BACKGROUND AND PURPOSE: 

• Krebs et al. (JAMA, 2018) assessed whether there was a difference in long-term outcomes of opioids compared with nonopioid medications for chronic back, knee or hip pain 

METHODS: 

• Pragmatic, 12-month, randomized trial with masked outcome assessment 
• Patients had moderate to severe chronic back pain or hip or knee osteoarthritis pain despite analgesic use 
• Patients were recruited from Veterans Affairs primary care clinics, with a 1- to 3-year follow-up 
• Opioid and nonopioid medication therapy followed a treat-to-target strategy aiming for improved pain and function 
• The groups were started on the following medications
  • Opiod Group: immediate-release morphine, oxycodone, or hydrocodone/acetaminophen 
  • Nonopiod group: acetaminophen (paracetamol) or nonsteroidal anti-inflammatory drugs 
• The primary outcome was pain-related function over 12 months, measured using the Brief Pain Inventory [BPI] interference scale 
• The primary adverse outcome was medication-related symptoms (patient-reported checklist; range, 0-19) 
• Secondary outcome was pain intensity (BPI severity scale) 
• For both BPI scales (range, 0-10; higher scores = worse function or pain intensity), a 1-point improvement was clinically important 

RESULTS: 

• 240 patients were randomized and completed the trial 
  • Mean age, 58.3 years; women made up 13% of participants
• Pain related function did not differ between groups (p = .58) 
  • Mean 12-month BPI interference was 3.4 for the opioid group and 3.3 for the nonopioid group (difference, 0.1 [95% CI, −0.5 to 0.7]) 
• Pain intensity was significantly better in the nonopioid group over 12 months (p= .03) 
  • Mean 12-month BPI severity was 4.0 for the opioid group and 3.5 for the nonopioid group (difference, 0.5 [95% CI, 0.0 to 1.0]) 
• The opioid group had significantly greater adverse medication-related symptoms over 12 months (p = .03) 
  • Mean medication-related symptoms at 12 months were 1.8 in the opioid group and 0.9 in the nonopioid group (difference, 0.9 [95% CI, 0.3 to 1.5]) 

CONCLUSION: 

• Opioid medications did not significantly improve pain-related function and may lead to greater adverse symptoms, compared to nonopioid treatment 

Learn More – Primary Sources: 

Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis PainThe SPACE Randomized Clinical Trial

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