This is a loaded topic. Opioid misuse is everywhere. It’s all over the news. The Trump administration has signed a bill to confront the epidemic plaguing us right now. It’s called the Support for Patients and Communities Act.
I believe it’s a step in the right direction especially since in the United States, the prescription of opioids for lower back pain and non-cancer musculoskeletal pain has skyrocketed with sales quadrupling from 1999 to 2010.
Use of potent opioids is higher in North America than in other developed countries: twice the rate seen in the United Kingdom; three times the rate in the Netherlands; and 26 times that in Japan. (Deyo, Von Korff, and Duhrkoop, 2015).
What’s shocking to note is a highly unfortunate history contributing to the huge uptick of opioid prescription – the New England Journal Medicine misrepresented their studies claiming in a one-paragraph letter that the use of morphine and other opioids were low-risk and that addiction was rare in long-term opioid use. Prescribers were uncritical about this claim and led to ‘quick-to-dish’ opioid treatments. In 2007, the manufacturer of Oxycontin and three major executives plead guilty to federal criminal charges that they misled regulators, doctors and patients about the potential addictive nature of the drug (Leung, MacDonald, Stanbrook, Dhalla, Juurlink, 2017).
Efficacy of Opioids for Lower Back Pain
Overall, opioid therapy for low back pain is based on low quality evidence in terms of efficacy, safety, and optimal prescribing.
Patients who received more than seven days worth of opioids were twice as likely to remain work disabled at one year. It may be that opioids create a hindrance to returning to work because it induces physical deactivation and apathetic mood (Deyo et al, 2015).
For chronic pain patients, no trials have lasted longer than four months so there is scant evidence to extrapolate from. The strength of the evidence out there suggests opioids are helpful for short-term pain but very inconclusive for long-term use and improving function.
Also, there appears to be a paradoxical effect with opioid use and treating pain effectively. It appears that opioids can increase tolerance, therefore dependence, and increase sensitivity to pain (Watkins, Hutchinson ,Rice, and Maier, 2009). In other words, prolonged use of opioids lowers your own natural painkilling abilities.
Long term use can lead to more complications down the line – falls, fractures, motor vehicle accidents, cognitive and mood effects, hypogonadism (i.e., endocrine issue where there is reduction or absence of hormone secretion of ovaries or testes), and sexual dysfunction. Not to mention sedation, dizziness, depression, decreased levels of testosterone, constipation, nausea, vomiting, itchiness, and dry mouth.
Dependent on the patient, the costs might outweigh the benefits. For some, they are unaware of the pitfalls of long-term use. This is when proper education and taking the time to discuss potential benefits and risks of opioid treatment can help promote informed decision making.
New Safety Guidelines
To reduce mortality and overdose risks, many argue alternative treatments should be covered more with easier access and made more affordable. Exercise therapy, cognitive behavioral therapy, and spinal manipulation, acupuncture, and massage are advocated because they are safer alternatives.
A guiding principle for lower back pain is self-care and maintaining physical activities as much as possible. A push to focus less on pain and more on participation of daily activities will improve function as well.
This is in line
And if you want more information for patients in long-term opioid use, here’s a great infographic promoting current best practice – https://www.bmj.com/content/350/bmj.g6380/infographic
We are at a point socially where opioid prescriptions and overdose deaths are epidemic. Many doctors and patients have underestimated the risk of opioid drugs and had overzealous expectations for its efficacy. It’s high time we lower doses, for shorter windows of time, less readily, and to fewer patients.
- Deyo, RA., Von Korff, M., Duhrkoop, D. (2015). Opioids for low back pain. BMJ, 350:g6380, doi: 10.1136/bmj.g6380
- Leung, PTM, MacDonald, EM., Stanbrook, MB., Dhalla, IA., Juurlink, DN. (2017). A 1980 Letter on the Risk of Opioid Addiction. N Engl J Med, 376:2194-2195, DOI: 10.1056/NEJMc1700150
- Watkins, LR., Hutchinson, MR., Rice, KC., Maier, SF. (2009).. The “Toll” of Opioid-Induced Glial Activation : Improving the Clinical Efficacy of Opioids by Targeting Glia. Trends Pharmacol Sci, 30(11): 581–591. doi:10.1016/j.tips.2009.08.002.
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