Nonopioids just as good as opioids for chronic back pain, hip and knee osteoarthritis pain

Minneapolis VA study suggests opioids are not worth their risks

Nonopioid medications are just as good as opioid medications for treating pain and pain-related function in people with chronic back pain or pain from hip or knee osteoarthritis, according to a study published online in JAMA on March 6.

In the study, researchers assessed pain-related function in 240 patients at Minneapolis Veterans Affairs primary care clinics using the 7-item Brief Pain Inventory (BPI) interference scale, in which patients note how often pain interferes with general activity, mood, walking ability, normal work such as housework, relationships with other people, sleep, and enjoyment of life. They also evaluated the patients’ pain intensity with the 4-item BPI severity scale, in which patients rate their pain at its best and worst over the previous 24 hours, their average pain, and the pain they had at the time of the evaluation. Patients had moderate, treatment-resistant, chronic back pain or hip or knee osteoarthritis pain nearly every day for 6 months or more.

Patients were then assigned to one of two intervention groups, opioid and nonopioid. Each intervention included multiple medication options in three steps. In the opioid group, the first step included immediate release opioids, the second step consisted of sustained-action opioids, and the third step consisted of transdermal fentanyl. In the nonopioid group, the first step included acetaminophen and NSAIDs; the second step included adjuvant oral medications such as nortriptyline, amitriptyline, or gabapentin; and the third step consisted of tramadol and medications that required prior authorization, such as pregabalin and duloxetine. Patients were followed monthly until their medication regimens were stable, then every 1 to 3 months. They had in-person visits at 6 and 12 months, and other follow-up took place over the phone.

At 12 months, the mean BPI interference was 3.4 in the opioid group and 3.3 in the nonopioid group, a result the researchers did not consider statistically significant. However, pain intensity was significantly better in the nonopioid group, at 3.5 compared with 4.0 in the opioid group. Moreover, medication-related symptoms were more common in the opioid group. In their conclusion, the researchers write, “Overall, opioids did not demonstrate any advantage over nonopioid medications that could potentially outweigh their greater risk of harms.”


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