Back and neck pain relief – Opioids similar to placebo

Researchers recruited 347 participants, with an average age 44,7 years. The participants were all women and had suffered from lower back pain or neck pain for 12 weeks or less.

The participants were randomly split into two groups in which they received guideline-recommended care and opioid oxycodone-naloxone or guideline-recommended care, and an identical placebo for up to 6 weeks.

Guideline-recommended care included reassurance and advice to stay active. Participants could seek additional care after 6 weeks if needed.

Researchers also assessed the intensity of pain in patients before and after treatment using the Brief Pain Inventory’s Pain Severity Subscale. This scale measures pain on a 0-10.

After 6 weeks, there was no significant difference between the opioid and placebo groups in terms of pain scores. The results were unchanged after adjusting for both the location of the pain and the number days since the pain began.

Researchers noted that the pain scores of the placebo and opioid groups did not differ much at all after 12 weeks, but that by 52 weeks, the placebo group had slightly reduced pain scores.

The average pain scores for the opioids group and placebo group at week six were 2,78 and 2,25 respectively. The pain score for the placebo group at 52 weeks was 1.81, while the opioid group’s was 2.37.

The researchers also found that there was no difference in the physical component of the quality of life between the two groups. The placebo group did experience a small but significant improvement in mental well-being at 6 and 12-weeks.

The opioid group was more susceptible to developing opioid abuse, even though there was no difference between the proportions of participants reporting adverse effects.

On the Current Opioid Misuse Measure Scale, after 52 weeks, 20% in the opioid group and 10% in the placebo group were classified as being “at risk”.

MNTasked for Dr. Wang Lushun, senior consultant orthopaedic surgeon at Arete Ortho, Singapore, who was not involved in the research, to explain why opioids might be ineffective in treating lower back and neck problems.

“Opioids, which are commonly used to relieve pain, may not be as effective in treating lower back and neck problems. Recent studies have shown this.” This is because opioids are primarily used to treat the perception of pain, and not the cause of the pain,” explained Dr. Wang.

By binding to opioid receptors, the drugs block the sensation of pain. “However, inflammation or physical injury — the common causes for these pains — is not actually alleviated,” explained he.

Over time, the body may also develop a tolerance to opioids. This can lead to the need for higher dosages to achieve the desired level of pain relief. This could lead side effects and possible dependency — one side effect is a phenomena known as opioid-induced Hyperalgesia which can result in even worse pain.

– Dr. Wang Lushun

Dr. Joel Frank, licensed psychologist at Duality Psychological Services, California, who was not involved in the research, responded to MNT when asked about the limitations of the study: “Firstly the treatment protocol was medication focused, but 42% were non-compliant. Second, their guideline care’ included recommendations for physical activity, but they claimed that the care was not monitored.

Dr Frank said, “Thirdly their primary measure of pain severity was the BPI. This is a self report measure.” Self-report measures by their very nature are subjective. It is important to include measures that evaluate pain categorization when using self-report pain measures. This will give a more complete picture of the subjective pain level.

MNT spoke with Dr. Vernon Williams who is a sports neurologist, pain management specialist and founding director of Cedars-Sinai Kerlan-Jobe Institute’s Center for Sports Neurology and Pain Medicine. He was not involved in the research.

Dr. Williams pointed out that the results were limited, as they did not compare opioid use with no treatment but rather compared it with a placebo which can induce a physical reaction.

“There are physiological effects related to your response to the expectation that the active treatment will be effective and your body’s reaction to the potential benefit – or expectation – of the placebo. The study did not show that the opioid was ineffective, but rather that it did not perform better than the placebo. He noted that it’s a subtle but significant difference.

MNT asked Dr. Gustavo De Carvalho Machado of the University of Sydney in Australia, who was not involved in the research, about the limitations of the study. He warned that:

The findings are not directly applicable in pre-hospital settings, such as those who require an ambulance or emergency departments. The results of this trial were not directly applicable to pre-hospital settings, where patients require an ambulance.

MNT and spoke with De Mesa regarding alternative treatments for lower back and neck discomfort.

“More effective alternative treatments for lower back and cervical pain address the underlying cause of pain. A physician can help determine the exact muscles and/or accompanying structures, such as tendons or ligaments, that are involved. He noted that physical therapy, ergonomic improvements and exercise could be prescribed.

“Spinal pain is often multifactorial, so a holistic approach to treatment can help an individual achieve long-term healing. Nutrition, acupuncture and cognitive behavioral programs, as well as physical conditioning, are also beneficial. As needed, anti-inflammatory over-the-counter medications can be used. The best treatment plan depends on the individual and their circumstances.

De Mesa said that spine surgeons, pain specialists and board-certified physiatrists could be recommended to treat chronic spinal pain.

“Chronic Pain may be caused either by arthritis in the spinal joints or by inflammation of the vertebral ends.” He explained that injections may be recommended to treat the source of the pain and pinpoint the pain generator.

“Radiofrequency ablation (destruction) of the spinal medial branches nerves and Basivertebral Nerve Ablation are two example of interventional procedures that may reduce pain and improve your quality of life. He noted that surgical options are only performed if medically necessary. They are usually reserved as a final resort.