Opioids: Not the Best Option for Lower Back Pain

Acute lower back pain is defined as pain in the lower lumbar region for up to 6 weeks. Subacute lower-back pain is pain in the lower lumbar region from 6 weeks up to 12 weeks, and chronic lower back pain is pain that lasts for 12 or more weeks.

About 80% of people will experience lower-back pain at some point during their lives.¹ It is the most common reason for disability and the second most common reason why adults see a physician.2 Lower-back pain is also a very common reason for an opioid prescription. Opioids may mask pain in the short term, but they do not treat the underlying problem.²

Non—evidence-based treatment of lower-back pain, such as opioids, can actually cause serious problems.

INCREASE OF OPIOID TREATMENT

Multiple factors have contributed to the intense increase in opioid prescribing. In 1996, the American Academy of Pain Medicine and the American Pain Society issued their support for opioid therapy for chronic pain. At the same time, expert opinion wrongly determined that analgesic benefits were achievable without the risk of aberrant drug-taking behaviors.¹

The US Department of Veterans Affairs in 2000 and the Joint Commission in 2012 introduced programs emphasizing routine pain assessment, describing pain as a fifth vital sign.1 Finally, in the absence of high-quality evidence concerning the benefits and risks of using long-term opioid therapy, pharmaceutical companies unwaveringly marketed opioids for chronic noncancer pain.¹

RISKS OF LONG-TERM OPIOID THERAPY

As we know, there is an epidemic of opioid abuse, diversion, and misuse in the United States. Aberrant drug-taking behaviors, such as early refills, dose escalations without clinician consent, and using opioids to induce feelings of intoxication, have been reported as a result of patients being prescribed opioids for chronic pain.

These patients are also at risk for higher rates of substance-abuse disorders. The occurrence rates are at 5% to 25% among patients taking opioids for chronic lower-back pain alone.¹

The number of fatal prescription-drug overdoses has consistently increased from when it was considered “fair game” to prescribe long-term opioids to treat chronic pain. Between 1999 and 2017, the number of prescription-drug overdoses resulting in death more than quadrupled. In 1999, there were 16,849 deaths from prescription-drug overdose. By 2007, this figure had more than doubled to 36,101 overdose deaths; by 2017, it had more than doubled again to 70,237 overdose deaths.³

About 20% of patients receiving long-term opioid therapy develop an opioid use disorder.⁴ Considering the prevalence of chronic lower-back pain in the United States, recognizing effective non-opioid alternatives for this condition is of paramount importance. These treatments include, as follows:⁵

• Acetaminophen (APAP): This is a mild pain reliever commonly used to treat lower-back pain.
• Antidepressants and anti-seizure medications: Certain antidepressants, such as amitriptyline, duloxetine, and nortriptyline, and certain anti seizure medications, such as gabapentin and pregabalin, have been shown to be beneficial for nerve pain. If the lower-back pain is the result of a pinched nerve, this can be valuable.
• Corticosteroids: These are the strongest anti-inflammatory drugs available, and can be taken by injection to the back. Injectable corticosteroids include dexamethasone, methylprednisolone, and triamcinolone. Oral corticosteroids include methylprednisolone and prednisone.
• Muscle relaxants: Medications that relax the muscles are also effective for treating lower-back pain. Muscle relaxants include baclofen, carisoprodol, cyclobenzaprine, and tizanidine. These medications may also be combined with nonsteroidal antiinflammatory drugs (NSAIDs) for a possible better outcome.
• NSAIDs: These are typically first-line treatment for lower-back pain. They can be OTC, such as ibuprofen or naproxen, or prescription, such as celecoxib, diclofenac, and meloxicam. Nonsteroidal anti-inflammatory drugs can be combined with APAP for a potential better outcome.
• Tramadol: This functions like an opioid in that it acts on the opioid receptor in the brain. It is a good pain reliever, with less abuse potential than true opioids.

Opioids can include many drugs, such as codeine, hydrocodone, morphine, and oxycodone, and are a last resort for lower-back pain as they have significant abuse potential. These drugs act on the opioid receptors in the brain to decrease the brain’s reaction to pain.

There are a number of alternative treatments available. These include the following⁶:

• Acupuncture: An acupuncture practitioner inserts thin needles into specific points on the body. Part of traditional Chinese medicine, acupuncture can help to restore function and relieve pain and may continue to work well over time.
• Anti-inflammatory diet: Some diets, especially those containing processed and sugary foods, can promote or worsen inflammation. These include ones with artificial trans fats, excessive alcohol, high-fructose corn syrup and sugar, processed meats, refined carbohydrates, and seed and vegetable oils.⁷ An antiinflammatory diet includes beans, fish, fruit, herbs, nuts, spices, and vegetables.⁸
• Correct posture: The spine is stable and strong when correct posture is used. Slouching or stooping can cause ligaments and muscles to strain to keep balance. This can lead to back pain, headaches, and other problems.⁹
• Exercise: Although people experiencing pain may find it difficult to be active, movement is one of the best treatments for many types of pain. Exercises that strengthen or stretch the back or neck muscles can reduce pain in those areas.
• Physical therapy: This involves doing particular exercises and stretches under the guidance of a licensed physical therapist. This can relieve tension and strengthen specific muscles, leading to less pain.
• Proper footwear: Wearing the wrong type of footwear, especially if standing for long periods of time, can cause the back, hips, and legs to misalign, resulting in back pain. Patients may wish to speak to a foot specialist about wearing orthotics.
• Spinal manipulation: Also known as chiropractic manipulation, this involves adjustment, massage, and/or stimulation of the spine. Keep in mind that spinal manipulation is not safe for everyone. Patients who have arthritis, osteoporosis, or spinal cord problems should not undergo chiropractic manipulation. Only licensed providers, such as chiropractors, osteopathic physicians, physical therapists, and some medical doctors, should perform these treatments. When trained specialists perform spinal manipulation, serious adverse effects are rare. • Stress management: Stress can cause tension in muscles, which can cause or worsen back pain. Stress can also change the body’s perception of pain.
• Transcutaneous electrical nerve stimulation (TENS): Electrode patches attached to the area of pain will provide TENS when the battery-powered device is turned on. This interrupts the flow of pain signals to the brain.
• Weight loss: Being overweight can cause increased strain on the muscles of the back and the spine, resulting in lower back pain. If weight is a factor, losing weight can help alleviate all or some of the associated back pain.

Kathleen Kenny, PharmD, RPh, has more than 25 years of experience as a community pharmacist and is a freelance clinical medical writer based in Colorado Springs, Colorado.

REFERENCES

• Lall MP. Opioid therapy for chronic low back pain: prescribing considerations for advanced practice registered nurses. J Neurosci Nurs. 2014;46(6):361-366; quiz E1-2. doi: 10.1097/JNN.0000000000000093.
• Chase D. The opioid crisis is partly fueled by insurers’ and employers’ approach to back pain. StatNews. statnews.com/2019/03/27/opioid-crisis-insurersemployers- back-pain/. Published March 27, 2019. Accessed January 14, 2020.
• Overdose death rates. National Institute on Drug Abuse website. drugabuse.gov/ related-topics/trends-statistics/overdose-death-rates. Updated January 2019. Accessed February 14, 2020.
• Waljee JF, Brummett CM. Opioid prescribing for low back pain: what is the role of payers? JAMA Netw Open. 2018;1(2):e180236. doi: 10.1001/jamanetwork open.2018.0236.
• Back pain. Mayo Clinic. mayoclinic.org/diseases-conditions/back-pain/ diagnosis-treatment/drc-20369911. Accessed February 14, 2020.
• Berry J. 11 ways to treat back pain without surgery. MedicalNewsToday. June 28, 2019. medicalnewstoday.com/articles/325609.php. Accessed February 14, 2020.
• Spritzler F. 6 foods that cause inflammation. Healthline. November 12, 2019. healthline.com/nutrition/6-foods-that-cause-inflammation#1. Accessed January 12, 2020.
• Anti-inflammatory diet: road to good health? WebMD. webmd.com/diet/antiinflammatory- diet-road-to-good-health#1. Accessed February 14, 2020.
• Good posture tips. Mayo Clinic. mayoclinic.org/healthy-lifestyle/adult-health/ multimedia/back-pain/sls-20076817?s=1. Accessed February 14, 2020.