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Harms and benefits of opioids for management of non-surgical acute and chronic low back pain: a systematic review
  1. Hannah-Rose Tucker1,
  2. Katie Scaff1,
  3. Tess McCloud1,
  4. Kimberly Carlomagno1,
  5. Kathleen Daly1,
  6. Alessandra Garcia1,
  7. Chad E Cook2
  1. 1 Doctor of Physical Therapy, Duke University School of Medicine, Durham, North Carolina, USA
  2. 2 Physical Therapy, Duke University, Durham, North Carolina, USA
  1. Correspondence to Hannah-Rose Tucker, Doctoral Student, Duke University Division of Physical Therapy, Durham NC 27708, USA; hannah.rose.tucker{at}


Background Consequences of prescription opioid use involve harms, addiction, tolerance and death. Despite routine prescription, opioids are not recommended for initial intervention by any major multidisciplinary low back pain (LBP) guideline.

Objective Our primary purpose was to improve overall understanding of the harms and benefits associated with oral opioid interventions prescribed for treatment of acute or chronic back pain. Our second goal was to evaluate pain intensity and to compare and contrast these data with the harms. Our last objective was to evaluate conflicts of interest among the study authors and the findings.

Design/data/eligibility criteria Studies incorporating oral prescription opioid management of non-surgical LBP were evaluated. After systematic assessment, no studies that met inclusion included participants with specifically acute LBP. Therefore, extracted data reflects only populations with subacute and chronic LBP. Data on reported harms, severe harms, pain outcomes and withdrawal rates were extracted and meta-analyses were completed for opioid versus placebo trials and opioids versus non-opioid trials.

Results Fourteen studies met inclusion/exclusion requirements. All trials involved short-term management with limited follow-up. A high percentage of harms were identified across most studies. Opioids were not shown to be superior to other medications, and only showed superiority to placebo comparators (at cost of additional harms).

Conclusion This review identified trends of higher harms rates and higher percentages of severe harms in opioid arms for the management of subacute and chronic LBP. The majority of trials that demonstrated benefits with opioids also had potential conflicts of interest. Lastly, non-opioid medications demonstrated statistically significant pain improvement compared with opioids. We feel that the results of the trial are supportive of current LBP guidelines and do not condone the initial use of opioids in management of subacute or chronic LBP.

Trial registration number CRD42017070914

  • back
  • lower back
  • pharmacology
  • spine

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  • Contributors CEC generated the study idea. AG led and executed meta-analyses and GRADE. H-RT served as lead author and managed overall organisation and planning, led writing and aided GRADE execution. KS extracted and reported outcome data and researched and reported conflicts of interest. TMC extracted harms and described trends. KC was key in writing methodology and aiding with overall editing. KD tabulated all data and formatted all tables. All authors contributed to the data extraction and writing. All authors approved the final version of the manuscript.

  • Funding CEC is funded by the NIH/DOD/VA UG3/UH3 collaborative AT-17-001 and by the DOD W81XWH-13-PRORP-TRA.

  • Competing interests CEC receives royalties from Book sales and educational material. CEC is a paid editor for JOSPT. All other authors report no competing interests.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Any unpublished data such as meta-analyses graphs or harms tables can be retrieved from Hannah-Rose Tucker via email at or

  • Patient consent for publication Not required.