Every now and then a study comes along that makes you smile and think “Ah, I knew it!” This one landed quietly in JAMA Internal Medicine while we were all looking the other way. The New York Times did a tiny little blog piece on it, but for the most part, the world didn’t know the results of studies looking at nearly 8,000 participants that found opioids are often ineffective for back pain [1].
This is a little piece of evidence that points to something we have strongly suspected for quite a while: you can’t just mask back pain. You’ve got to address what’s causing it.
The study was a meta-analysis collating placebo-controlled, randomised control trials in any language. It aimed to fill an important void in the body of knowledge surrounding the common practice of using opioid analgesics for low back pain. There had been no systematic evaluation of the practice. Hence, the study’s authors set out to “evaluate the efficacy and tolerability to opioids in the management of back pain; and investigate the effect of opioid dose and use of an enrichment study design on treatment effect [1].”
For the sake of the study, pain and disability outcomes were converted to a 0-100 scale, with anything greater than 20 points considered as being of clinical importance. The researchers found 20 included randomised control trials of opioid analgeics, resulting in nearly 8000 participants.
The New York Times remarked that [2]:
“The studies tested various narcotics; most of the studies were funded by pharmaceutical companies. Seventeen of the studies compared the opioid with a placebo, and three compared two opioids with each other. None had a follow-up longer than 12 weeks.
The drugs relieved pain slightly, but the effects were not clinically significant, and the medicines did little to improve disability. There was some evidence that larger doses worked better, but most trials had high dropout rates, some up to 75 percent, because of adverse side effects or inefficacy.
Measured on a 100-point scale, the magnitude of relief did not reach the 20-point level the researchers defined as clinically effective, little different from Nsaids like aspirin.”
The big takeaway? Opioid analgesics just weren’t helping all that much. Tolerance of the medication could be an issue. Efficacy could be an issue. And the significant side-effects resulted in a high number of people choose to discontinue use. The magnitude of relief was not there. While the article didn’t recommend better solutions for low back pain, lead author Andrew McLachlan did remark that exercise regimes and staying active played a big part in recovery [2].
At the end of the study, the authors of the study were left stating that [1]:
“For people with chronic low back pain who tolerate the medicine, opioid analgesics provide modest short-term pain relief but the effect is not likely to be clinically important within guideline recommended doses. Evidence on long-term efficacy is lacking. The efficacy of opioid analgesics in acute low back pain is unknown [1].”
Low back pain contributes significantly to the burden of disease in Australia and indeed abroad. In Australia, it is estimated that lifetime prevalence of low back pain could be as high as 79.2%. One in ten people report experiencing significant activity limitation because of it [3]. The Medical Journal of Australia reported that “Back pain and intervertebral disc disorders were identified as by far the most significant work-related problems in the National Health Survey for the financial year 2004–05, and were reported as a long-term health condition more frequently than NHPA conditions [National Health Priority Areas] such as asthma, osteoarthritis and hypertension. In addition, the prevalence of back pain has increased over successive national surveys to a greater extent than some current NHPA conditions, and this may have major implications for Australian productivity [3].
This concern simply hasn’t dissipated over the years. It remains a problem for a huge percentage of the population. Another article published in the same issue of JAMA Internal Medicine called for more research into nonpharmacological interventions into low back pain, stating:
“Studies focused on nonpharmacologic interventions are particularly needed, given that many barriers exist regarding the use of pharmacologic treatments in this target population. Studies further document that older adults with chronic pain are receptive to nonpharmacologic therapies; many already use nondrug treatments and cite concerns about adverse drug effects and the use of too many medications as reasons [4].”
Various studies have demonstrated the high level of efficacy of chiropractic for low back pain. In reviewing our evidence based practice, it is important that we are aware of the efficacy of chiropractic care recommended, as well as alternatives that people may be considering, such as opioids. One such study states [5]:
“Our data synthesis suggests that recommendations can be made with some confidence regarding the use of SMT and/or MOB as a viable option for the treatment of both low back pain and NP.”
The initial research is there, and chiropractic care is recognised by many as a way to deal with chronic low back pain. What this study does is once again heap importance on advancing quality research in our profession so that we can continue to practice evidence-based care with higher levels of congruency, and so that we can confidently wave the chiropractic flag, and do so backed by more evidence.
References
[1] Shaheed, CA, Maher, CG, Williams, KA, Day, R, McLachlan A (2016), “Efficacy, Tolerability, and Dose-Dependant Effects of Opioid Analgesics for Low Back Pain: A Systematic Review and Meta-Analysis,” JAMA Intern Med. Published online May 23, 2016. doi:10.1001/jamainternmed.2016.1251
[2] Bakalar, N (2016), “Opioids Often Ineffective for Low Back Pain,” New York Times, retrieved 7 June 2016
[3] Carrington-Reid, M, Ong, A, Henderson, C, (2016), “Why We Need Nonpharacologic Approaches to Manage Chronic Low Back Pain In Older Adults,” JAMA Intern Med. 2016;176(3):338-339. doi:10.1001/jamainternmed.2015.8348. retrieved 7 June 2016
[4] Briggs, A and Buchbinder, R (2009), “Back pain: a National Health Priority Area in Australia?” Medical Journal of Australia, 2009; 190 (9): 499-502 , retrieved 7 June 2016
[5] Bronfort G, Haas M, Evans RL, Bouter LM. Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence synthesis. Spine J. 2004 May-Jun;4(3):335-56.
