What opioid could be used for an adult with uncomplicated low back pain?

Opioid Options for Uncomplicated Acute Low Back Pain

Opioids should NOT be used as first-line therapy for uncomplicated acute low back pain, and if severe pain necessitates their use, prescribe oxycodone 5-15 mg every 4-6 hours as needed for a maximum of 7 days. 1

Why Opioids Are Not Recommended

• NSAIDs are more effective than opioids for acute low back pain, with fewer adverse effects (placebo and acetaminophen had fewer adverse effects than NSAIDs, which in turn had fewer adverse effects than opioids). 1
• The most recent high-quality trial (2023) found opioids provided NO significant pain relief compared to placebo for acute low back pain (mean pain score at 6 weeks: oxycodone 2.78 vs placebo 2.25, p=0.051). 2
• The American College of Physicians and American Pain Society recommend opioids ONLY for severe, disabling pain not controlled by acetaminophen or NSAIDs. 1
• Workers treated with opioids within 6 weeks of acute low back injury for more than 7 days had significantly higher risk for long-term disability. 1

If Opioids Must Be Prescribed

Specific Drug Selection

Oxycodone is the preferred short-acting opioid, with the following options from the FDA-approved formulations: 1, 3

• Oxycodone immediate-release: 5-15 mg orally every 4-6 hours as needed 1, 3
• Oxycodone/acetaminophen: 5-15 mg oxycodone component every 4-6 hours (acetaminophen now limited to ≤325 mg per pill) 1
• Alternative: Hydrocodone/acetaminophen 5-15 mg hydrocodone component every 4-6 hours 1

Critical Prescribing Parameters

• Maximum duration: 7 days (risk of long-term disability increases significantly beyond this timeframe) 1
• Start with the lowest dose (5 mg) and use "as needed" dosing, not around-the-clock scheduled dosing for acute pain 3
• The median opioid consumption after ED discharge is less than 50 morphine milligram equivalents (MME) total, suggesting most patients need very limited amounts 1

What NOT to Do

• Do NOT prescribe sustained-release or long-acting opioid formulations for acute uncomplicated low back pain (no evidence of superiority and higher abuse potential) 1
• Do NOT combine opioids with benzodiazepines (increases mortality risk 3- to 10-fold due to respiratory depression; FDA black box warning issued in 2016) 4
• Do NOT prescribe opioids for sciatica/radicular pain without first trying NSAIDs, as NSAIDs show no difference from placebo in acute sciatica while opioids show only moderate efficacy 1, 5
• Do NOT escalate opioid doses as first-line pain management (no evidence of superiority over other therapies and higher adverse event rates) 1

Evidence-Based First-Line Approach

Prescribe NSAIDs (e.g., naproxen 500 mg twice daily or ibuprofen 600 mg three times daily) as first-line therapy, as they provide slightly better short-term symptomatic relief than opioids with fewer adverse effects. 1, 6

If NSAIDs are insufficient, add a non-benzodiazepine muscle relaxant (e.g., cyclobenzaprine 5-10 mg three times daily or tizanidine 2-4 mg three times daily) for 7-14 days maximum before considering opioids. 6, 4

Safety Monitoring

• 85% of patients on opioids for low back pain report adverse events, with constipation and sedation being most common 1
• 35% of patients report at least one adverse event in short-term use, with opioid-related adverse events (constipation 7.5%, nausea, vomiting) significantly more common than placebo 2
• Opioid-naive patients have increased risk of developing long-term opioid use beginning with the third day of therapy, and 11% of ED patients with current opioid dependence trace their initial exposure to an ED prescription 1