Perks of Naproxen vs. perils of Percocet for low back pain

Naproxen alone is better for acute, non-traumatic, non-radicular lower back pain than in combination with Percocet (oxycodone/acetaminophen) or cyclobenzaprine, according to a report published in the Journal of the American Medical Association on October 20th. “These findings do not support the use of these additional medications in this setting. Opioids, when combined with naproxen, are not more effective than naproxen alone for the majority of patients with low back pain,” Dr. Benjamin Friedman of the Montefiore Medical Center, Albert Einstein School of Medicine in New York City said. “We demonstrated that adding cyclobenzaprine or oxycodone/acetaminophen to naproxen is unlikely to benefit the patient. Emergency physicians should counsel their patients that passage of time will bring improvement and eventual relief to most patients.”

Friedman and colleagues followed 323 patients who visited the Montefiore Medical Center emergency department complaining of non-traumatic, non-radicular low back pain that had lasted for two weeks. The patients were enrolled in a double-blind, three-group study and were randomized to be given either 60 tablets of placebo, 5 mg cyclobenzaprine, or 5 mg oxycodone/ 325 mg acetaminophen to be taken every 8 hours as needed, in addition to 20 tablets of 500 mg, to be taken two times a day for 10 days. The main result was an improvement in the Roland-Morris Disability Questionnaire, in which all participants scored higher than 5 (0 meaning no functional impartment and 24 being maximum impairment).

The researchers found that functional impairment and use of healthcare resources were not different between the study groups at 7 days or at 3 months after the visit to the emergency room. About two/thirds of patients showed considerable improvement in low back pain and function regardless of which treatment group they were in. Conversely, 40% of the cohort reported moderate or severe pain, 50% reported functional impairment one week after the original visit; 60% of the study participants said they were still using medication after one week. Use of opioids for low back pain was not common among participants regardless of treatment group 3 months after the first visit; less than 3% of the patients in the opioid group said they were taking medication in the previous 3 days.

Dr. Friedman told MedPage Today that “our data leave clinicians and patients in a difficult position. Many patients have already taken NSAIDs for LBP before they arrive in the ED. Some patients may have taken insufficient doses at incorrect intervals and could be instructed to optimize their NSAID regimen. But for those patients who have already optimized their NSAID regimen, there are no additional evidence-based medical therapies available. We don't have good medical treatment for acute low back pain.”

The researchers remarked that “acute low back pain is a frustrating condition” that causes over 27 million yearly visits to emergency departments in the United States. “Pain outcomes for these patients (who are usually treated with nonsteroidal anti-inflammatory drugs, acetaminophen, opioids, skeletal muscle relaxants or any combination thereof) are generally poor,” the study authors wrote. A week after an ED visit, 70% of patients reported persistent functional impairment associated with back pain, and 69% reported continued use of analgesics. After 3 months, about 48% reported functional impairment and 46% reported persistent analgesic use, including 19% who still needed opioids.

For a few physicians, this report preaches to the choir. For example, director of integrative pain management in the department of anesthesiology-pain at Mount Sinai School of Medicine in New York City Dr. Houman Danesh said that “this is another study to add to the pile that says narcotics are not appropriate to treat back pain. We know that narcotics lower testosterone levels in both men and women. In women, you have no idea of where or how to replace testosterone, so you are changing their biochemistry, which can make them more sensitive to pain.” Danesh added that “most back pain gets better on its own without anything,” and Friedman and colleagues noted as well that activity produces better outcomes that bed rest. May we add that pain management medical supplies online – such as electrotherapy devices – are also available to treat pain without the side effects linked to opioid painkillers.

Related: How can TENS units help fight a prescription opioid epidemic?