Reducing Opioid Prescriptions for Lower Back Pain Increases NSAID, Paracetamol Use
Reducing the number of opioid prescriptions for patients with lower back pain did not result in an increased use of other, risky pain medications.
Guideline-based care models can reduce opioid prescriptions for lower back pain in the emergency department while increasing the use of the recommended analgesics, according to a secondary analysis published in JAMA Health Forum.1
Reducing Opioid Prescriptions for Lower Back Pain Increases NSAID, Paracetamol Use / Dmitrijs - stock.adobe.com
Although current clinical guidelines advise using nonsteroidal anti-inflammatory drugs (NSAIDs) and/or paracetamol rather than opioids for lower back pain, many patients who present to the emergency department with lower back pain are prescribed opioids—two thirds of patients in Australia and 40% in the United States.
READ MORE: Cannabis Use Does Not Predict Relief in Patients With Chronic Pain
In the Sydney Health Partners Emergency Department (SHAPED) trial, guideline-based lower back pain care models were implemented across 4 emergency departments in Australia. The program significantly reduced opioid prescriptions from 62.8% to 50.5% and did not adversely affect patient outcomes of pain intensity, disability, quality of life, or care satisfaction. However, the initial study did not assess what pain medications were prescribed in lieu of opioids: the recommended medications or other risky medications. These medications, including benzodiazepines and antiepileptics, presents risks of misuse, addiction, and overdose.
The researchers conducted a secondary analysis of the SHAPED trial. The SHAPED trial included a 13-month control phase consisting of usual care followed by a 4-week trial period. Participants included 4625 adults presenting to the emergency department with nonspecific or radicular lower back pain. Patients who were under 18 or had a diagnosis of serious spinal pathology were excluded.
The control period included 3233 presentations of lower back pain, and the intervention period included 1392. The rate of use for nonopioid pain medications only increased by 2.19, while the rate of prescribing no pain medication reduced by 0.79. The researchers did not find increased rates of prescriptions for benzodiazepines, corticosteroids, or antidepressants. The rate of antiepileptic use increased by 2.45 from control to intervention, but the number of patients prescribed these drugs was small.
After analyses, the researchers did not find evidence that emergency department physicians prescribed other risky pain medications instead of opioids. The use of NSAIDs alone and NSAIDs with paracetamol significantly increased, with rates increasing by 1.4% and 7.1%, respectively. They also found that benzodiazepine use decreased significantly by 2.3%. Overall, the proportion of patients with lower back pain who were treated solely with nonopioid pain medication increased by 10.4%.
The results of this analysis represent a shift towards the guideline-recommended pain medications while reducing the number of opioids prescribed. The researchers note that the results may not be generalizable to other settings or countries.
Future research should focus on the optimal ways of implementing these guideline-based care models into more emergency department settings.
READ MORE: Nonopioid Pain Management
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