Opioid use among low back pain patients in primary care

Although opioids are commonly used in the management of low back pain (LBP), there is limited evidence of their efficacy. The IASP Pain Management Research Review (Issue 13, 2013) comments that there is ongoing debate about when, how much and how long opioids should be prescribed for non-cancer pain. It questions if functional outcomes obtained and whether quality of life is restored without undue adverse effects.


Although individual randomised controlled trials of opioid analgesics in LBP have demonstrated evidence of short-term pain relief and modest functional improvement, there is a lack of evidence for longer-term pain relief or clinically significant functional improvement.


A review by White et al (2011) concluded that “in terms of efficacy in LBP, opioids could not be recommended as a first-line treatment for LBP in view of their side effect profile, potential for tolerance with long-term use, and in the absence of any evidence of superior efficacy compared with NSAIDs.”


Ashworth et al (2013) explored the relationship between prescribed opioids and disability at baseline and 6 months follow-up, in a prospective study cohort of 715 primary care patients with back pain. Analysis did reveal a significant association between baseline opioid prescription and increased disability at 6 months, although the level of effect was small, with opioid recipients having only a 1.18-point higher mean Roland-Morris Disability Questionnaire score than those who were not prescribed opioids.


It is indicated that receipt of an opioid prescription did not improve functional outcome from LBP. The findings of Ashworth et al (2013) suggest that those who are prescribed opioids differ not only in terms of the nature and intensity of reported pain but also in terms of how they respond to that pain, as assessed by self-reported distress, self-efficacy, and coping strategies. Ashworth et al (2013) states itt is possible that these and other responses may influence not only disability associated with LBP, but also prescribing behavior of clinicians


As in previous studies exploring opioid validity in primary care, and the study by Ashworth et al (2013), opioids were prescribed for patients with higher levels of pain, disability, distress, fear avoidance and catastrophising, but at 6 months they did not have better outcomes than those who did not receive opioids. The IASP Pain Management Research Review (Issue 13, 2013) states that “although this study does not show that opioids should not be used in this group of patients, it does show that they also require management of their response to pain to improve their outcomes.”


It is important to note that the prescription of opioids for LBP may not improve patient function. Closer monitoring of the response to opioid analgesics in terms of both pain and function should be undertaken, and it may provide opportunity to cease opioid use where there is no evidence of benefit. Consideration of alternative therapeutic strategies with greater evidenced bassed support including non-pharmacological, active and psychologically based approaches should be advocated. Workplace Physiotherapy staff have all undertaken extensive training to monitor use of opioids and when necessary assist with medication reduction planning.



Ref: Pain Management Research Review (Issue 13, 2013).
Julie Ashworth, Daniel J. Green, Kate M. Dunn, and Kelvin P. Jordan (2013) Opioid use among low back pain patients in primary care: Is opioid prescription associated with disability at 6-month follow-up?
Pain. 2013 Jul; 154(7): 1038–1044. White A.P., Arnold P.M., Norvell D.C., Ecker E., Fehlings M.G.
Pharmacologic management of chronic low back pain: synthesis of the evidence. Spine (Phila Pa 1976) 2011;36:S131–S143.


The comments above are the implicit advice of Workplace Physiotherapy. The views expressed are based on current evidence-based research and accepted best practice approaches. Unless otherwise stated, these comments are not the view of WorkCover NSW or any other professional body. No reproduction or forwarding of this advice is permitted without the consent of the author.


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