Low back pain is a common problem affecting more than 80% of us at some point in our lives. Recommended treatments include staying active and, if possible, avoiding strong pain medicines such as opioids.
Despite this, opioids (such as oxycodone) and opioid combination medicines (such as paracetamol plus codeine) are the most commonly prescribed drugs for low back pain in Australia. The most recent analysis showed that 45.6% of all pain medicines GPs recommended for low back and neck pain in 2013/2014 were opioids, up from 40.2% in 2005/2006.
Our research, published this week in the journal Medicine Today, shows opioids should only be considered in limited circumstances for low back pain and greater efforts are needed to help people come off opioids.
Benefits of opioids
A 2016 review of the research found commonly prescribed doses of opioids provided a small amount of pain relief for people with chronic low back pain in the short term. But higher doses did not meaningfully improve pain levels.
Opioid drugs work by interacting with opioid receptors in the body. This triggers a cascade of effects, including reducing the release of neurotransmitters (“chemical messengers”) that send pain information to the brain.
Ongoing benefits of opioid pain relievers are not known, as there are no clinical trials reporting long-term data. Observational studies show long-term opioid use has uncertain benefits for pain levels, while increasing harms.
The specific effects of opioids in patients with acute low back pain (pain lasting less than three months) are also not known, as there have been no clinical trials conducted in this population.
Harms of opioids
There are also risks of more serious harms, such as dependency which results in withdrawal symptoms when the medicine is stopped. These include anxiety, nausea, restlessness, sweating, vomiting or abdominal pain, and make it hard to stop taking opioids.
Other serious harms include opioid overdose and death. About 62 people die each day in the United States from prescription opioid overdoses. In Australia, there has been a rise in opioid-related deaths in recent years alongside an increase in opioid prescribing.
Short-term back pain
Acute low back pain is rarely the result of a serious condition and will generally resolve quickly with time. It’s important to maintain regular activity and avoid bed rest. You can also try a heat pack for pain relief and may not need other treatments.
If medicines are required for pain relief, consult a doctor or pharmacist about appropriate drug choices. This may involve short-term use of simple pain medicines such as paracetamol or a non-steroidal anti-inflammatory medicine such as ibuprofen.
Opioids should only be considered if the pain is severe, other treatments have not worked and the benefits outweigh the harms. Your doctor will assess whether you are a suitable candidate and guide you through the process.
If opioids are recommended, use them for the shortest time possible, at the lowest effective dose, in conjunction with other non-drug treatments, such as staying active. Opioid use should stop after the pre-agreed treatment period. You should inform your doctor of any unwanted effects while on the medicine.
Chronic back pain
Low back pain lasting longer than three months is more complex so it’s important not to rely solely on drug treatments to get better. Start with non-drug treatments such as exercise and physiotherapy.
Sometimes you may need the expertise of multiple health professionals, such as GPs, allied health professionals and medical specialists, as there may be many contributing factors to your pain. Some programs combine exercise with psychological approaches such as cognitive behavioural therapy, which is designed to change unhealthy habits of feeling, thinking or behaving.
If pain medicines are required, follow the same principles as for acute low back pain. If opioids are required, you should have a clear plan to wean and cease the opioid, especially if there’s no improvement in pain.
Coming off opioids
Consider coming off opioids if:
- there has not been any meaningful improvement in pain and function within a few days of starting the medicine, even with increased doses
- you have unwanted side effects
- you notice early warning signs for overdose risk such as confusion, slurred speech, or work/family problems related to opioid use.
If you have been taking an opioid for some time, it may not be a good idea to stop the medicines suddenly due to potential withdrawal effects. Your doctor can help you to come off the medicines gradually, as well as arrange referrals to other support services if needed.
Long-term care plans may involve opioid substitution programs such as the methadone program, which aim to stabilise the dependency. These programs are offered in some community pharmacies and hospitals. Your doctor will usually be able to coordinate a care pathway suitable for you.
The journey toward stopping these medicines is challenging, but not impossible. Be assured many people experience improved function, without worsening pain while coming off opioids.
Christine Lin receives funding from The National Health and Medical Research Council (NHMRC), Australia, for a Career Development Fellowship and a project grant investigating the effects of opioid medicines in people with acute spinal pain. She has previously received NHMRC funding for salary and other project grant support, as well as in-kind support from Pfizer Australia for a trial on pregabalin for sciatica. However she has retained full autonomy in the conception, design, conduct and reporting of her research.
Stephanie Mathieson receives fellowship support from a National Health and Medical Research Council (NHMRC) program grant (#AP1113532) which investigates using healthcare wisely, and reducing inappropriate use of tests and treatments.
Christina Abdel Shaheed does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.
Authors: Christine Lin, Principal Research Fellow and Associate Professor, University of Sydney