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Early Prescription Opioid Use for Musculoskeletal Disorders and Work Outcomes

A Systematic Review of the Literature

Carnide, Nancy MSc*,†; Hogg-Johnson, Sheilah PhD*,†; Côté, Pierre DC, PhD†,‡; Irvin, Emma BA*; Van Eerd, Dwayne PhD*,§; Koehoorn, Mieke PhD*,∥; Furlan, Andrea D. MD, PhD*,#

The Clinical Journal of Pain: July 2017 - Volume 33 - Issue 7 - p 647–658
doi: 10.1097/AJP.0000000000000452
Review Articles

Objectives: Musculoskeletal disorders (MSDs) are a common source of work disability. Opioid prescribing for MSDs has been on the rise, despite a lack of data on effectiveness. The objective of this study was to conduct a systematic review to determine whether early receipt of opioids is associated with future work outcomes among workers with MSDs compared with other analgesics, no analgesics, or placebo.

Methods: MEDLINE, EMBASE, CINAHL, and CENTRAL were searched from inception to 2014 and reference lists were scanned. Studies were included if opioids were prescribed within 12 weeks of MSD onset. Eligible outcomes included absenteeism, work status, receiving disability payments, and functional status. Two reviewers independently reviewed articles for relevance, risk of bias, and data extraction using standardized forms. Data synthesis using best evidence synthesis methods was planned.

Results: Five historical cohort studies met the inclusion criteria, all including workers filing wage compensation claims. Four studies demonstrated a significant association between early opioids and prolonged work disability. One study found a shorter time between prescriptions to be associated with shorter work disability. However, all studies were found to be at a high risk of bias and a best evidence synthesis could not be conducted. The main limitations identified were with exposure measurement and control of confounding.

Discussion: Current literature suggests that opioids provided within the first 12 weeks of onset of an MSD are associated with prolonged work disability. However, the conclusions of these studies need testing in a high-quality study that addresses the methodological shortcomings identified in the current review.

*Institute for Work & Health, Toronto, ON, Canada

Dalla Lana School of Public Health

#Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada

Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa ON, Canada

§School of Public Health and Health Systems, University of Waterloo, Waterloo, ON Canada

School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada

N.C., S.H.-J., P.C., E.I., D.V.E., and A.D.F. participated in the conception of the research question and design of the review. All authors participated in study selection, risk of bias assessment, data extraction, and data synthesis. N.C. drafted the manuscript and all authors contributed substantially to the critical revision of the paper for important intellectual content.

A.D.F. developed the Opioid Manager, a point-of-care tool that distills information from the Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain. This app, available on iTunes for US$9.99, is owned by the University Health Network and all revenues are used to invest in the continued maintenance of the app itself. M.K. receives infrastructure funding from WorkSafeBC through a formal research agreement between the University of British Columbia and WorkSafeBC. WorkSafeBC provides grant funding for a separate project on opioid use (principal investigator: S.H.-J.; coinvestigators: N.C., P.C., A.D.F., M.K.), but did not fund this review. The Institute for Work & Health operates with the support of the Province of Ontario. N.C. was supported by a Vanier Canada Graduate Scholarship from the Canadian Institutes of Health Research (Canada) during the conduct of this research. The research was undertaken, in part, thanks to funding from the Canada Research Chairs program (Canada) to P.C. M.K. was supported in part by a Canadian Institutes of Health Research Chair in Gender, Work and Health. The other authors declare no conflict of interest.

The views expressed in this document are those of the authors and do not necessarily reflect those of the Province of Ontario.

Reprints: Nancy Carnide, MSc, Institute for Work & Health, 481 University Avenue, Suite 800, Toronto, ON, Canada, M5G 2E9 (e-mail:

Received May 11, 2016

Received in revised form December 12, 2016

Accepted October 22, 2016

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