Pain Management: Opioids versus Non-Opioids

To compare opioid vs non-opioid medications for chronic non-cancer pain among a randomized sample of US veterans, Krebs and colleagues conducted a 12 month investigation to compare the efficacy, pain-related function, pain intensity, and adverse effects between opioid based versus non-opioid based medications.

Study participants were selected on the basis of having moderate to severe chronic back pain or hip or knee osteoarthritic pain despite analgesic use. A total of 240 were veterans, randomized to receive either opioid or nonopioid medication therapy followed a “treat-to-target” strategy aiming for improved pain control and function. Patient treatment was individualized as much as possible based upon objective measure of pain control. The nonopioid group initially received acetaminophen (paracetamol) or a nonsteroidal anti-inflammatory drug. Medications were changed, added, or adjusted within the assigned treatment group according to individual patient response.

Using the Brief Pain Inventory (BPI) interference scale over 12 months and the pain intensity (BPI severity scale) were used to determine results.

Groups did not significantly differ on pain-related function over 12 months (overall P = .58); mean 12-month BPI interference was 3.4 for the opioid group and 3.3 for the non-opioid group (difference, 0.1 [95% CI, -0.5 to 0.7]). Pain intensity was significantly better in the non-opioid group over 12 months and BPI severity was 4.0 for the opioid group and 3.5 for the non-opioid group (difference, 0.5 [95% CI, 0.0 to 1.0]). Adverse medication-related symptoms were significantly more common in the opioid group over 12 months (overall P = .03); mean medication-related symptoms at 12 months were 1.8 in the opioid group and 0.9 in the non-opioid group (difference, 0.9 [95% CI, 0.3 to 1.5]).

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Why Does This Matter?

Treatment with opioids was not superior to treatment with non-opioid medications for improving pain-related function over 12 months. Although some in the non-opioid group did receive Tramadol, a scheduled mood-altering analgesic, but overall, the results do not support initiation of opioid therapy for moderate to severe chronic back, hip or osteoarthritic knee pain.

Patients presenting with chronic pain syndromes require a full medical work up and medical education on the down regulation of nociceptors as a result of administration exogenous opioids. This can cause hyperalgesia and thus increased tolerance to opioids. Non-steroidal medications such as ibuprofen and acetaminophen are effective in some patients.

It’s difficult to determine how much pain someone is in. It’s more often than not a subjective call for the treating physician. Assessing for SUDs and psychopathology is essential, as depression and pain nearly always co-occur and exasperate the sequelae in a bi-directional manner. Lastly, checking pharmacy histories will provide more objective data to enable physicians to make the right call.


Krebs EEEffect of Opioid vs Non-opioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial. JAMA. 2018 Mar 6;319(9):872-882. doi: 10.1001/jama.2018.0899.