associate Professor of Physical Medicine and Rehabilitation at the University of Colorado School of Physical Medicine and Rehabilitation and Outpatient Medical Director of Rehabilitation Services at the University of Colorado Hospital, in Aurora, CO.

Overlapping treatments include acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), skeletal muscle relaxants, and opioids, explained Dr. Sullivan. In contrast to acute pain, oral steroids and benzodiazepines are questionable when used long-term for chronic pain. Additional agents used for chronic pain but not acute pain include antidepressants and anti-seizure medications, Dr. Sullivan told the audience.
medication in a pharmacist trayNonopioid medications include acetaminophen, NSAIDs and skeletal muscle relaxants. Photo“The basis of chronic pain can be nociceptive, neurogenic, or neuropathic; thus, there are a lot of different components to chronic pain that make it a completely different animal from acute pain or perioperative pain,” Dr. Sullivan told the audience.

Acetaminophen and NSAIDs

Limited data is available on use of acetaminophen for chronic back pain, Dr. Sullivan said, pointing to a recent systematic review showing “no or little efficacy with dubious clinical relevance” in patients with hip or knee osteoarthritis.1 In addition, in a 2017 review of pharmacotherapy for low back pain, Chou et al found no studies that adequately evaluated acetaminophen for chronic back pain or back pain conditions, Dr. Sullivan said.2

The Chou study found a small effect of NSAIDs on pain reduction in chronic low back pain, but little to no effect on the Roland–Morris Disability Questionnaire (RDQ).2

When choosing between acetaminophen or NSAIDs, it is important to individualize treatment based on side effects, Dr. Sullivan said. “If you are treating somebody with liver failure, there are potentially more side effects with acetaminophen, and if you’re treating somebody with gastrointestinal conditions, there may be more side effects with NSAIDs,” he noted.

In addition, the 2015 American Geriatrics Society (AGS) Beers Criteria recommended avoiding use of NSAIDs in the elderly unless other alternatives are not effective or the patient can take gastroprotective agents (eg, proton-pump inhibitors or misoprostol).3

Skeletal Muscle Relaxants

The review by Chou et al found insufficient evidence of efficacy of skeletal muscle relaxants on chronic low back pain based on three placebo-controlled trials with inconsistent results and methodological shortcomings that were published 25 to 40 years ago, Dr. Sullivan explained.2 He added the muscle relaxant carisoprodol has a significant active metabolite called meprobamate that is a “scheduled, highly addictive anxiolytic.” This agent should be avoided in elderly patients, according to the AGS Beers Criteria.3


The Chou et al review found that tricyclic antidepressants had no effect on pain in four randomized, controlled trials (RCTs) and no effect on function in two other RCTs.2 Serotonin specific reuptake inhibitors showed no effect on pain in 3 RCTs. In addition, duloxetine showed a small effect on pain in 3 RCTs with a small effect on function.

According to the AGS Beers Criteria, antidepressants are linked to anticholinergic adverse effects, sedation, and an increased risk of fractures.3 The AGS questioned the effectiveness of antidepressants at dosages that are tolerated by older adults, and recommended avoiding use of tricyclic antidepressants as well as all skeletal muscle relaxants in the elderly.

Anti-Seizure Medications

In the treatment of chronic back pain with a neuropathic component, pregabalin showed no effect on pain or Oswestry Disability Index (ODI) in a study by Baron et al, and no effect or worse RDQ in a study by Markman et al.4,5

Topiramate showed “questionable effectiveness” in the review by Chou et al, Dr. Sullivan said.2 Small to moderate effects of topiramate were found on some measures of pain in one fair quality and one low quality trial. No effect on leg pain or ODI was reported in one of the trials.


Opioids remain a treatment option for chronic low back pain, Dr. Sullivan said. A Cochrane Review showed short-term efficacy (moderate for pain and small for function) with use of opioids compared with placebo for chronic low back pain.6 The AGS recommends avoiding use of opioids in the elderly due to the fall risk, Dr. Sullivan noted.3

The 2016 Centers for Disease Control and Prevention (CDC) guideline for prescribing opioids for chronic pain examined the effectiveness of long-term opioid therapy versus placebo or nonopioid therapy on long-term outcomes (>1 year) and found no studies or “evidence” of efficacy, and few RCTs or systemic reviews on opioid use specific to spine conditions.7

“The CDC concluded that non-pharmacologic and nonopioid agents are preferred [for chronic pain],” Dr. Sullivan said. “And, while that is great, I don’t know if it makes sense to give a nonopioid medication if it really doesn’t have an effect, and what you’re using it for is different than what it actually does.”

Dr. Sullivan agreed with the CDC’s recommendation to establish goals of opioid treatment with patients and then periodically discussing what the risks and benefits are of continued opioid use.

“The CDC recommends use of immediate-release instead of extended-release or long-acting opioid agents, and a lot of that is based on studies [showing how these long-acting agents] lead to chronic use,” Dr. Sullivan noted. “Certainly, using the lowest effective dose as is recommended by the CDC fits into the multimodal idea of using the smallest dose that is effective to minimize any side effects.”

In addition, “it makes sense that chronic opioid abuse often starts with acute pain, and to review opioid use after 1 to 4 weeks,” as recommended by the CDC, Dr. Sullivan said.

The guideline also calls for “regularly evaluating for harms, looking at prescription drug monitoring program data, and performing urine drug screens at the start of treatment and annually thereafter,” Dr. Sullivan said. He added that such testing may need to be performed more regularly in some patient populations.

Dr. Sullivan agreed with the CDC guideline that “it makes sense to avoid concurrent benzodiazepines,” and said this is a “big hot-button issue” as he sees many patients in the Veterans Affairs system concurrently taking benzodiazepines and opioids. In addition, Dr. Sullivan said it is important to identify and have partners to refer patients to if they have either suspected or clearly diagnosed opioid use disorders.


Currently, there are limited well-studied options for adequate pain relief in chronic pain conditions, especially regarding alternatives to opioids, Dr. Sullivan concluded. “The geriatric population provides another wrinkle in our treatment of chronic pain and the different medications that we choose to use,” he said.

“Opioids certainly remain one option for chronic pain,” Dr. Sullivan said. “Steps can be taken when using opioids to ensure that a balance between the risks and benefits,” as was described in the final session at this meeting.

View the other presentations in this symposium:

Dr. Sullivan disclosed that he is on the Board of Directors of NASS (Secretary) and has received travel expenses from NASS.

Updated on: 05/21/19
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Nonopioid Medications and Acute Low Back Pain

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