Pain education could end the opioid crisis

Low back pain is today a leading cause of disability worldwide. It occurs across all ages, socioeconomic levels and countries, but it has not been adequately addressed.

In 2018, one in six Australians had back problems and there were 181,000 hospitalisations. Research says that only about 5% of patients with low back pain who present to emergency departments have severe spinal pathology. The rest could be treated as outpatients with non-opioid interventions.

But about two-thirds of them are prescribed opioids, although, to date, no placebo control trial has tested the effectiveness of opioids in controlling low back pain.

A study published last year showed that introducing low back patients to opioids in the emergency department doubled the risk of ongoing use compared to patients not treated with opioids.

“This is concerning because there are many harms associated with opioid use including addiction, overdose and even death,” says Gustavo Machado, a physiotherapist and postdoctoral research fellow at the Institute for Musculoskeletal Health, University of Sydney. “Two-thirds of drug-induced deaths in Australia are opioid-induced. Of these, about 70% are prescription opioids.”

New research, published today in the British Medical Journal, found that when clinicians are educated about evidence-based pain management and pain services available, patients with low back pain are less likely to be prescribed opioids.

“Reducing opioid prescriptions by 12% without adversely impacting pain, disability and satisfaction with care is significant,” says Machado, one of the study’s authors.

The study involved four emergency departments across New South Wales and almost 4500 patients. Participants were randomised into two groups – the intervention group and those who received standard care.

The intervention group received care from clinicians who had been trained in evidence-based pain management alternatives to opioids. These clinicians attended seminars and were given educational material on non-opioid interventions. They were also educated on referral options to outpatient services such as specialist back clinics and physiotherapy.

Researchers observed a decrease in opioid prescriptions in the intervention group compared to the group that received standard care, but without affecting patient outcomes.

“We wanted to improve care and reduce low-value practices in patients with low back pain in the ED setting, especially considering the harms associated with opioid use,” says Machado.

The excessive use and misuse of opioids have led to a global opioid crisis. In Australia, around 3.1 million people were dispensed opioid prescriptions in 2016 and 2017. Between 2007 and 2017, there was a 25% rise in hospitalisations due to opioid poisoning. In the same period, pharmaceutical opioids were more likely than heroin to be involved in opioid deaths.

Last June, the Australian government introduced regulatory changes in opioids prescriptions to face this crisis. But restricting access to opioids without offering valid alternatives has left many Australians in pain.

“The challenge is to restrict the uptake and ongoing use of opioids for pain while ensuring patients continue to have access to safe, effective and adequate pain relief,” says Carol Bennett, CEO of national peak body painaustralia. “This study provides some insight into one mechanism for achieving this.”

Bennett says the study highlights that when health professionals have a sound pain education, they can offer valid alternatives to opioids in pain management.

“We created resources to help the clinicians thoroughly assess, manage and refer these patients to appropriate follow up, so they received the best possible care,” Machado says.

He said that this model of care can be implemented in other EDs and is appropriate for general practice too, although it would need to be tested in GP clinics.

“We think that other EDs can use an implementation strategy like ours to help clinicians manage low back pain patients in a more evidence-based way and in turn optimise patient care,” says Machado.

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