Trial helps reduce ED opioid interventions for back pain

The University of Sydney-led study looked at the effectiveness of a multifaceted intervention to apply recommendations for low-back pain in hospital emergency departments (EDs).
 
From 4625 episodes of care for low-back pain across four News South Wales EDs, totalling 4491 patients, opioid use was reduced from 62% to 50%, without adversely affecting patient outcomes.
 
Using two questionnaires, ED doctors’ beliefs and knowledge about care for low-back pain were measured before and after the intervention. The observed scores showed significant improvement after receiving the training, with their answers more closely aligned with current guideline recommendations.
 
Study author Dr Gustavo Machado, a physiotherapist and postdoctoral research Fellow at the Institute for Musculoskeletal Health, University of Sydney, hopes the results will change the way back pain is managed.
 
‘By working closely with emergency doctors to design an intervention to reduce opioid use for back pain in the hospital, we found use reduced on average by 12%,’ he told newsGP.
 
‘Patients were satisfied with the new program and we did not see any increase in pain levels despite emergency doctors giving out fewer opioids. We also found that the medical professionals’ skills at treating back pain improved.’
 
Results varied across the four EDs, with one showing a 24% drop in the use of opioids for back pain.
 
Dr Machado said interventions to reduce opioid use for patients post-hospital discharge is equally important.
 
‘We got doctors and nurses to undergo a training course about the long-term harms of opioids if started in the ED, [and] we thought of other non-opioid medicines for pain relief they could use such as anti-inflammatories and non-addictive muscle relaxants,’ he said.
 
‘We also supplied heat wraps to each ED and provided real-time feedback to emergency doctors on their opioid prescription rates, and organised early follow up with the physiotherapist and rheumatologist in outpatient back pain clinics.’
 
A 2013 Cochrane review found limited evidence that opioids are more effective than anti-inflammatories, such as ibuprofen, for chronic back pain.
 
An earlier review found that superficial heat or heat wraps are effective at reducing short-term back pain. Heat is also recommended as first-line treatment for low-back pain in international clinical guidelines, while back pain has been shown to respond better to non-drug interventions.
 
Similarly, a 2015 randomised trial shows strong evidence that adding an opioid to an anti-inflammatory does not provide additional pain relief or better mobility than an anti-inflammatory alone in patients with back pain visiting EDs.
 
Dr Paul Grinzi, GP and addiction medicine specialist, says that while the study reports on patients with back pain presenting to EDs, it is still relevant to the general practice context where the same patients may present.
 
‘[This study] does provide reassurance that avoiding the use of opioids with patients with back pain does not worsen patient-reported pain and reduces the known risks of opioids for this cohort,’ Dr Grinzi told newsGP.
 
‘A lot of acute back pain is related to paraspinal muscular spasm and the use of heat packs can be effective in helping reduce this type of pain – this is a good “breakthrough pain” treatment modality.’
 
Dr Grinzi said GPs can facilitate a switch from the older expectation of opioids for back pain to more modern and evidenced-based approaches, as outlined in the study.
 
‘There is greater professional and community awareness of the potential harms of opioids, and we can now share this understanding with our patients,’ he said.
 
Dr Machado agrees on GPs’ role in facilitating a reduction in opioids for patients with back pain after release from hospital.
 
He recommends offering reassurance to patients with non-specific low-back pain that symptoms are likely to gradually resolve over six weeks, and encourage them to stay active.
 
‘Reassure patients that they are not causing further damage by moving, this will actually speed recovery,’ Dr Machado said.
 
‘Set the expectation with patients that pain will slowly continue to improve, and if the pain worsens, set an action plan, [such as] using non-pharmacological treatments like heat packs, hot showers, gentle movement, massage, and simple analgesics including paracetamol and NSAIDS [non-steroidal anti-inflammatory drugs] if not contraindicated.’
 
For patients continuing to use opioids for acute and chronic pain, follow up and education is key, according to Dr Machado and Dr Grinzi.
 
‘Start a conversation about the need for slow wean of these medications, with the plan to institute safer treatment options [such as] physiotherapy. Involvement of a clinical psychologist can also be useful for patients with chronic pain,’ Dr Machado said.
 
‘This will help to reduce anxiety and allow opportunity to reinforce messages to patients to keep moving, use simple analgesics, [and] that pain will slowly continue to improve.’
 
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back pain emergency departments opioids pain management