Nonopioid Medication May Be as Effective as Opioids for Chronic Pain

Recent systematic reviews suggest that, when compared with placebo, opioids have only a small beneficial effect on pain. Further confounding the subject is the fact that few studies address optimal opioid dosing for pain, function and tolerability. Recently, investigators asked how opioid medication compares with nonopioid medication in improving pain-related function in patients with chronic, moderate to severe back pain or hip or knee osteoarthritis (OA).

The new study reveals that, for patients with compromised function due to pain, 12 months of treatment with opioids was not superior to treatment with nonopioid medication. The findings by Erin E. Krebs, MD, MPH, core investigator at the Minneapolis Veterans Affairs (VA) Health Care System in Minnesota, and colleagues do not support the common practice of initiating opioid therapy in patients with chronic, moderate to severe back pain or hip or knee OA pain. They published their results on March 6 in JAMA.¹

The randomized, controlled trial included a total of 240 patients who had characteristics that were representative of the patients who typically receive opioids in VA primary care. The mean age of the patients was 58.3 years and 13% of the patients were women. The majority (65%) had back pain as their primary pain diagnosis, and the remainder has a diagnosis of pain related to hip or knee OA. The patients were randomized to receive opioids or non-opioids. Most patients in the opioid group received low or moderate dosage therapy, with fewer than 15% of patients in the opioid group receiving a mean dispensed dosage of 50 mg/d morphine equivalent or more. Because the pragmatic study included complex interventions, the investigators were unable to mask patients.

Pain intensity was significantly better in the nonopioid group, with mean Brief Pain Inventory (BPI) severity of 4.0 for the opioid group and 3.5 for the nonopioid group (P=0.03) at Month 12. The investigators measured functional response, which was defined as a greater than 30% improvement in BPI interference. They found that 59.0% of patients in the opioid group and 60.7% of patients in the nonopioid group experienced a functional response to treatment. Specifically when measured on an 11-point scale, pain-related function at 12 months was 3.4 for opioid therapy and 3.3 for nonopioid therapy.

When the researchers examined secondary outcomes, they found only anxiety symptoms were significantly better in the opioid group. Health-related quality of life was similar between the two groups, as was overall mental health. However, adverse medication-related symptoms were significantly more common in the opioid group than in the nonopioid group (P=0.03). The investigators found no significant differences in adverse outcomes or potential misuse measures. They did not document any deaths, doctor shopping, diversion or opioid use disorder diagnoses.