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REVIEW

Systematic Review: Opioid Treatment for Chronic Back Pain: Prevalence, Efficacy, and Association with Addiction

Bridget A. Martell, MD, MA; Patrick G. O'Connor, MD, MPH; Robert D. Kerns, PhD; William C. Becker, MD; Knashawn H. Morales, ScD; Thomas R. Kosten, MD; and David A. Fiellin, MD

16 January 2007 | Volume 146 Issue 2 | Pages 116-127

Background: The prevalence, efficacy, and risk for addiction for persons receiving opioids for chronic back pain are unclear.

Purpose: To determine the prevalence of opioid treatment, whether opioid medications are effective, and the prevalence of substance use disorders among patients receiving opioid medications for chronic back pain.

Data Sources: English-language studies from MEDLINE (1966–March 2005), EMBASE (1966–March 2005), Cochrane Central Register of Controlled Clinical Trials (to 4th quarter 2004), PsychInfo (1966–March 2005), and retrieved references.

Study Selection: Articles that studied an adult, nonobstetric sample; used oral, topical, or transdermal opioids; and focused on treatment for chronic back pain.

Data Extraction: Two investigators independently extracted data and determined study quality.

Data Synthesis: Opioid prescribing varied by treatment setting (range, 3% to 66%). Meta-analysis of the 4 studies assessing the efficacy of opioids compared with placebo or a nonopioid control did not show reduced pain with opioids (g, –0.199 composite standardized mean difference [95% CI, –0.49 to 0.11]; P = 0.136). Meta-analysis of the 5 studies directly comparing the efficacy of different opioids demonstrated a nonsignificant reduction in pain from baseline (g, –0.93 composite standardized mean difference [CI, –1.89 to –0.03]; P = 0.055). The prevalence of lifetime substance use disorders ranged from 36% to 56%, and the estimates of the prevalence of current substance use disorders were as high as 43%. Aberrant medication-taking behaviors ranged from 5% to 24%.

Limitations: Retrieval and publication biases and poor study quality. No trial evaluating the efficacy of opioids was longer than 16 weeks.

Conclusions: Opioids are commonly prescribed for chronic back pain and may be efficacious for short-term pain relief. Long-term efficacy (16 weeks) is unclear. Substance use disorders are common in patients taking opioids for back pain, and aberrant medication-taking behaviors occur in up to 24% of cases.

Editors' Notes Context Patients with low back pain often request pain medication, and many physicians prescribe opioids despite concerns about drug dependence. Contribution Opioid prescribing rates in 11 studies varied widely (3% to 66%). In 4 short-term randomized trials, pain relief was similar with opioids and either active treatment or placebo. In poor-quality, heterogeneous studies, the prevalence of substance abuse disorders in patients taking long-term opioids for back pain varied from 5% to 24%. Caution Study quality was weak overall. Implications Opioids seem to have limited, if any, short-term value in chronic low back pain. Evidence about developing substance abuse is too limited to draw any conclusions. —The Editors

 

Author and Article Information

From Yale University School of Medicine, New Haven, Connecticut; VA Connecticut Health Care System, West Haven, Connecticut; and University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.

Grant Support: Dr. Martell was supported by a Veterans Administration Career Development Award during the conduct of this study.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: David A. Fiellin, MD, Yale University, 333 Cedar Street, PO Box 208025, New Haven, CT 06520-8025; e-mail, david.fiellin{at}yale.edu.

Current Author Addresses: Dr. Martell: Pfizer, New Haven Clinical Research Unit, 50 Pequot Avenue, Mailstop 3000, New London, CT 06330.

Drs. Kerns and Kosten: VA Connecticut Health Care System, Psychology Service, 116B, 950 Campbell Avenue, West Haven, CT 06516.

Dr. Morales: Department of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, 626 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104-6021.

Drs. Fiellin, O'Connor, and Becker: Yale University, 333 Cedar Street, PO Box 208025, New Haven, CT 06520-8025.

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