Opioids for back and neck pain: the OPAL trial
Authors: Medhat Wahba, Pamela E Macintyre
Journal: The Lancet (2024)

We read with interest the study by Caitlin Jones and colleagues1Jones CMP Day RO Koes BW et al.Opioid analgesia for acute low back pain and neck pain (the OPAL trial): a randomised placebo-controlled trial.Lancet. 2023; 402: 304-312Summary Full Text Full Text PDF PubMed Scopus (39) Google Scholar and their conclusion that short-term, judicious use of opioids for acute back pain conferred no benefit over placebo. However, we have some concerns. Although opioids are generally not recommended in this setting, current guidelines suggest they be prescribed only after use of simple analgesics and non-pharmacological interventions, after careful assessment of risk–benefit, and that immediate-release formulations are used at the lowest effective dose and for the shortest duration possible.2Australian Commission on Safety and Quality in Health CareLow back pain clinical care standard.https://www.safetyandquality.gov.au/standards/clinical-care-standards/low-back-pain-clinical-care-standardDate: September, 2022Date accessed: May 9, 2023Google Scholar This study instead used modified-release opioids, which many guidelines discourage for acute pain management.2Australian Commission on Safety and Quality in Health CareLow back pain clinical care standard.https://www.safetyandquality.gov.au/standards/clinical-care-standards/low-back-pain-clinical-care-standardDate: September, 2022Date accessed: May 9, 2023Google Scholar, 3Dowell D Ragan KR Jones CM Baldwin GT Chou R CDC clinical practice guideline for prescribing opioids for pain—United States, 2022.MMWR Recomm Rep. 2022; 71: 1-95Crossref PubMed Scopus (394) Google Scholar, 4Australian and New Zealand College of Anaesthetists and Faculty of Pain MedicinePS41(G) position statement on acute pain management 2023.https://www.anzca.edu.au/getattachment/558316c5-ea93-457c-b51f-d57556b0ffa7/PS41(G)-Position-statement-on-acute-pain-management-2023Date: September, 2023Date accessed: October 1, 2023Google Scholar, 5Srivastava D Hill S Carty S et al.Surgery and opioids: evidence-based expert consensus guidelines on the perioperative use of opioids in the United Kingdom.Br J Anaesth. 2021; 126: 1208-1216Summary Full Text Full Text PDF PubMed Scopus (34) Google Scholar The majority of patients were not given simple analgesia or non-steroidal anti-inflammatory drugs, and non-pharmacological interventions were not standardised or recorded. Rather than titrating opioids to patient function as suggested in guidelines,4Australian and New Zealand College of Anaesthetists and Faculty of Pain MedicinePS41(G) position statement on acute pain management 2023.https://www.anzca.edu.au/getattachment/558316c5-ea93-457c-b51f-d57556b0ffa7/PS41(G)-Position-statement-on-acute-pain-management-2023Date: September, 2023Date accessed: October 1, 2023Google Scholar pain scores of 0–1 were targeted, which might not be considered judicious use. Included were patients with pain duration up to 12 weeks and the pain could have been a flare rather than new acute nociceptive pain (management is different). Interventions were then applied for up to 6 weeks (primary outcome: pain score at 6 weeks), which is not usually considered short-term use, nor defined as acute pain.3Dowell D Ragan KR Jones CM Baldwin GT Chou R CDC clinical practice guideline for prescribing opioids for pain—United States, 2022.MMWR Recomm Rep. 2022; 71: 1-95Crossref PubMed Scopus (394) Google Scholar Most acute non-specific back or neck pain would have naturally resolved by 6–12 weeks. Neuropathic pain (less opioid responsive) was not excluded and adds further to selection biases. We believe that this study can only conclude that modified-release opioids used for the management of subacute low back pain, with or without neuropathic pain, were no better than placebo. No change to current guidelines can be based on this conclusion. We declare no competing interests. Opioid analgesia for acute low back pain and neck pain (the OPAL trial): a randomised placebo-controlled trialOpioids should not be recommended for acute non-specific low back pain or neck pain given that we found no significant difference in pain severity compared with placebo. This finding calls for a change in the frequent use of opioids for these conditions. Full-Text PDF Opioids for back and neck pain: the OPAL trial – Authors' replyWe thank Asaf Weisman and colleagues, and Medhat Wahba and Pamela E Macintyre for their correspondence about our study.1 We chose to use modified-release oxycodone–naloxone combination to reduce the risk of opioid-induced constipation and protect blinding.1 This regimen also allowed the medication to be taken every 12 h (rather than every 4 h with immediate-release oxycodone), to facilitate treatment adherence. Regular doses of modified-release opioid will achieve equivalent steady-state oxycodone exposure compared with dosing with an immediate-release opioid within a few days. Full-Text PDF