Management of low back pain amidst an opioid crisis

One of the most common chief complaints in primary care, urgent care, and emergency room settings is that of low back pain. It is, in fact, according to a presentation by Roger Chou, MD, per Providers Clinical Support System, the 5th most common reason for office visits in the United States. That equates to about 5% of primary care office visits. The prevalence of this chief complaint is rising, which is resulting in more prescriptions of opioids for treatment of this pain. Opioids are, in fact, the most commonly prescribed medication for low back pain. However, given that we are in the midst of an opioid crisis, the last thing we, as providers, want to do is to contribute to this problem, if at all possible. So, what exactly can we do to treat our patients effectively, while minimizing harm to the patient, and potentially to others? 

Opioids for Short Term Relief

Per the same presentation referenced above, it has been shown that opioids are effective for short term relief of low back pain, as in, less than twelve weeks duration. But what about patients that have chronic back pain, that lasts longer than twelve weeks? There is limited evidence supporting the practice of opioid prescribing past the twelve-week mark. There have been some studies that show that the use of opioids for low back pain are, in fact, associated with poorer patient outcomes. 

SPACE Trial

Some providers may have heard about the SPACE trial. The SPACE trial was a randomized control trial out of primary care clinics in the VA system over a 12-month period, in which one group of patients that had chronic low back pain was prescribed opioid therapy, and the other group was prescribed non-opioid therapy for treatment. The first group was prescribed medications such as immediate-release morphine, oxycodone, hydrocodone/acetaminophen, sustained-release morphine, and fentanyl. The second group was prescribed medications such as acetaminophen or NSAIDs, nortriptyline, amitriptyline, gabapentin, duloxetine, and topicals, such as capsaicin and lidocaine. Surprisingly, at the end of the twelve months, there was no difference in function, and, as a matter of fact, pain scores were WORSE in the opioid group! 

What Can We Do?

So, what can we, as providers, do to help with this problem? We have patients that may truly need our help in feeling better, but have no idea what to do. And of course, we will also have the patients that say that the only thing that helps for them is a narcotic pain medication. We must do what we can, as providers, to prevent harm when at all possible, and educate, educate, EDUCATE! Educating patients on the reasons for if and when to use opioids is a MUST. Opioids are designed for severe, unrelenting pain, and should be reserved for the worst pain only during an acute episode, when at all possible. Although they have their stigma, they do have a time and place for use. However, they should not be the only treatment that a patient receives for low back pain. Educating that the use of non-opioid medications, along with non-pharmacologic treatments, are the current mainstays of treatment of low back pain. Educate on remaining active, along with treatment methods such as relaxation techniques, yoga, massage, acupuncture, and physical therapy. If these non-pharmacologic treatments do not work, advise the use of NSAIDs, and offer a prescription medication, such as a muscle relaxant, or an antidepressant that can also be used for musculoskeletal pain, such as duloxetine or amitriptyline, etc. If these treatments fail, opioid therapy can be considered, but on a case-by-case basis. 

Overall, educating our patients on multimodal treatment methods for low back pain, and the minimization of usage of opioids for therapy can help to decrease the amount of opioid prescriptions being put out into the community, and can minimize potential harm. 

1 thought on “Management of low back pain amidst an opioid crisis”

  1. I would add to this discussion that referral to PM&R should be considered after a trial of therapy in the primary care setting. Triger point injections followed by some manual physical therapy can be most beneficial. Obtaining plain films with flexion and extension views should be done before ordering MRI. And, unless you are going to be the one to discuss the results but also provide the treatment, defer ordering MRI to the specialty groups.

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