Opioids for chronic low-back pain.
BACKGROUND
The use of opioids in the long-term management of chronic low-back pain (LBP) appears to be increasing. Despite this trend, the benefits and risks of these medications remain unclear.


OBJECTIVE
To determine the efficacy of opioids in adults with chronic LBP.


METHODS
We electronically searched CENTRAL, CINAHL and PsycINFO to May 2006; MEDLINE and EMBASE to May 2007. We supplemented our search by reviewing references in relevant systematic reviews and identified trials.


METHODS
We included randomized or quasi-randomized controlled trials assessing the use of opioids (as monotherapy or in combination with other therapies) for longer than four weeks, in adults with chronic LBP. Studies were included if they compared non-injectable opioids to other treatments. Comparisons between opioids were excluded.


METHODS
Two authors independently assessed methodological quality and extracted data onto a pre-designed form. Results were statistically pooled using RevMan 4.2. We reported on pain and function using standardized mean difference (SMD) with 95% confidence interval (95% CI) and on side effects using absolute risk difference (RD) with 95% CI.


RESULTS
We included four trials. Three compared tramadol to placebo. Pooled results revealed that tramadol was more effective than placebo for pain relief, SMD 0.71 (95% CI 0.39 to 1.02), and improving function, SMD 0.17 (95% CI 0.04 to 0.30). The two most common side effects of tramadol were headaches, RD 9% (95% CI 6% to 12%) and nausea, RD 3% (95% CI 0% to 6%). One trial comparing opioids to another analgesic (naproxen) found opioids were statistically significant for relieving pain but not improving function. When re-calculated, the results were not statistically significant for either pain relief (SMD -0.58; 95% CI -1.42 to 0.26) or improving function (SMD -0.06; 95% CI -0.88 to 0.76) .


CONCLUSIONS
Despite concerns surrounding the use of opioids for long-term management of chronic LBP, there remain few high-quality trials assessing their efficacy. The trials in this review, although achieving high internal validity scores, were characterized by a lack of generalizability, inadequate description of study populations, poor intention-to treat analysis, and limited interpretation of functional improvement. Based on our results, the benefits of opioids in clinical practice for the long-term management of chronic LBP remains questionable. Therefore, further high-quality studies that more closely simulate clinical practice are needed to assess the usefulness, and potential risks, of opioids for individuals with chronic LBP.
Deshpande
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University Health Network, TWH-Comprehensive Pain Unit, 399 Bathurst St, 4th Floor, Toronto, Ontario, Canada, M5T 2S8. adeshpan@uhnres.utoronto.ca
Furlan
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Mailis-Gagnon
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Atlas
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Turk
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D000701:Analgesics, Opioid / Q000009:adverse effects / Q000627:therapeutic use*; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000627:therapeutic use; D002908:Chronic Disease; D006801:Humans; D017116:Low Back Pain / Q000188:drug therapy*; D009020:Morphine / Q000627:therapeutic use; D009288:Naproxen / Q000627:therapeutic use; D016032:Randomized Controlled Trials as Topic; D014147:Tramadol / Q000009:adverse effects / Q000627:therapeutic use
D000701:Analgesics, Opioid; D000894:Anti-Inflammatory Agents, Non-Steroidal; D014147:Tramadol; D009288:Naproxen; D009020:Morphine