{"id":881,"date":"2015-11-06T16:10:03","date_gmt":"2015-11-06T16:10:03","guid":{"rendered":"http:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/?p=881"},"modified":"2017-08-21T11:29:08","modified_gmt":"2017-08-21T11:29:08","slug":"primary-care-corner-with-geoffrey-modest-md-opiates-for-acute-low-back-pain","status":"publish","type":"post","link":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2015\/11\/06\/primary-care-corner-with-geoffrey-modest-md-opiates-for-acute-low-back-pain\/","title":{"rendered":"Primary Care Corner with Geoffrey Modest MD: Opiates for Acute Low Back Pain?"},"content":{"rendered":"<p><strong>By Dr. Geoffrey Modest <\/strong><\/p>\n<p>JAMA just published a randomized clinical trial on the use of opioids or cyclobenzaprine in addition to naproxen\u00a0for patients going to the emergency room with acute low back pain (see\u00a0JAMA. 2015;314(15):1572-1580\u200b).<\/p>\n<p>Details:<\/p>\n<ul>\n<li>Setting: inner city ER in the Bronx, New York City, looked at patients with nontraumatic, nonradicular low back pain (LBP) of &lt;2 weeks&#8217; duration and had score &gt;5 on Roland-Morris Disability Questionnaire (RMDQ), a 24-item instrument used to assess functional\u00a0impairment in patients with LBP, with scores ranging from 0 to 24. A 5-point improvement\u00a0is considered clinically significant<\/li>\n<li>323 patients (mean age 39, 50% men, 45% never had LBP before and 12% had it &gt;1x\/year, 28% had on-the-job injury, 5% positive depression screen, and\u00a0mean RMDQ was\u00a020) were randomized to naproxen 500 bid, along with either placebo, cyclobenzaprine 5mg , or oxycodone\/acetaminophen 5\/325 mg (all\u00a0to take 1-2 q8hrs as needed, 60 pills given). All received a standard 10-minute LBP educational session prior to discharge from the ER<\/li>\n<li>Patients were contacted 7 days and 3 months after the ER visit<\/li>\n<li>Results, assessed 1 week later:\n<ul>\n<li>Mean RMDQ in placebo group = 9.8<\/li>\n<li>\u200bMean RMDQ in cyclobenzaprine\u00a0group = 10.1<\/li>\n<li>\u200bMean RMDQ in oxycodone\/acetaminophen group = 11.1<\/li>\n<li>None of these were a statistically significant difference in terms of functional pain<\/li>\n<li>\u200bAt 7 days,\u00a040% rated their pain as moderate-to-severe,\u00a0&gt;50% of those in each group continued to need pain meds after 7 days, and 70% would\u00a0want\u00a0the same treatment with subsequent LBP episodes (no significant difference between groups)<\/li>\n<li>Also no difference in use of health care resources (ER\/primary care\/specialty\/PT visits), frequency of naproxen use or frequency of use of\u00a0study med<\/li>\n<li>More than\u00a075% took naproxen daily and 2\/3 took it bid; only 1\/3 used the study medicine &gt;1x\/day and 40% used it intermittently,\u00a0though there was no significant difference in outcome if limit the analysis\u00a0to those taking the study medicine &gt;1x. Secondary analysis did find that of\u00a0those who took their study meds &gt;1x, more on opiates rated their pain\u00a0as mild to none.<\/li>\n<li>More adverse events in those not on placebo (mostly drowsiness, dizziness, nausea\/vomiting with oxycodone\/acetaminophen; less impressive increase in\u00a0drowsiness with cyclobenzaprine)<\/li>\n<li>\u200b3 months later: 1 in 4 patients in each group\u00a0still had moderate or severe LBP, and 2.3% were taking opioids. 80% of each group had resumed their usual activities and 80% were back to fulltime work. Again, no difference between the groups.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>The JAMA authors cite other\u00a0studies finding that 70% of patients still have functional impairment and continued analgesic use 1 week after an ER visit for acute\u00a0LBP. Also, despite the prevalent usage, studies suggest that\u00a0combining meds (e.g. cyclobenzaprine and opioids) is no more efficacious than prescribing monotherapy.<\/p>\n<p>So, this article does raise a few issues:<\/p>\n<ul>\n<li>Most of these patients with pretty severe acute LBP did not take their full complement of pain medications (only 2\/3 took the naproxen bid and most did not take their additional\u00a0study med very much)<\/li>\n<li>In my (limited) experience, very few patients who go to the ER with acute low back pain do not leave without an array of scripts including opiates (and I have seen several patients who were given opiate meds even though they explicitly asked not to get them, with &#8220;well, take the prescription anyway, just\u00a0in case you need it&#8230;.&#8221;). This and other studies suggest that polypharmacy does not add anything<\/li>\n<li>It is impressive but not surprising that 1 week later, there was\u00a0pretty\u00a0dramatic improvement in the disability scores. But it seemed that adding the cyclobenzaprine or oxycodone did not seem to add anything to the naproxen.<\/li>\n<li>One difficult issue for some patients might be to convince them that simple over-the-counter remedies (e.g. naproxen, or even acetaminophen from other studies) is sufficient to treat their pretty disabling pain. But, perhaps a persuasive &#8220;this is really the best medication for you, works as well as any other medication,\u00a0and has many fewer side-effects than the\u00a0others&#8221; may work (we have had pretty good success with a similar line of argument in decreasing the use of antibiotics for viral illnesses, esp. when given in a positive, reasonably\u00a0exuberant and\u00a0reassuring fashion).<\/li>\n<\/ul>\n<p>For my\u00a0litany of articles on chronic pain management, see\u00a0<a href=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/category\/pain\/,\">https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/category\/pain\/,<\/a> and especially\u00a0<a href=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2015\/06\/17\/primary-care-corner-with-geoffrey-modest-md-mass-med-society-opioid-prescription-guidelines\/\">https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2015\/06\/17\/primary-care-corner-with-geoffrey-modest-md-mass-med-society-opioid-prescription-guidelines\/<\/a> and\u00a0<a href=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2015\/03\/16\/primary-care-corner-with-geoffrey-modest-md-feel-good-gene\/\">https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2015\/03\/16\/primary-care-corner-with-geoffrey-modest-md-feel-good-gene\/<\/a>\u00a0\u200b<\/p>\n<p>&nbsp;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Primary Care Corner with Geoffrey Modest MD: Opiates for Acute Low Back Pain?  [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2015\/11\/06\/primary-care-corner-with-geoffrey-modest-md-opiates-for-acute-low-back-pain\/\">Read More&#8230;<\/a><\/p>\n","protected":false},"author":148,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[14283],"tags":[],"class_list":["post-881","post","type-post","status-publish","format-standard","hentry","category-archive"],"jetpack_featured_media_url":"","jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/881","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/users\/148"}],"replies":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/comments?post=881"}],"version-history":[{"count":0,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/881\/revisions"}],"wp:attachment":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/media?parent=881"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/categories?post=881"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/tags?post=881"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}