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  • JAMA Study: Opioids No Better Than Nonopioids in Improving Pain-Related Function, Intensity for Chronic Back Pain, Hip/Knee OA

    In brief:

    • 240 patients with chronic back pain or hip or knee osteoarthritis pain were divided into 2 treatment groups: 1 group received opioids, 1 group received nonopioid medications
    • After 12 months, researchers found no differences between the groups' reported improvement in function, and a slightly better improvement rate in pain intensity for the nonopioid group
    • Among individuals who achieved improvements of 30% or more, numbers were nearly equal for the 2 groups in terms of function, and better for the nonopioid group in terms of pain intensity
    • Authors conclude that given the potential risks associated with opioids, results of the study do not support opioid prescription for chronic back pain or knee or hip osteoarthritis pain

    APTA's #ChoosePT opioid awareness campaign makes the case that opioids simply "mask" pain—but a new study in JAMA has concluded that the drugs probably don't even do that much, at least not any more effectively than nonopioid medications. The research, which focused on individuals with chronic back pain or hip or knee osteoarthritis (OA) pain, led authors to an unequivocal conclusion: there's no support for opioid therapy for moderate-to-severe cases of those types of pain.

    The published findings (abstract only available for free) are based on a study of 240 randomized patients in the Minneapolis, Minnesota, Veterans Affairs (VA) health care system who reported chronic back pain or knee or hip OA pain, defined as daily moderate-to-severe pain for 6 months or more with no relief provided by analgesic use. Participants were divided into 2 groups: 1 that received an opioid regimen, and a second group that received nonopioid drugs.

    To more closely resemble real-world treatment, researchers used a "treat-to-target" approach that stepped up the drugs as needed for participants to reach identified goals. The opioid regimen began with immediate-release morphine, hydrocodone/acetaminophen, and oxycodone, but the regimen could advance to sustained-action morphine and oxycodone, and on to transdermal fentanyl. The nonopioid approach began with acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDS), but it could move on to topical analgesics and finally to drugs requiring prior authorization (such as pregabalin and duloxetine), including tramadol. All participants also were permitted to pursue nondrug treatment during the study, but researchers did not evaluate data related to those treatments.

    Participants were monitored throughout the study and evaluated at 12 months using a range of tests, with the primary focus on how pain interfered with function, assessed through the Brief Pain Inventory (BPI); and pain intensity, measured using the BPI severity scale. Both measures are 10-point scales, with higher numbers indicating more pain-related interference or pain intensity. Other areas assessed as secondary outcomes included quality of life, depression, sleep disturbance, headache, anxiety, sexual function, and fatigue.

    At the 12-month mark, researchers found no significant differences in pain-related interference between the 2 groups (average BPI function scores of 3.4 in the opioid group and 3.3 in the nonopioid group), and a greater reduction of pain intensity among the nonopioid group (average of 3.5 in the nonopioid group vs 4.0 in the opioid group).

    When it came to the achievement of what authors called a "functional response"—a 30% or better improvement in a BPI score—the number of participants who achieved that level of improvement in function was roughly equal among groups, with 69 patients in the opioid group and 71 patients in the nonopioid group reaching the threshold. But the difference was notable in pain intensity scores, with 63 participants in the nonopioid group reporting improvement of 30% or more, compared with 48 participants in the opioid group reaching that level of improvement.

    The researchers also analyzed group differences by the type of pain treated:

    Back pain

    • Average score, interference with function: 2.9 in opioid group; 3.3 in nonopioid group
    • Average score, pain intensity: 3.7 in opioid group; 3.6 in nonopioid group

    Hip or knee OA

    • Average score, interference with function: 4.4 in opioid group; 3.4 in nonopioid group
    • Average score, pain intensity: 4.5 in opioid group; 3.4 in nonopioid group

    Similar to a study published recently, researchers also found that quality-of-life measures did not differ significantly between the 2 groups. The only area in which results from the opioid group bettered the nonopioid group in a notable way was in reduction of anxiety symptoms, although authors point out the only a small number—9% of all participants—reported moderate-to-severe anxiety at baseline.

    Authors acknowledged observational studies that associate long-term use of opioids with poor pain outcomes but say that those outcomes may not tell the whole story.

    "In this trial, pain-related function improved for most patients in each group," authors write. "Poor pain outcomes associated with long-term opioids in observational studies may be attributable to overprescribing and insufficient pain management resources rather than to direct negative effects of opioids."

    Still, they argue, given the "risk for serious harms without sufficient evidence for benefits," there seems to be no compelling reason to even begin a course of opioid-based treatment for certain conditions

    Among patients with chronic back pain or hip or knee osteoarthritis pain, treatment with opioids compared with nonopioid medications did not result in significantly better pain-related function over 12 months," authors write. "Overall, opioids did not demonstrate any advantage over nonopioid medications that could potentially outweigh their greater risk of harms."

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website

    APTA's award-winning #ChoosePT campaign is aimed at informing consumers that physical therapy is an effective alternative to drugs for the treatment of pain. Members can also learn more about the PT's role in pain management through offerings on PTNow, including a webpage with resources for pain management and an opioid awareness checklist.