We do love to give out opiates in the emergency department. Kidney stone? Opiates. Broken arm? Opiates. Gunshot wound? Opiates. Sore throat? Dexamethasone. And opiates.
So of course we’re here with opiates for your back pain.
In this modern day, we are far, far more judicious than in times of yore, back when pharma had lobbied for pain to become the “fifth vital sign”. But, nonetheless, those patients who are struggling to manage despite non-opiate analgesia frequently end up with some sort of small supply to try and resolve an acutely painful condition.
The OPAL trial, published in The Lancet, is yet another in a series of trials decrying the disutility of virtually anything for back pain – in the context of prior work diminishing the efficacy of skeletal muscle relaxants, as well as even acetaminophen added to ibuprofen. In this trial, patients with “acute” low back pain were prescribed an oxycodone-based opiate or matching placebo, and their functional recovery was assessed in follow up. Unfortunately, no advantage was seen for patients randomized to oxycodone, while there were small, but likely real, risks for opiate misuse at later intervals.
However, does this trial apply to the emergency department?
- Patients were eligible if they had low back pain for up to 3 months. This is not exactly “acute” – especially since early versions of the protocol excluded patients whose back pain had been ongoing for less than 2 weeks.
- Modified-release oxycodone-naloxone was the opiate of choice in this Australian trial. The naloxone itself does not exert much influence on the analgesic effect, but the preparation itself differs from preparation used commonly in the emergency department.
- The follow-up interval was at six weeks, a good patient-oriented timeframe for long-term clinical resolution. However, emergency department treatment tends to choose opiate analgesia with the goal of short-term mobilization and return to activity, so 48- or 72- hour relief or functioning may be more relevant.
The most notable problem with this trial is not, in fact, the trial itself. Rather, the issue remains the paucity of true short-term data regarding any added benefit for the minimally effective quantity of opiates usually dispensed from the emergency department. Spring into action, team!