Are They a Good Choice?

By – Lucy Willis MD

Low back pain is an extremely common ED complaint, for which opiates are frequently prescribed. The last 20 years has seen the development of an opioid overdose epidemic. The rate of death from prescription opioids has increased fourfold and is now higher than heroin and cocaine combined.

As emergency physicians, we are are always weighing risk/benefit ratios when making treatment decisions, and this is now a complex task when it comes to treating pain. There is a lack of literature demonstrating the effectiveness of opiates for the treatment of low back pain. ( See ACEP clinical policy on Opioids).

For our first NYP LM Journal Club, we are reviewing the recent JAMA study, Naproxen With Cyclobenzaprine, Oxycodone/APAP, or Placebo for Treating Acute Low Back Pain. This was a randomized, double blind, 3 group study carried out in an urban ED in the Bronx. Patients with nonradicular acute low back pain were randomized to either naproxen + placebo, naproxen + cyclobenzaprine, or naproxen + oxycodone/APAP.

The primary outcome was an improvement in functional outcome at 1 week. There was no difference between the 3 groups! However, there was a trend toward benefit in the oxycodone/APAP group as they were more likely to report pain levels of mild or none, with a NNT of 6. However, if you balance this against the NNT of 5 for adverse effects (drowsiness, dizziness, stomach irritation, n/v) and the potential for abuse, the authors of the study conclude that their study does not support the addition of these medication to NSAIDs in this setting.

The BUNDLE