In recent years, there has been a growing focus on reducing opioid prescriptions for managing low back pain (LBP) in emergency departments (EDs). This shift is driven by the significant risks of opioid misuse, addiction, and overdose, which have become major public health concerns. A recent study published in JAMA Health Forum explored an alternative approach through the SHAPED (Sydney Health Partners Emergency Department) trial. The research aimed to encourage the use of simpler, safer pain relief methods, such as nonsteroidal anti-inflammatory drugs (NSAIDs) and paracetamol, in place of opioids for patients presenting with LBP.
The trial implemented a new care model across multiple EDs in Australia, aiming to align with clinical guidelines that prioritize non-opioid treatments for LBP. These guidelines recommend NSAIDs and paracetamol as the first line of defense against pain, reserving opioids only for situations where other treatments have proven insufficient. Despite this, the study notes that many EDs still resort to opioids, with around two-thirds of patients receiving them in Australia and nearly 40% in the United States.
As Dr. Claudia Côté-Picard, one of the lead researchers, pointed out, “Our goal was to see if we could reduce opioid use without compromising patient care.”
The SHAPED trial’s results were promising. It showed that the intervention reduced the use of opioids from 62.8% to 50.5% of cases without negatively affecting outcomes like pain intensity, disability, quality of life, or overall patient satisfaction. This reduction represents a significant step forward in addressing the opioid crisis, especially in settings like emergency departments where quick decisions about pain management are often necessary.
Dr. Chris G. Maher, another study co-author, emphasized the significance of these findings: “The reduction in opioid use means we are better adhering to best practice guidelines, which ultimately makes care safer for patients.”
However, the researchers also wanted to explore whether this reduction in opioid use led to an increase in the use of other potentially risky pain medications, such as benzodiazepines or antiepileptics, which carry their own risks of misuse and addiction. Through a detailed secondary analysis, they found no evidence of such substitution. Instead, there was a clear shift towards using NSAIDs and paracetamol, either alone or in combination. The use of NSAIDs, in particular, increased significantly, suggesting that clinicians were embracing these safer alternatives more readily.
One of the most noteworthy outcomes was the increased proportion of LBP patients who received only nonopioid pain medications or no pain medication at all, which rose by 10.4%. This suggests a broader acceptance of non-drug approaches or minimal intervention when appropriate, aligning with the recommendations of many international pain management guidelines.
Dr. Gustavo C. Machado, who also contributed to the study, highlighted, “The fact that we saw no increase in other risky medications is a positive sign. It indicates that clinicians are not just replacing one potentially harmful medication with another.”
The shift towards nonopioid options in the ED could have significant long-term implications. For one, it helps to mitigate the risk of patients developing opioid dependencies, a critical issue given the rising rates of opioid addiction in many parts of the world. Additionally, it underscores the importance of clinician education and adherence to guidelines, suggesting that with the right training and protocols, it is possible to change prescribing behaviors even in high-pressure environments like emergency departments.
The study does acknowledge some limitations. Its findings, while robust within the trial’s Australian context, may not directly translate to other countries with different healthcare systems and practices. Moreover, the intervention involved several components, such as clinician training and ongoing support, which might be challenging to replicate elsewhere without similar resources. Future research is needed to identify which elements of the intervention were most effective and how they could be adapted for broader use.
Despite these challenges, the SHAPED trial offers a blueprint for how emergency departments can move towards safer, evidence-based management of low back pain. By reducing reliance on opioids and increasing the use of safer alternatives like NSAIDs, the study suggests that it is possible to improve patient outcomes while also addressing a key public health issue. As Dr. Côté-Picard noted, “It’s a win-win for patients and for the healthcare system when we can provide effective pain relief without the risks associated with opioids.”
The broader implications of this study are significant, especially considering the ongoing global efforts to curb opioid misuse. If similar approaches are adopted in other regions, there could be a substantial reduction in the number of patients exposed to the risks of opioid medications. Moreover, it could inspire further research into how other types of acute pain are managed in emergency settings and whether similar shifts could be made towards nonopioid treatments.
For more, visit: https://doi.org/10.1001/jamahealthforum.2024.3008
