Are non-opioid therapies more desirable than opioids for chronic pain?

Opioid medications achieve no better results than non-opioid medications for long-term treatment of chronic back pain and osteoarthritis pain, according to researchers from the Minneapolis VA Health Care System.

Findings of the study were presented in April at the SGIM 2017 Annual Meeting, in Washington, D.C., and is said to be the first completed randomized controlled trial of long-term opioid therapy for chronic pain.

Krebs

“This study is pertinent to managed care executives because opioid therapy is widely prescribed and not as effective as non-opioid pain treatment options,” says Erin Krebs, MD, the chief author, who holds appointments at the Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System.

The randomized study of 240 veterans compared opioid therapy versus non-opioid medication therapy over 12 months. Patients treated for back, hip, or knee pain at VA primary care clinics were identified through searches of the electronic medical record and screened by telephone for eligibility. Patients with chronic back pain or hip or knee osteoarthritis pain of at least moderate severity despite analgesic use were eligible. Eligible patients who consented and completed a baseline assessment visit were randomized to either the opioid therapy arm or the non-opioid medication therapy arm.

Multiple medications available on the formulary were included in each arm. Both interventions (opioid therapy and non-opioid therapy) were delivered using a telecare collaborative management model, with pain medication management provided for 12 months; medications were tailored to patient preferences and adjusted within the assigned treatment arm to achieve improvement in pain and individual functional goals.

Outcomes were evaluated by masked assessors at three, six, nine, and 12 months after enrollment. The primary outcome was the Brief Pain Inventory (BPI) interference scale, a patient-reported measure of pain interference with function. The BPI severity scale was used to assess pain intensity and a checklist of adverse symptoms was used to evaluate side effects of medication therapy.

“We found no significant advantage of opioid therapy compared with non-opioid medication therapy over 12 months,” Krebs says. “More patients treated with non-opioid medications had significant improvement in pain. Patients treated with opioid medications had more medication side effects. In the context of prior studies that have documented higher rates of serious harms among patients receiving opioid therapy, our findings support the recent CDC recommendation that non-opioid therapies are preferred over opioids for chronic pain.”

Next: More pain-related findings

Additional findings

The study also found:

Pain-related interference with function did not differ between opioid and non-opioid medication arms.

• Mean BPI-I scores at 12 months did not differ between opioid (3.4) and non-opioid (3.3) arms (P=0.584). 

• The proportion of patients with clinically important improvement in pain-related functional interference did not differ between opioid (59.0%) and non-opioid (60.7%) arms (P=0.722).

Pain intensity improved more in the non-opioid medication arm than in the opioid arm.

• Mean BPI-S scores at 12 months were worse in the opioid arm (4.0) than in the non-opioid (3.5) arm (P=0.034)

• The proportion of patients with clinically important improvement in pain intensity was lower in the opioid (41.0%) arm than in the non-opioid (53.9%) arm (P =0.007). 

Patient-reported medication side effects were worse in the opioid arm than in the non-opioid arm. 

• The mean number of medication-related adverse symptoms was higher in the opioid arm (1.7) than in the non-opioid (0.8) arm (P =0.040).

Managed care executives can help by increasing access to and encouraging use of evidence-based chronic pain therapies, in addition to discouraging overuse of long-term opioid therapy, according to Krebs.

“This study used a pharmacist care manager to deliver the effective non-opioid medication management intervention,” she says. “Improving integration of clinical pharmacists into primary care to assist with pain medication management would be an important contribution to improving clinical care.”

Based on the study, Krebs offers the following take-aways:

• For long-term treatment of chronic back pain and osteoarthritis pain, non-opioid medication therapy is superior to opioid therapy for both pain and side effects. 

• This study is directly relevant to decisions about starting long-term opioid therapy. This study did not examine treatment options for patients who are already on long-term opioid therapy.

• This study used collaborative telecare medication management by a clinical pharmacist in both treatment arms. This model of collaborative telecare medication management is effective in improving pain medication management and highly applicable to managed care settings. • A prior study published in JAMA of this model found that it doubled the rate of pain improvement compared with usual care.