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Opioids Compared With Placebo or Other Treatments for Chronic Low Back Pain: An Update of the Cochrane Review

Chaparro, Luis Enrique, MD*; Furlan, Andrea D., MD, PhD; Deshpande, Amol, MD; Mailis-Gagnon, Angela, MD, MSc, FRCPC§; Atlas, Steven, MD; Turk, Dennis C., PhD

doi: 10.1097/BRS.0000000000000249
Cochrane Collaboration

Study Design. Systematic review and meta-analysis.

Objective. To assess the efficacy of opioids in adults with chronic low back pain (CLBP).

Summary of Background Data. Opioids for CLBP has increased dramatically. However, the benefits and risks remain unclear.

Methods. We updated a 2007 Cochrane Review through October 2012 of randomized controlled trials from multiple databases. Use of noninjectable opioids in CLBP for at least 4 weeks was compared with placebo or other treatments; comparisons with different opioids were excluded. Outcomes included pain and function using standardized mean difference (SMD) or risk ratios with 95% confidence intervals (CIs), and absolute risk difference with 95% CI for adverse effects. Study quality was evaluated using Grading of Recommendations Assessment, Development, and Evaluation criteria.

Results. Fifteen trials (5540 participants), including twelve new, met the criteria. Tramadol was better than placebo for pain (SMD, −0.55; 95% CI, −0.66 to −0.44) and function (SMD, −0.18; 95% CI, −0.29 to −0.07). Compared with placebo, transdermal buprenorphine decreased pain (SMD, −2.47; 95% CI, −2.69 to −2.25), but not function (SMD, −0.14; 95% CI, −0.53 to 0.25). Strong opioids (morphine, hydromorphone, oxycodone, oxymorphone, and tapentadol), were better than placebo for pain (SMD, −0.43; 95% CI, −0.52 to −0.33) and function (SMD, −0.26; 95% CI, −0.37 to −0.15). One trial demonstrated little difference with tramadol compared with celecoxib for pain relief. Two trials (272 participants) found no difference between opioids and antidepressants for pain or function. Reviewed trials had low to moderate quality, high drop-out rates, short duration, and limited interpretability of functional improvement. No serious adverse effects, risks (addiction or overdose), or complications (sleep apnea, opioid-induced hyperalgesia, hypogonadism) were reported.

Conclusion. There is evidence of short-term efficacy (moderate for pain and small for function) of opioids to treat CLBP compared with placebo. The effectiveness and safety of long-term opioid therapy for treatment of CLBP remains unproven.

Level of Evidence: 1

We assessed the outcomes of opioid therapy in adults with chronic low back pain (15 trials). There is “very low- to moderate-quality” evidence for short-term efficacy (for pain and function) compared with placebo but no evidence for long-term safety or efficacy. Serious adverse effects were not reported.

*Department of Anesthesiology, Hospital Pablo Tobon Uribe, Medellin, Colombia;

Institute for Work and Health, Toronto, Canada;

Toronto Western Hospital, Comprehensive Pain Program, University Health Network, Toronto, Canada;

§Department of Medicine, Toronto Western Hospital, Comprehensive Pain Program, Toronto, Canada;

Medical Practices Evaluation Center, Massachusetts General Hospital, Boston, MA; and

Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA.

Address correspondence and reprint requests to Luis Enrique Chaparro, MD, Department of Anesthesiology, Hospital Pablo Tobon Uribe, Medellin, Colombia; E-mail:

Acknowledgment date: November 14, 2013. Acceptance date: November 18, 2013.

The device(s)/drug(s) is/are FDA-approved or approved by corresponding national agency for this indication.

No funds were received in support of this work.

Relevant financial activities outside the submitted work: board membership, payment for lecture, travel/accommodations/meeting expenses, employment, royalties, consultancy, grants, payment for manuscript preparation, payment for development of educational presentations.

© 2014 by Lippincott Williams & Wilkins