By David Borenstein MD, Executive Editor, theSpineCommunity.com
Prescription opioid or narcotic use is associated with an increasing number of deaths with approximately 20,000 victims in 2014 according to the National Center for Health Statistics from the Centers for Disease Control and Prevention (CDC). These unfortunate deaths have brought into question the benefit of opioid analgesics in the setting of low back pain.
In a press release from the American Society of Anesthesiologists in Chicago, Dr. Asokumar Buvanendran reported on his survey of 2000 people with low back pain, with about 1000 of those people taking opioids. He found opioids were very successful, somewhat successful, moderately successful or unsuccessful in 13%, 44%, 31%, and 12%, respectively. Of those 1000 people, over 75% reported toxicities from the opioids including constipation (65%), sleepiness (37%), cognitive problems (32%) and addiction (29%).
This preliminary study is another in a group of studies that emphasize the limitation of opioid therapy in the treatment of chronic pain. Opioid therapy has a limited ability to remove the complex sensations associated with a painful process. For example, opioids do not diminish the heat and swelling associated with an inflammatory disorder like gout. The patient with acute gout may not experience pain with an opioid drug, but will remain with a hot, swollen digit that will return to being painful once the opioid is metabolized by the body. Nonsteroidal anti-inflammatory drugs, like naproxen, are much better at relieving the pain and inflammation.
In general, opioids should be used as an exception, as opposed to the rule. The goal of opioid use is to maintain function, but for total pain control. Other forms of non-drug therapy should be prescribed first. If opioids are needed, they should be used at the lowest effective dose for the shortest period of time. For those individuals who require long-term opioid therapy, they should be monitored in regard to a gradual escalation in dose. In most individuals, a gradual decrease in dose paradoxically results in greater efficacy of the opioid over time. The goal is to have a functional individual without the need for opioid medication.
American Society of Anesthesiologists. (2016.) Many back pain patients get limited relief from opioids and worry about taking them, survey shows. [Press release.] Can be retrieved from: https://www.asahq.org/about-asa/newsroom/news-releases/2016/10/back-pain-and-opioids
Ballantyne J. Avoiding opioid analgesics for treatment for chronic low back pain. JAMA 2016:315:2459-60. Can be retrieved from: http://jamanetwork.com/journals/jama/article-abstract/2528194