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Opioid Analgesics 
Panel findings and recommendations: 
 -   When used only for a time-limited course, opioid analgesics are an option in the management of patients with low back problems.  The decision to use opioids should be guided by consideration of their potential complications relative to other options.  (Strength of Evidence = C.) 
 -   Opioids appear to be no more effective in relieving low back symptoms than safer analgesics, such as acetaminophen or aspirin or other NSAIDs. (Strength of Evidence = C.) 
 -   Clinicians should be aware of the side effects of opioids, such as decreased reaction time, clouded judgment, and drowsiness, which lead to early discontinuation by as many as 35 percent of patients.  (Strength of Evidence = C.) 
 -   Patients should be warned about potential physical dependence and the danger associated with the use of opioids while operating heavy equipment or driving.  (Strength of Evidence = C.)  
 Oral opioid analgesics commonly given to patients with low back problems include morphine derivatives (opioids) and synthetic opioids. The therapeutic objective in treating low back problems is temporary pain relief. 
Opioid Analgesics 
Literature Reviewed     Evidence on Efficacy   Potential Harms and Costs      Summary of Findings     Author's Example 
Opioid Analgesics 
  Literature Reviewed.  No RCTs were found that compared opioid analgesics (either alone or in combination with other drugs) to a placebo.  Therefore, three studies were evaluated that compared opioid analgesics to other medications, 115, 116, 117 recognizing that results of the evaluation would not entirely answer the question of whether opioids are any better than placebo for back symptoms.  Another article118 contained information used by the panel. 
  Evidence on Efficacy.    All three studies evaluated patients with low back problems, but with a mixed group of medications.  Two reports compared acetaminophen with codeine to diflunisal (an NSAID) with patients treated for 1 and 2 weeks, respectively. 115,116  The third study compared three groups, one group receiving codeine, one oxycodone plus aspirin, and one acetaminophen. 117 
  At the conclusion of treatment, Muncie, King, and DeForge116 and Brown, Bodison, Dixon, et al.115 found no significant differences between groups in terms of pain relief or functional improvement. 
  Wiesel, Cuckler, Deluca, et al., 117 who evaluated a population of military recruits with acute low back pain, found no difference between the three medication groups in amount of time before patients returned to full activities.  Pain relief was claimed to be superior in groups receiving opioid analgesics compared with acetaminophen, with the greatest effect seen in the first 3 days of treatment.  No statistics were reported to support the claim. 
  Potential Harms and Costs.  Side effects reported by subjects receiving acetaminophen with codeine included dizziness, fatigue, inability to concentrate, impaired vision, drowsiness, nausea, and constipation.115 
, 116  In one study, 35 percent of subjects receiving acetaminophen with codeine had to discontinue the medication because of intolerable side effects.116  Prolonged use of opioid analgesics is associated with the development of tolerance and physical dependence.  A risk of developing physical dependence with short-term use of opioids has also been reported.118 
  The expense of treatment with these medications varies greatly, depending on the medication used and the length of treatment. 
  Summary of Findings.  There are no well-designed controlled studies that evaluate the use of opioid analgesics compared with no treatment in patients with low back problems.  The studies reviewed found that patients taking opioid analgesics did not return to full activity sooner than patients taking NSAIDs or acetaminophen.  In addition, two studies found no difference in pain relief between NSAIDs and opioids.  Finally, side effects of opioid analgesics were found to be substantial, including the risk for physical dependence.  These side effects are an important concern in conditions that can become chronic, such as low back problems. 
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