Study Suggest Opioids Should Not Be First Line Therapy for Chronic Non-Cancer Pain

PainRelief.com Interview with:

Dr. Jason Busse PhD Associate Professor McMaster University

Dr. Busse


Dr. Jason Busse PhD
Associate Professor
McMaster University

PainRelief.com: What is the background for this study?  

Response: The United States prescribes more opioids per capita than any other country in the world, and opioids are associated with addiction, overdose, and death. Many individuals living with chronic noncancer pain are managed with opioid therapy; however, we have limited knowledge regarding benefits and harms. We conducted a systematic review and meta-analysis to synthesize the evidence from all RCTs that explored an opioid vs. a non-opioid comparator for patients with chronic noncancer pain, and followed participants for at least 1 month.

PainRelief.com: What are the main findings?

Response: Most of the 96 trials we reviewed compared opioids against placebo instead of active comparators, and were funded by industry. No trial explicitly enrolled patients with past or present substance use disorders, or other mental illness, and only 20 of the 26,169 enrolled patients were receiving disability benefits. The median follow-up was 60 days, and no trial followed patients for more than 6 months.

High quality evidence found that, compared to placebo, opioids provided small improvements in pain (average reduction of 0.69cm on a 10cm scale), physical functioning (average improvement of 2.04 points on a 100-point scale) and sleep quality (average improvement of 3.42mm on a 100mm scale), and increased risk of vomiting, drowsiness, constipation, dizziness, nausea, dry mouth, and itching.

Compared to placebo, opioids showed no important improvement in social, role, or emotional functioning.

Comparisons of opioids with nonopioid alternatives (e.g. NSAIDs, anti-depressants) suggest the benefit for pain and functioning may be similar but these studies provided only low to moderate quality evidence.

No study provided rates of opioid use disorder.

PainRelief.com: What should readers take away from your report?

Response: Given their risks, modest benefits, and the comparable effectiveness of alternatives, our results support that opioids should not be first line therapy for chronic non-cancer pain. Interested readers can access our clinical practice guideline for opioids and chronic noncancer pain here: https://app.magicapp.org/app#/guideline/2849

PainRelief.com: What recommendations do you have for future research as a result of this work?

Response: Future trials should explore the effects of opioids vs. active comparators, follow patients for longer time periods (e.g. 1 year), report rates of opioid use disorder, and enroll patients that better reflect chronic pain patients in practice. 

PainRelief.com: Is there anything else you would like to add?

Response: There is currently enthusiasm for substitution of opioids with medicinal cannabis in the management of chronic pain. Clinicians, patients and policy-makers would be well-advised to learn from the example of opioids to ensure that use of cannabis for chronic pain does not exceed the evidence.

Any disclosures?

Response: Our study received no industry funding, and was entirely supported by government grants from Health Canada and the Canadian Institutes of Health Research (CIHR). 

Citation:

Busse JW, Wang L, Kamaleldin M, et al. Opioids for Chronic Noncancer PainA Systematic Review and Meta-analysisJAMA. 2018;320(23):2448–2460. doi:10.1001/jama.2018.18472

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