Patients with moderate to severe chronic back pain or hip and knee-related osteoarthritis pain do not require opioids in place of nonopioid treatments, according to a study published in JAMA.

Erin E Krebs, MD, PhD, of the Center for Chronic Disease Outcomes Research at the Minneapolis Veterans Affairs Health Care System in Minnesota, and colleagues conducted a randomized clinical trial to assess the treatment outcomes of opioids vs nonopioids in patients with chronic pain.

From June 2013 to December 2016, 240 eligible patients from Veterans Affairs—with chronic back pain or hip or knee osteoarthritis pain—were selected for randomization and follow-up with either an opioid or nonopioid treatment to target, alleviate, and facilitate function of the affected region. The average age was 58.3 years, 87% of participants were men, and 97.5% of participants completed the study.

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The main outcomes were pain-related function during the 12-month treatment (primary) and pain intensity (secondary) given in units of Brief Pain Inventory (BPI) interference scale.

Both cohorts received treatments in 3-step multi-treatment therapies. Participants in the opioid group were administered immediate-release morphine (first step), oxycodone, or hydrocodone/acetaminophen, while participants in the nonopioid group were treated with acetaminophen (paracetamol) or a nonsteroidal anti-inflammatory drug as the primary step. In the following steps, medications were altered in each group according to patient reactions to treatment.

The primary outcome did not vary greatly among the two groups. The average 12-month BPI interference for the opioid group was 3.4, compared with 3.3 for the nonopioid group. The secondary outcome was in favor of the nonopioid group (P=.03). The average 12-month BPI severity for the opioid group was 4.0 and 3.5 for the nonopioid group.

Significantly more adverse events were reported in patients in the opioid group (P=.03), with average treatment-related symptoms at the end of the study being 1.8 for the opioid participants and 0.9 for the nonopioid participants.

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“Recent systematic reviews have concluded that opioids have small beneficial effects on pain compared with placebo that may be outweighed by common adverse effects,” stated the authors.

“Treatment with opioids was not superior to treatment with nonopioid medications for improving pain-related function over 12 months,” continued the investigators. “Results do not support initiation of opioid therapy for moderate to severe chronic back pain or hip or knee osteoarthritis pain.”


  1. Krebs EE, Gravely A, Nugent S, et al. Effect of opioid vs nonopioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain: The SPACE randomized clinical trial. JAMA. 2018 March 6. doi:10.1001/jama.2018.0899