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176 Chronic low-back pain
limited to short-term use for acute exacerbations. 2 No significant long-term
benefit is identified when opioid use is compared with placebo or non-opioid
therapy. 4–7 It is noteworthy that the majority of the individual studies from
the meta-analysis identified some benefit from various opioid preparations.
Among these are were acetaminophen (paracetamol) plus oxycodone,
acetaminophen plus codeine, sustained-release oxycodone or oxymorphone,
and transdermal fentanyl. 2
The utility of opioids in CLBP is limited not only by their marginal analge-
sic efficacy but also by the risk of addictive behavior. As the introductory
chapters state, concerns about drug-seeking behavior are inappropriately
exaggerated as applied to the general ED population. Furthermore, all
patients should get the benefit of the doubt. With that caveat, it should be
noted that clinical experience and available data corroborate an impression
that the patient population with CLBP constitutes a high-risk group for
“aberrant medication behavior” (i.e. manifestations of inappropriate drug
seeking). Meta-analysis assessing nine studies in which aberrant medication
behaviors were reported found such behaviors occurred in 5–24% of patients
receiving opioids. 2
The meta-analysis’ final recommendation was that, although opioids are
commonly prescribed for CLBP, the limited efficacy of opioids also comes
with an appreciable cost of addiction. 2 Opioids cannot be recommended as
first-line agents for patients with CLBP.
While NSAIDs have a well-established place in the management of some
forms of acute LBP, extended-duration prescription of these agents for CLBP
lacks solid evidence basis. The limited chronic-use efficacy of NSAIDs for
CLBP is, in part, the result of the agents’ side effect profile. Besides wellpublicized
ulcer, renal, and cardiovascular risk, long-term NSAID use risks
abdominal pain, diarrhea, edema, dry mouth, rash, dizziness, headache, and
tiredness. 3 In the past, some experts have recommended NSAIDs for CLBP;
these recommendations were modified by the reviewers’ subsequent clarification
that the supporting evidence came from studies of six (or fewer) weeks
of NSAID use. 4,5
With the caveat that available data are derived from studies of somewhat
limited duration, there are data supporting use of various NSAIDs for treating