Opioids are no better than nonopioid pain relievers for treating the chronic pain of osteoarthritis, a clinical trial has found.
Researchers randomized 240 patients with moderate to severe chronic back pain or hip or knee osteoarthritis to either an opioid (morphine, oxycodone or hydrocodone) or to nonopioid pain relievers (such as Tylenol, topical lidocaine or nonsteroidal anti-inflammatory drugs). The study, in JAMA, used 11-point pain and function scales to measure the effect of treatment, with higher scores indicating poorer results. This is, the authors write, the first randomized trial of opioid therapy to report long-term pain and function outcomes.
At the end of 12 months, the opioid group scored an average 3.4 on the function scale, and the nonopioid group 3.3, an insignificant difference. On the pain scale, the nonopioid group did slightly better — 3.5, compared with 4.0 for the opioid group.
Unsurprisingly, there were significantly more medication side effects in the opioid group than in those who took nonopioids.
“Should we use opioids if nonopioids don’t work?” asked the lead author, Dr. Erin E. Krebs of the Minneapolis Veterans Affairs Health Care System. She answered her own question: “No. We tried four different nonopioids — don’t give up on them too soon — and we should also be using exercise and rehab for most osteoarthritic pain.”
Actual Report below
Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis PainThe SPACE Randomized Clinical Trial
Question For patients with moderate to severe chronic back pain or hip or knee osteoarthritis pain despite analgesic use, does opioid medication compared with nonopioid medication result in better pain-related function?
Findings In this randomized clinical trial that included 240 patients, the use of opioid vs nonopioid medication therapy did not result in significantly better pain-related function over 12 months (3.4 vs 3.3 points on an 11-point scale at 12 months, respectively).
Meaning This study does not support initiation of opioid therapy for moderate to severe chronic back pain or hip or knee osteoarthritis pain.
Importance Limited evidence is available regarding long-term outcomes of opioids compared with nonopioid medications for chronic pain.
Objective To compare opioid vs nonopioid medications over 12 months on pain-related function, pain intensity, and adverse effects.
Design, Setting, and Participants Pragmatic, 12-month, randomized trial with masked outcome assessment. Patients were recruited from Veterans Affairs primary care clinics from June 2013 through December 2015; follow-up was completed December 2016. Eligible patients had moderate to severe chronic back pain or hip or knee osteoarthritis pain despite analgesic use. Of 265 patients enrolled, 25 withdrew prior to randomization and 240 were randomized.
Interventions Both interventions (opioid and nonopioid medication therapy) followed a treat-to-target strategy aiming for improved pain and function. Each intervention had its own prescribing strategy that included multiple medication options in 3 steps. In the opioid group, the first step was immediate-release morphine, oxycodone, or hydrocodone/acetaminophen. For the nonopioid group, the first step was acetaminophen (paracetamol) or a nonsteroidal anti-inflammatory drug. Medications were changed, added, or adjusted within the assigned treatment group according to individual patient response.
Main Outcomes and Measures The primary outcome was pain-related function (Brief Pain Inventory [BPI] interference scale) over 12 months and the main secondary outcome was pain intensity (BPI severity scale). For both BPI scales (range, 0-10; higher scores = worse function or pain intensity), a 1-point improvement was clinically important. The primary adverse outcome was medication-related symptoms (patient-reported checklist; range, 0-19).
Results Among 240 randomized patients (mean age, 58.3 years; women, 32 [13.0%]), 234 (97.5%) completed the trial. Groups did not significantly differ on pain-related function over 12 months (overall P = .58); mean 12-month BPI interference was 3.4 for the opioid group and 3.3 for the nonopioid group (difference, 0.1 [95% CI, −0.5 to 0.7]). Pain intensity was significantly better in the nonopioid group over 12 months (overall P = .03); mean 12-month BPI severity was 4.0 for the opioid group and 3.5 for the nonopioid group (difference, 0.5 [95% CI, 0.0 to 1.0]). Adverse medication-related symptoms were significantly more common in the opioid group over 12 months (overall P = .03); mean medication-related symptoms at 12 months were 1.8 in the opioid group and 0.9 in the nonopioid group (difference, 0.9 [95% CI, 0.3 to 1.5]).
Conclusions and Relevance Treatment with opioids was not superior to treatment with nonopioid medications for improving pain-related function over 12 months. Results do not support initiation of opioid therapy for moderate to severe chronic back pain or hip or knee osteoarthritis pain.
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