Opioids for pain: what’s the problem?
28 September 2018
First published by BMJ Blog. Georgia Richards is a SPCR doctoral student at the University of Oxford.
The long-term use of opioids for pain: what’s the problem?
People receiving long-term pain relief for low back pain gain no benefits from opioids. Georgia Richards discusses her research on why this might be the case.
I celebrated the milestone of my first, lead author research publication which investigates the effects of using strong painkillers, called opioids, for long durations in people with chronic low back pain . But, this publication is more than just the dissemination of my research. Rather, it recognises an important window of time I spent listening to patients who were taking opioids.
What did we do?
We included 40 patients with chronic low-back pain who were either taking long-term opioids or not taking any opioids and also a ‘pain-free’ control group of 20 participants. We then explored the differences between the groups on measures of cognitive performance and inflammatory markers from blood samples.
What did we find?
We found only minor differences between the two patient groups on all measures despite nearly half of the patients taking opioids for their pain. Patients receiving opioids performed significantly worse in attention and had significantly lower pain self-efficacy beliefs than patients not taking opioids.
So, what’s the problem with opioids?
Opioids are effective treatments for the relief of acute pain such as after an operation, trauma, cancer and end-of-life pain. However, in the 1990’s they were heavily marketed for chronic pain conditions such as low-back pain. The prescribing of opioids began rising in high-income countries, including the United States (US), Canada, the United Kingdom, Germany and Australia. Clinical reviews have since found that the long-term use of opioids cause significant side effects and dependence. In the US, legislative action to restrict access to prescription opioids was effective in reducing prescribing but resulted in increased heroin distribution and abuse. Now, more people in the US are dying from opioid overdoses than motor vehicle-related and firearm-related deaths. This is the “opioid epidemic”.
I’ve dedicated my three-year Doctor of Philosophy (Oxford’s way of referring to a PhD thesis) to investigate the appropriateness of prescribing and the quality of research on opioids. I’m currently systematically reviewing the evidence to determine the drivers of prescribing opioids at high-doses in primary care. The protocol for this systematic review is registered here, published in the BMJ Evidence-Based Medicine journal here and was presented at the 2018 Evidence Live conference in Oxford (Figure below).
The future of pain management
In the midst of the “opioid epidemic”, both acute and chronic pain remain undertreated in most of the world. Even where there is access to opioids, pain continues to be poorly managed. Opioids will and should continue to be an important part of pain management in the future. But, their appropriate use alongside appropriate research efforts are needed before the management of pain will truly be evidence-based. So, let us not be pro-opioid or anti-opioid. But, let us be pro-patient and pro-evidence.
 Richards, G. C., et al. (2018). “Effects of long-term opioid analgesics on cognitive performance and plasma cytokine concentrations in patients with chronic low back pain: a cross-sectional pilot study.” Pain Rep 3(4): e669.
Author: Georgia C Richards is a doctoral researcher (DPhil candidate) in the Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences at the University of Oxford. She can be contacted on twitter (@Richards_G_C) or by email (email@example.com)
Acknowledgements: GCR is jointly funded by the NHS National Institute of Health Research (NIHR) School for Primary Care Research (SPCR), the Naji Foundation and the Rotary Foundation.