REVIEW OF: Krebs EE et al, JAMA 2018;319(9):872–882

Rising rates of opioid overdose deaths have sounded alarm bells over opioid prescribing practices for chronic pain. Unfortunately, and despite the absence of quality data on their risks vs benefits, long-term opioid management has remained a common approach to managing chronic musculoskeletal pain. CATR covered this topic in the 2018 May/June issue (See: “Treating Chronic Pain When There’s Addiction: A Primer”).

This study examined long-term outcomes in chronic pain with opioid vs non-opioid treatment. Researchers conducted a 12-month randomized trial evaluating patients who—despite analgesic use—had moderate to severe chronic back pain or hip/knee osteoarthritic pain. Patients were recruited from Veterans Affairs primary care clinics in Minneapolis, Minnesota between 2013 and 2015.

The study compared opioid and non-opioid therapy. Patients in each group were prescribed multiple medications over 3 steps. In total, 240 patients were randomized, with a mean age of 58.3 years; females made up 13% of the group.

In the opioid group, the first phase was immediate release morphine, oxycodone, or hydrocodone/acetaminophen. Second- and third-step options included sustained action morphine and transdermal fentanyl.

For the non-opioid group, the first stage was acetaminophen or an NSAID. Second- and third-phase choices comprised adjuvants, such as gabapentin or nortriptyline; topical analgesics; and drugs such as duloxetine and tramadol.

Outcomes measured included the impact of pain on daily functioning, rated on the Brief Pain Inventory [BPI] interference scale; pain intensity on the BPI severity scale; and adverse medication–related symptoms. The BPI interference scale records the influence of pain on activities like sleep, walking, relationships, work, and life enjoyment. For both BPI scales, the range is 0–10, with higher scores indicating worsened functioning or higher pain intensity.

Over 12 months, the groups did not significantly differ on pain-related function. The mean BPI interference was 3.4 for the opioid group and 3.3 for the non-opioid group. Unexpectedly, the non-opioid group reported significantly less pain intensity at 12 months, with a BPI severity of 4.0 for the opioid group and 3.5 for the non-opioid group. Adverse medication–related symptoms were significantly more common in the opioid group.

CATR’s Take
The noteworthy result here is that chronic pain patients on opioids may not be any better off than those taking alternative agents. While psychiatrists are not the primary treaters of musculoskeletal pain, the current opioid crisis has had wide-ranging impact, and there are calls for a multipronged approach. As such, and since many patients develop opioid dependence after long-term opioid treatment for chronic pain, we should be ready to share these results with our patients and medical colleagues.