The Skeptics Guide to Emergency Medicine Global SGEM Global Authors

Date: October 26, 2023

Reference: Jones et al. Opioid analgesia for acute low back pain and neck pain (the OPAL trial): a randomised placebo-controlled trial placebo-controlled trial. Lancet July 2023
Guest Skeptic: Dr. Sergey Motov is an Emergency Physician in the Department of Emergency Medicine, Maimonides Medical Center in New York City. He is also one of the world’s leading researchers on pain management in the emergency department, specifically the use of ketamine. His twitter handle is @PainFreeED.
Case: A 37-year-old man without a significant past medical history presents to the emergency department (ED) with a chief complaint of lower back pain that started three days prior to the ED visit after unloading a truck with furniture. He states that pain is severe (7/10 in intensity), sharp, constant, non-radiating, and is exacerbated by any movement. The patient is unable to go to work due to pain and is experiencing severe limitations in his daily activities. He denies any weakness or numbness of the lower extremities or bowel or bladder dysfunction. You perform a physical examination and note prominent tenderness to palpation at bilateral lumbar paraspinal regions with normal neuro-vascular examination. You engage the patient in shared decision making about his most likely diagnosis (muscle strain) and treatment approach such as a short course of non-steroidal anti-inflammatory drugs (Ibuprofen) and gradual physical activity as tolerated. The patient, however, believes that ibuprofen will not touch his pain and insists on receiving an opioid-containing medication.
Background: Low back pain and neck pain are extremely common conditions worldwide [1]. We have covered the issue of back pain several times on the SGEM including:



SGEM#87:Let Your Back Bone Slide (Paracetamol for Low-Back Pain)
SGEM#173: Diazepam Won’t Get Back Pain Down
SGEM#240: I Can’t Get No Satisfaction for My Chronic Non-Cancer Pain
SGEM#304: Treating Acute Low Back Pain – It’s Tricky, Tricky, Tricky
SGEM#366: Relax, Don’t Do It – Skeletal Muscle Relaxants for Low Back Pain

Back pain and neck pain are leading causes of disability on a global scale [2,3]. The substantial disability burden imposes enormous costs both directly on healthcare systems, and indirectly through productivity losses [4,5].
Not only are these conditions common and painful they are difficult to treat. Many pharmacologic treatments have been tried with limited efficacy.


Acetaminophen (Williams et al Lancet 2014)
Muscle relaxants (Friedman et al JAMA 2015)
NSAIDs (Machado et al  Ann Rheum Dis 2017)
Steroids (Balakrishnamoorthy et al Emerg Med J 2014)
Benzodiazepines (Friedman et al Ann Emerg Med 2017)

Many non-pharmacologic therapies have also been tried with limited efficacy.


Cognitive Behavioral Therapy and mindfulness (Cherkin et al JAMA 2016)
Chiropractic (Paige et al JAMA 2017)
Physical therapy (Paolucci et al J Pain Research 2018)
Acupuncture (Colquhoun and Novella Anesthesia and Analgesia 2013)

One treatment modality, opioids, can be effective but comes with very real potential harms. The American College Physicians (ACP) has a 2017 policy on guidelines for treating non-radicular low back pain (Qaseem et al Annals of Int Med). Their third recommendations states:


Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients. (Grade: weak recommendation, moderate-quality evidence)

The American College of Emergency Physicians (ACEP) has addressed the issue of opioid use in patients being discharged home after an acute episode of pain. They give a Level C Recommendations saying:


Do not routinely prescribe, or knowingly cause to be co-prescribed, a simultaneous course of opioids and benzodiazepi...