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Systemic Review of Opioids for the Treatment of Chronic Non-Cancer Pain

Use was associated with reduced pain and improved physical functioning, but increased incidence of vomiting

A PPM Brief

In a meta-analysis1 of randomized controlled trials (RCTs) of patients with chronic non-cancer pain, the use of opioids compared with placebo was associated with significantly less pain and improved physical functioning. However, the magnitude of the association was small, reported the authors. Several databases were searched from their inception to April 2018 for RCTs of opioids for chronic non-cancer pain versus any non-opioid control, using random-effects models and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) to rate evidence quality.

A total of 96 RCTs, including 26,169 participants (61% female; median age 58 years), were reviewed. Of these, 25 trials were of neuropathic pain, 32 were of nociceptive pain, 33 of central sensitization, and 6 of mixed types of pain. Compared with placebo, opioid use was associated with:

  • reduced pain (weighted mean difference [WMD], − 0.69 cm [95% CI, − 0.82 to − 0.56 cm] on a 10-cm visual analog scale for pain; modeled risk difference for achieving the MID, 11.9% [95% CI, 9.7% to 14.1%])
  • improved physical functioning (WMD, 2.04 points [95% CI, 1.41 to 2.68 points] on 100-point SF-36 PCS; modeled risk difference for achieving MID, 8.5% [95% CI, 5.9% to 11.2%])
  • increased vomiting (5.9% with opioids vs 2.3% with placebo for trials that excluded patients with adverse events during run-in period).

While use was associated with reduced pain and improved physical functioning, there was an increased incidence of vomiting. (Source: 123RF)

Lesser-quality evidence suggested similar associations of opioids with improvements in pain and physical functioning compared with:

  • NSAIDs (pain: WMD, − 0.60 cm [95% CI, − 1.54 to 0.34 cm]; physical functioning (WMD, − 0.90 points [95% CI, − 2.69 to 0.89 points])
  • tricyclic antidepressants (pain: WMD, − 0.13 cm [95% CI, − 0.99 to 0.74 cm]; physical functioning: WMD, − 5.31 points [95% CI, − 13.77 to 3.14 points])
  • anticonvulsants (pain: WMD, − 0.90 cm [95% CI, − 1.65 to − 0.14 cm]; physical functioning: WMD, 0.45 points [95% CI, − 5.77 to 6.66 points]).

“Comparisons of opioids with non-opioid alternatives suggested that the benefit for pain and functioning may be similar, although the evidence was from studies of only low to moderate quality,” the authors concluded.

Last updated on: January 10, 2019
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