Opioid analgesia for acute low back pain and neck pain (the OPAL trial): a randomised placebo-controlled trial

Opioid analgesics are commonly used for acute low back pain and neck pain, but supporting efficacy data are scarce. We aimed to investigate the efficacy and safety of a judicious short course of an opioid analgesic for acute low back pain and neck pain. OPAL was a triple-blinded, placebo-controlled...

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Published in:	The Lancet (British edition) Vol. 402; no. 10398; pp. 304 - 312
Main Authors:	Jones, Caitlin M P, Day, Richard O, Koes, Bart W, Latimer, Jane, Maher, Chris G, McLachlan, Andrew J, Billot, Laurent, Shan, Sana, Lin, Chung-Wei Christine, McLachlan, Hanan, Webb, Melissa, Hamilton, Melanie, Ahedi, Harbeer, Barber, Angie, Mak, Wendy, Mathieson, Stephanie, Petrova, Veronika, Bompoint, Severine, Murnion, Bridin, Buckley, Nicholas, Demirkol, Apo, Wrigley, Paul, Needs, Christopher, Brooks, Louise, Cantori, Samuel, Preisz, Paul, Aitken, James, Allan, Sujata, Burke, Michael, Cameron, Greg, Cepeda, Francisco Javier Valencia, Davis, Christopher, Dullur, Jayasree, Emmanuel, Joseph, Errey, Catherine, Fieuw-Makaroff, Sabine, Gaudry, Adam, Genua, L, Longhurst, Ian, McCroary, Kenneth, Merhi, Diana, Nguyen, Tanya, Obayd, Zahra Rassoly, Penm, Michelle, Pobbathi, Sharan, Poh, William S, Schnitzler, Paul, Shahnaz, Sabiha, Tan, Ven, Tang, Danny, Tan, Brian, Thu, Win Kyaw, Triantopolous, Thrasivolous, Venkatesan, Ramana, Wong, Wicky Chun Fai, Yang, Shu Ching
Format:	Journal Article
Language:	English
Published:	England Elsevier Ltd 22-07-2023 Elsevier Limited
Subjects:	Acute Pain - drug therapy Adolescent Adult Adverse events Analgesia Analgesics Analgesics, Opioid - adverse effects Australia Back pain Clinical trials Constipation Drug dosages Drug stores Effectiveness Emergency medical care Emergency medical services Female Humans Low back pain Low Back Pain - drug therapy Male Medical research Medicine Naloxone Narcotics Neck Neck pain Neck Pain - drug therapy Opioids Oxycodone Oxycodone - adverse effects Pain Pain perception Placebos Prescription drugs Primary care Randomization Research ethics Safety Social networks Australia United States > US
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Summary:	Opioid analgesics are commonly used for acute low back pain and neck pain, but supporting efficacy data are scarce. We aimed to investigate the efficacy and safety of a judicious short course of an opioid analgesic for acute low back pain and neck pain. OPAL was a triple-blinded, placebo-controlled randomised trial that recruited adults (aged ≥18 years) presenting to one of 157 primary care or emergency department sites in Sydney, NSW, Australia, with 12 weeks or less of low back or neck pain (or both) of at least moderate pain severity. Participants were randomly assigned (1:1) using statistician-generated randomly permuted blocks to guideline-recommended care plus an opioid (oxycodone–naloxone, up to 20 mg oxycodone per day orally) or guideline-recommended care and an identical placebo, for up to 6 weeks. The primary outcome was pain severity at 6 weeks measured with the pain severity subscale of the Brief Pain Inventory (10-point scale), analysed in all eligible participants who provided at least one post-randomisation pain score, by use of a repeated measures linear mixed model. Safety was analysed in all randomly assigned eligible participants. The trial was registered with the Australian New Zealand Clinical Trials Registry (ACTRN12615000775516). Between Feb 29, 2016, and March 10, 2022, 347 participants were recruited (174 to the opioid group and 173 to the placebo group). 170 (49%) of 346 participants were female and 176 (51%) were male. 33 (19%) of 174 participants in the opioid group and 25 (15%) of 172 in the placebo group had discontinued from the trial by week 6, due to loss to follow-up and participant withdrawals. 151 participants in the opioid group and 159 in the placebo group were included in the primary analysis. Mean pain score at 6 weeks was 2·78 (SE 0·20) in the opioid group versus 2·25 (0·19) in the placebo group (adjusted mean difference 0·53, 95% CI –0·00 to 1·07, p=0·051). 61 (35%) of 174 participants in the opioid group reported at least one adverse event versus 51 (30%) of 172 in the placebo group (p=0·30), but more people in the opioid group reported opioid-related adverse events (eg, 13 [7·5%] of 174 participants in the opioid group reported constipation vs six [3·5%] of 173 in the placebo group). Opioids should not be recommended for acute non-specific low back pain or neck pain given that we found no significant difference in pain severity compared with placebo. This finding calls for a change in the frequent use of opioids for these conditions. Australia's National Health and Medical Research Council, University of Sydney Faculty of Medicine and Health, and ReturnToWorkSA.
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ISSN:	0140-6736 1474-547X
DOI:	10.1016/S0140-6736(23)00404-X