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Three Part Question

[In patients presenting with severe acute low back pain] is [the addition of strong opiates better than treatment with paracetamol, NSAIDS and weak opiates] at [relieving pain and improving return to normal function]

Clinical Scenario

A 24 year old man presents to the emergency department with severe lower back pain. He developed back pain after twisting awkwardly whilst lifting a box. There are no neurological signs on examination and he has no "red flag" signs or symptoms. You make a diagnosis of low risk musculoskeletal back pain, reassure him and prescribe analgesia. He was brought to the emergency department by ambulance and initially treated with NSAIDS, paracetmol and Codeine. You review him later and he tells you that the pain killers were worthless and that the last time this happened his GP gave him a presciprition of oramorph. He asks that you do the same.

Search Strategy

MEDLINE using OVID interface via Athens. 1966-May 2005.
EMBASE using OVID interface via Athens 1986-May 2005
Cochrane via NeLH The Cochrane Library 2005, Issue 2
opiates.mp. or exp Narcotics/or opiate.mp. or morpine.mp. or diamorphine.mp. or exp Heroin/buprenorphine.mp. or exp BUPRENORPHINE/] and [back pain.mp. or exp Back Pain/
or exp Low Back Pain/ or lumbar pain.mp.] limit to (humans and english language and abstracts)

Search Outcome

MEDLINE 134 papers of which none addressed the use of strong opiates in the management of acute back pain.
EMBASE 582 papers of which none addressed the use of strong opiates in the management of acute back pain.
Cochrane 23 references none of which were relevant to three part question

Comment(s)

The clinical situation in the three part question occurs fairly regularly in emergency clinical practice. There are a number of patients who present in the acute phase of back pain who seem to gain little benefit from standard analgesic medication. Although there are a number of trials assessing the utility of patients with chronic lower back pain it is dissapointing that there are none examining the management of acute low back pain. We have seen patients prescribed a short course, or even a single dose, of strong opiate in order to facilitate early mobilisation but this practice appears to be based upon clinical impression rather than properly controlled trials. However, one must remember that the lack of evidence is not proof of a lack of utility and the clinician may still feel that this is an appropriate therapy in selected cases.

Clinical Bottom Line

There are no published trials examining the use of strong opiates in acute low back pain.

Level of Evidence

Level 3 - Small numbers of small studies or great heterogeneity or very different population.