Pubdate: Tue, 06 Mar 2018
Source: Los Angeles Times (CA)
Copyright: 2018 Los Angeles Times
Author: Karen Kaplan


For years, doctors turned to opioid painkillers as a first-line
treatment for chronic back pain and aches in the joints. Even as the
dangers of addiction and overdoses became more clear, the drugs'
pain-relieving benefits were still thought to justify their risks.

Now researchers have hard data that challenges this view.

In the first randomized clinical trial to make a head-to-head
comparison between opioids and other kinds of pain medications,
patients who took opioids fared no better over the long term than
patients who used safer alternatives.

"There was no significant difference in pain-related function between
the 2 groups over 12 months," researchers reported Tuesday in the
Journal of the American Medical Assn.

By some measures, the people using non-opioid drugs such as Tylenol,
ibuprofen and lidocaine experienced more pain relief than people using
medications like morphine, Vicodin and oxycodone -- though the
differences weren't large enough to be considered statistically
significant. Patients in both groups saw similar improvements in their
quality of life.

The findings cast doubt on the medical community's "standard approach"
of using opioids to manage chronic musculoskeletal pain, the
researchers found.

"Overall, opioids did not demonstrate any advantage over nonopioid
medications that could potentially outweigh their greater risk of
harms," wrote the team led by Dr. Erin Krebs of the Minneapolis
Veterans Affairs Health Care System's Center for Chronic Disease
Outcomes Research.

Krebs and her co-authors said the impetus for their clinical trial was
the escalating opioid crisis, which now claims about 115 American
lives each day, according to the Centers for Disease Control and
Prevention. The number of overdose deaths linked to prescription drugs
like oxycodone and hydrocodone has increased by a factor of four since
1999, the CDC says.

The trial -- Strategies for Prescribing Analgesics Comparative
Effectiveness, or SPACE -- enrolled patients who were treated by the
Minneapolis VA. All of the patients had pain in their backs, hips or
knees for at least six months, and that pain was bad enough to
interfere with their daily activities and enjoyment of life.

A total of 240 patients were randomly assigned to either the opioid or
nonopioid group. About two-thirds of them had back pain, and the rest
had osteoarthritis pain in their knees and hips. The average age of
these patients was 58; 87% were men and 86% were white.

All patients started with lower levels of pain medications and were
able to "step up" their treatment as necessary. First-line medications
for the opioid group included morphine and oxycodone; patients in the
nonopioid group started out with acetaminophen and NSAIDs, a group
that includes aspirin and ibuprofen.

After a year of pain treatment, the researchers saw no evidence that
opioids were better than the alternatives.

Using a scale that rated pain severity from 0 to 10, patients in the
opioid group reported an average score of 4.0 and patients in the
nonopioid group had an average score of 3.5. Over the course of a
year, 41% of those taking opioids saw at least a 30% improvement in
their pain severity, as did 54% of those who weren't on opioids.

Measures of how pain interfered with things like work, sleep, mood and
general enjoyment of life were nearly identical in both groups. On a
scale of 0 to 10, the average score was 3.4 for those on opioids and
3.3 for those who weren't. After 12 months, 59% of those in the opioid
group and 61% of those in the nonopioid group reported an improvement
of at least 30%.

Other measures of health-related quality of life -- including general
fatigue, headaches, symptoms of depression and sexual function -- were
not significantly different between the two groups of patients. The
one exception was anxiety, which improved more for those taking opioids.

Patients in the opioid group had significantly more trouble with
medication-related symptoms. However, hospitalizations and emergency
room visits to deal with pain medications were similar in both groups,
as were rates of drug misuse.

The study authors cautioned that these results might not apply to pain
patients in general, since VA patients aren't representative of the
country as a whole.

However, the findings should prompt doctors to reconsider the use of
opioids as a first-line treatment for chronic musculoskeletal pain,
they wrote.

"Treatment with opioids compared with non-opioid medications did not
result in significantly better pain-related function over 12 months,"
Krebs and her colleagues concluded. "Results do not support initiation
of opioid therapy for moderate to severe chronic back pain or hip or
knee osteoarthritis pain."

The study was funded by the Department of Veterans Affairs.
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