Friday, August 30, 2013
QD: News Every Day--Little evidence supports opioids for low-back pain
There is very low to moderate quality evidence for short-term use of opioids to treat chronic lower back pain compared to placebo, according to an updated review of the literature.
To determine the efficacy of opioids in adults with chronic lower back pain, researchers reviewed 15 randomized controlled trials (5,540 participants) all at least four weeks in duration that assessed opioids as monotherapy or in combination with other therapies. The trials all compared non-injectable opioids to placebo or other treatments, and were excluded if they only compared different opioids.
Most people included in the trials were aged 40 to 50 years and all reported at least moderate low-back pain. Most of the trials were supported by the pharmaceutical industry.
Results appeared online Aug. 27 at The Cochrane Library.
The review concluded that tramadol (five trials; 1,378 participants) was better than placebo for pain (standardized mean difference [SMD], -0.55; 95% confidence interval [CI], -0.66 to -0.44; low quality evidence) and function (SMD -0.18, 95% CI -0.29 to -0.07; moderate quality evidence). One other trial with 1,583 participants demonstrated that tramadol compared to celecoxib showed little difference for pain relief (RR, 0.82; 95% CI, 0.76 to 0.90; very low quality evidence).
Transdermal buprenorphine (two trials, 653 participants) may make little difference for pain (SMD, -2.47; 95% CI, -2.69 to -2.25; very low quality evidence). There was no difference compared to placebo for function (SMD, -0.14; 95% CI -0.53 to 0.25; very low quality evidence).
Strong opioids such as morphine, hydromorphone, oxycodone, oxymorphone, and tapentadol (six trials; 1,887 participants), were better than placebo for pain (SMD, -0.43; 95% CI -0.52 to -0.33; moderate quality evidence) and function (SMD, -0.26; 95% CI -0.37 to -0.15; moderate quality evidence).
Two trials with 272 participants found no difference between opioids and antidepressants for either pain (SMD, 0.21; 95% CI -0.03 to 0.45; very low quality evidence) or function (SMD, -0.11; 95% -0.63 to 0.42; very low quality evidence).
Researchers noted that people who received opioids reported more pain relief and had less difficulty with daily activities in the short-term, but there is little data based on objective measures of physical functioning. There is no information supporting safety and efficacy beyond four months. The review did not show that opioids are more effective than other analgesics, such as anti-inflammatories or antidepressants, for low-back pain.
They wrote, “The initiation of a trial of opioids for long-term management should be done with extreme caution, especially after a comprehensive assessment of potential risks. There are no placebo-RCTs supporting the effectiveness and safety of long-term opioid therapy for treatment of chronic lower back pain.”
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Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.
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Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.
Controversies in Hospital
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).
db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.
Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.
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Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.
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Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.
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Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.
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