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Managing Chronic Pain: Should You Start with Opioids or Nonopioids?

Long-term Randomized Trial Finds No Advantages with Opioids Compared to Placebo

In a step to address the dearth of clinical research on opioid therapy for chronic pain, a new long-term study finds no advantages to opioid medications over nonopioids for the management of pain from hip or knee osteoarthritis or chronic back pain. Lead author Erin Krebs, MD, MPH, with the Minneapolis VA Health Care System and the University of Minnesota commented “Previous randomized controlled trials have been short-term—less than 16 weeks—and compared opioids with placebo. No prior randomized controlled trial reported long-term pain, function or quality of life outcomes of opioids. Long-term outcomes are important for people with chronic pain because chronic pain is long-term by definition.” The findings were published last week in the Journal of the American Medical Association.

The new study randomized 240 participants from VA primary care clinics to receive either opioid or nonopioid treatment for their moderate-to-severe chronic back pain or knee or hip osteoarthritis that had been refractory to prior analgesics. Each group followed a multi-step “treat-to-target” strategy to reduce pain and improve function. Initial stage treatment for the opioid group included immediate-release morphine, oxycodone or hydrocodone/acetaminophen. The nonopioid cohort were first administered an NSAID or acetaminophen. After 12 months, pain related function was not significantly different between the groups. Pain intensity was significantly better in the nonopioid group and medication-related adverse effects were less common. The authors conclude that “Treatment with opioids was not superior to treatment with nonopioid medications for improving pain-related function over 12 months. Results do not support initiation of opioid therapy for moderate to severe chronic back pain or hip or knee osteoarthritis pain.”

Read a news story about the findings.

The journal article may be read here.

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