Contributor: Jared Scott MD

Educational Pearls:

Should we use opioids to treat low back and neck pain? The OPAL Trial, published in The Lancet, in June 2023, attempted to answer this very question.

• Objective: Investigate the efficacy and safety of a short course of opioid analgesic (oxycodone-naloxone) for acute low back pain and neck pain.

• Trial Design: Triple-blinded, placebo-controlled randomized trial, conducted in Emergency and Primary Care in Sydney, Australia, involving adults with 12 weeks or less of low back or neck pain.

• Participants: 347 recruited adults (174 in the opioid group, 173 in the placebo group) with at least moderate pain severity.

• Intervention: Participants were assigned to receive either an opioid or a placebo for up to 6 weeks.

• Primary Outcome: Pain severity at 6 weeks measured with the pain severity subscale of the Brief Pain Inventory (10-point scale).

• Results: No significant difference in pain severity at 6 weeks between the opioid group (mean score 2.78) and placebo group (mean score 2.25).

• Adverse events were reported by 35% in the opioid group and 30% in the placebo group, with more opioid-related adverse events in the opioid group (e.g., constipation).

• Conclusion: Opioids should not be recommended for acute non-specific low back pain or neck pain, as there was no significant difference in pain severity compared with the placebo. The study calls for a change in the frequent use of opioids for these conditions.

Pharmacy Pearl: Why was naloxone mixed with oxycodone?

• Naloxone is an opioid receptor antagonist, meaning it can block the effects of opioids. When combined with oxycodone, naloxone's presence discourages certain forms of opioid misuse.

• Additionally, naloxone can bind to opioid receptors in the gut and improve symptoms of Opioid Induced Constipation (OIC).

• This is the same idea behind Suboxone (buprenorphine/naloxone).

References

1. Jones CMP, Day RO, Koes BW, Latimer J, Maher CG, McLachlan AJ, Billot L, Shan S, Lin CC; OPAL Investigators Coordinators. Opioid analgesia for acute low back pain and neck pain (the OPAL trial): a randomised placebo-controlled trial. Lancet. 2023 Jul 22;402(10398):304-312. doi: 10.1016/S0140-6736(23)00404-X. Epub 2023 Jun 28. Erratum in: Lancet. 2023 Aug 19;402(10402):612. PMID: 37392748.

2. Camilleri M, Lembo A, Katzka DA. Opioids in Gastroenterology: Treating Adverse Effects and Creating Therapeutic Benefits. Clin Gastroenterol Hepatol. 2017 Sep;15(9):1338-1349. doi: 10.1016/j.cgh.2017.05.014. Epub 2017 May 19. PMID: 28529168; PMCID: PMC5565678.

Summarized by Jeffrey Olson MS2 | Edited by Jorge Chalit, OMSII