It may be time to rethink prescribing opioids for chronic pain.
Opioid pain relievers demonstrated no advantages over non-opioid medications for treating chronic back and arthritis pain over a one-year period, but they did lead to more side effects, concludes a study published today in the Journal of the American Medical Association (JAMA).
“We already knew opioids were more dangerous than other treatment options because they put people at risk for accidental death and addiction. This study shows that extra risk doesn’t come with any extra benefit,” Dr. Erin Krebs, lead study author and women’s health medical director at the Minneapolis VA Health Care System, told Healthline.
The study recruited 240 individuals with chronic pain. One group was given an opioid pain medication while the other was treated with either acetaminophen or a nonsteroidal anti-inflammatory drug.
Researchers looked at a handful of outcomes: pain-related functioning, the degree to which pain affects quality of life (things like daily activities, working, and sleeping); pain intensity, the actual severity of pain; and adverse side effects from medication.
“Previous randomized controlled trials have been short term (less than 16 weeks) and compared opioids with placebo. This study is important because it is a randomized controlled trial (the highest level of scientific study), was long-term (12 months), and compared opioids with a realistic alternative treatment (non-opioid medications),” said Krebs.
“Opioids were no better for pain interference with life activities. Further, non-opioid medications improved pain intensity more and had fewer bothersome side effects than opioids,” she said.
Pain by the numbers
Krebs and her team used the Brief Pain Inventory (BPI) scale. It’s a simple 1 to 10 rating system, with 1 being the least severe and 10 being the most.
With it, the researchers were able to compare pain intensity with people using opioid and non-opioid medications.
For pain-related functioning, both groups were almost exactly the same. The opioid group measured 3.3, while the non-opioid group was 3.4.
For pain intensity, the non-opioid group measured 3.5 compared with 4.0 for the opioid group.
In addition, members of the opioid group had more symptoms directly related to their medication.
These symptoms included problems with sleep, gastrointestinal issues, sexual dysfunction, muscle aches, sweating, and fatigue.
Misuse of opioids
Researchers also evaluated for potential misuse of opioids. “No deaths, ‘doctor-shopping’ [when a patient visits multiple doctors to get a prescription], diversion, or opioid use disorder diagnoses were detected,” they reported.
However, says Krebs, the sample size of their study isn’t indicative of those problems on a national scale.
“The best way to study the risk of these serious, less frequent harms is to look at what happens in the real world to tens of thousands of people treated with opioids. Other studies have done this, which is how we know that higher opioid doses and longer-term use of opioids increase the risk of dying or becoming addicted,” she said.
Rates of opioid misuse, addiction, and opioid-related deaths have skyrocketed in recent years in the United States. In 2016, the Centers for Disease Control and Prevention (CDC) reported there were 64,000 drug overdose deaths in the United States. The sharpest increase was among synthetic opioids such as fentanyl.
Healthcare experts and lawmakers have increasingly criticized the role of prescription opioids in creating the current epidemic.
Last month, Purdue Pharmaceuticals — the company behind OxyContin, a popular prescription opioid — announced they’d halt marketing of the drug to doctors. The company has since laid off 200 sales employees, roughly half of the company’s U.S. salesforce.
Not effective in the long run
As a pain therapy, new research, including Krebs’ work, suggests that opioids — while effective for short-term pain management — aren’t always ideal for chronic pain.
The CDC and other regulatory agencies are, in some cases, now trying to phase out long-term opioid prescriptions for chronic pain.
The CDC’s current guidelines have shifted in recent years away from precautions over “high-risk patients” to instead focus on the potential risk for opioid use disorder and other serious side effects in all individuals using opioids for chronic pain.
Their recommendations include using the lowest possible doses, starting treatment with immediate-release opioids instead of extended-release forms, and following up with patients regularly to discuss the risks and benefits of continued opioid use.
“Opioids continue to be invaluable for management of pain at the end of life and for short-term management of severe pain due to serious disease, trauma, or surgery. These are traditional uses of opioids that aren’t being questioned,” said Krebs.
“[They] have never been proven to be better than standard pain medications or nonmedication treatments for most common pain problems, including chronic back pain and arthritis pain... If opioids are prescribed, we should recognize that they have serious risks for anyone who takes them — not just those who misuse them — and be much more careful in our prescribing and follow-up,” she said.