SPACE

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Krebs EE, et al. "Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain". JAMA. 2018. 319(9):872-882.
PubMedFull textClinicalTrials.gov

Clinical Question

In patients with moderate to severe chronic back or osteoarthritic hip/knee pain, despite analgesic use, does opioid compared to non-opioid medication therapy result in better pain-related function?

Bottom Line

In patients with severe back or hip/knee pain not currently receiving opioid therapy, there was no difference between opioid vs. non-opioid therapy used in an escalating treat-to-target approach over 12 months but there may be more adverse events associated with opioid therapy.

Major Points

Opioids became widely prescribed for chronic pain starting in the 1990s, largely driven by intensive marketing strategies by pharmaceutical companies like Purdue (led by the Sackler family).[1] Increasing availability of highly abusable opioids has been identified as a major driver of the opioid epidemic. In the US alone, overdose deaths grew from 17,000/year in 1999 to 70,000/year in 2017.[2] Despite the widespread prescription of opioids, their efficacy for chronic pain was unknown.

Published in 2018, the Strategies for Prescribing Analgesics Comparative Effectiveness (SPACE) trial randomized 240 VA ambulatory patients with moderate to severe chronic musculoskeletal pain (back, hip, or knee) on analgesics to opioid or non-opioid pain management strategies (e.g., NSAIDs, gabapentin, TCAs). At 12 months, overall pain was similar in each group, except a lower pain intensity in the non-opioid group and more adverse events in the opioid group. Given the male-predominant VA population, the trial's generalizability is somewhat limited. However, it provides initial evidence against the routine use of opioids for chronic musculoskeletal pain.

Guidelines

As of June 2019, no guidelines have been published that reflect the results of this trial.

Design

  • Single-center, open label, randomized trial
  • N=240
    • Opioid (n=120)
    • Non-opioid (n=120)
  • Setting: 62 American primary care clinicians affiliated with the Veterans Affairs
  • Enrollment: June 2013 to December 2015
  • Mean follow-up: 12 months
  • Analysis: Intention-to-treat
  • Primary Outcome: Improvement in pain-related function assessed with the Brief Pain Inventory (BPI)[3]

Population

Inclusion Criteria

  • Back pain or knee or hip pain associated with osteoarthritis not receiving opioids
  • Pain occurring almost every day for ≥6 months despite analgesic use
  • Brief Pain Inventory (BPI) scale average pain ≥5 and BPI interference score ≥5

Exclusion Criteria

  • Severe mental illnesses
  • Moderate severe cognitive function
  • Planned surgery to address pain in the next year
  • Long term opioid treatment
  • Contraindications to study medications
  • Life expectancy <12 months

Baseline Characteristics

From the opioid group.

  • Demographics: Mean age 57 years, 13% female, 88% white, 6% black, 6% other ethnicity, higher education 24%
  • Employment: Employed 42%, self-employed 6%, retired 36%
  • Pain eligibility: Back pain 65%, Hip/knee osteoarthritis pain 35%
  • Smoker 21%, hazardous alcohol use (AUDIT Score ≥8) 3%, illicit drug use in prior year 7%
  • Mental Health: Moderate depression 23%, Moderate anxiety 9%, PTSD 21%

Interventions

Participants were randomized to a group in and received stepwise approach to management of pain:

  • Opioid Group - Titrated to maximum of 100 morphine-equivalent mg:
  1. Morphine IR, hydrocodone/acetaminophen, oxycodone IR
  2. Morphine sustained release, oxycodone sustained release
  3. Transdermal fentanyl
  • Non-opioid
  1. Acetaminophen and NSAIDs
  2. Adjuvant oral medications (nortriptyline, amitriptyline, gabapentin), topical analgesics (capsaicin, lidocaine)
  3. Drugs requiring pre-authorization in VA system (pregabalin, duloxetine, tramadol)

Outcomes

Comparisons are opioid therapy vs. non-opioid therapy at 12 months.

Primary Outcomes

Pain-related function BPI Score[3] (efficacy outcome)
Out of 10 points, higher indicating worse function.
3.4 vs. 3.3 (difference 0.1; 95% CI -0.5 to 0.7; P=0.58)
Medication-related symptom checklist (adverse outcome)
Out of 19 points, higher indicates worse result.
1.8 vs. 0.9 (difference 0.9; 95% CI 0.3 to 1.5; P=0.03)

Secondary Outcomes

Efficacy Outcomes

Pain intensity on BPI
4.0 vs. 3.5 (difference 0.5; 95% CI 0.0 to 1.0; P=0.03)
VR-12 scores[4]
Out of 100 points, lower indicates worse reported symptoms.
Physical health: 32.7 vs. 33.9 (difference −1.3; 95% CI −3.8 to 1.3; P=0.23)
Mental health: 51.2 vs. 50.4 (difference 0.7; 95% CI −2.4 to 3.8; P=0.40)
RMDQ-11[5] pain-related physical function
Out of 11 points, higher indicates worse function.
5.8 vs. 5.9 (difference −0.1; 95% CI −1.0 to 0.8; P=0.47)
PHQ-8[6] depression symptoms
Out of 24, higher indicates worse depressive symptoms.
4.3 vs. 4.5 (difference −0.2; 95% CI −1.5 to 1.1; P=0.13)
GAD-7[6] anxiety symptoms
Out of 21, higher indicates worse anxiety symptoms.
2.5 vs. 2.8 (difference −0.4; 95% CI −1.4 to 0.7; P=0.02)
PROMIS[7] sleep disturbance
Out of 32; higher indicates worse sleep disturbance.
23.4 vs. 21.0 (difference 2.3; 95% CI 0.1 to 4.6; P=0.33)
MIDAS[8] headache disability
Out of 270; higher indicates worse headache.
3.7 vs. 3.2 (difference −0.5; 95% CI −2.7 to 3.6; P=0.82)
ASEX[9] sexual function
Out of 30; higher indicates worse sexual function.
17.9 vs. 19.0 (difference −1.1; 95% CI −2.8 to 0.7; P=0.49)
MFI[10]
Out of 20; higher indicates worse fatigue, activity, or motivation.
General fatigue: 12.5 vs. 12.0 (difference 0.6; 95% CI −0.6 to 1.7; P=0.68)
Mental fatigue: 9.2 vs. 9.3 (difference 0.1; 95% CI −1.3 to 1.0; P=0.39)
Physical fatigue: 12.4 vs. 11.8 (difference 0.7; 95% CI −0.5 to 1.9; P=0.73)
Reduced activity: 10.6 vs. 10.3 (difference 0.3; 95% CI −1.0 to 1.5; P=0.74)
Reduced motivation: 8.6 vs. 8.8 (difference −0.2; 95% CI −0.7 to 1.6; P = 0.09)

Adverse Events

All-cause hospitalization, P = 0.94
None: 83% vs. 83%
1: 13% vs. 13%
≥2: 5% vs. 4%
All-cause ED visit, P = 0.18
None: 50% vs. 61%
1: 28% vs. 25%
≥2: 22% vs. 14%
Patients with Falls after enrollment, P = 0.19
0: 53% vs. 53%
1: 22% vs. 14%
≥2: 25% vs. 33%

Criticisms

  • Not blinded
  • Patient self-reporting may by affected by bias
  • Generalizability limited due to VA population and unclear[11]
  • Reported adverse events may not represent highly concerning ones[12]
  • Patients using opioids excluded

Funding

  • Merit Review Award (I01-HX-000671) from the US Department of Veterans Affairs Health Services Research and Development Service

Further Reading

  1. Dyer O & OxyContin maker stops marketing opioids, as report details payments to advocacy groups. BMJ 2018. 360:k791.
  2. Overdose Death Rates page on the NIDA/NIH website. Accessed 2019-06-27.
  3. 3.0 3.1 Keller S et al. Validity of the brief pain inventory for use in documenting the outcomes of patients with noncancer pain. Clin J Pain 2004. 20:309-18.
  4. Selim AJ et al. Updated U.S. population standard for the Veterans RAND 12-item Health Survey (VR-12). Qual Life Res 2009. 18:43-52.
  5. Stroud MW et al. Assessment of self-reported physical activity in patients with chronic pain: development of an abbreviated Roland-Morris disability scale. J Pain 2004. 5:257-63.
  6. 6.0 6.1 Kroenke K et al. The Patient Health Questionnaire Somatic, Anxiety, and Depressive Symptom Scales: a systematic review. Gen Hosp Psychiatry 2010. 32:345-59.
  7. Yu L et al. Development of short forms from the PROMIS™ sleep disturbance and Sleep-Related Impairment item banks. Behav Sleep Med 2011. 10:6-24.
  8. Stewart WF et al. Development and testing of the Migraine Disability Assessment (MIDAS) Questionnaire to assess headache-related disability. Neurology 2001. 56:S20-8.
  9. McGahuey CA et al. The Arizona Sexual Experience Scale (ASEX): reliability and validity. J Sex Marital Ther 2000. 26:25-40.
  10. Smets EM et al. The Multidimensional Fatigue Inventory (MFI) psychometric qualities of an instrument to assess fatigue. J Psychosom Res 1995. 39:315-25.
  11. Wang W & Macaulay W Opioids vs Nonopioids for Chronic Back, Hip, or Knee Pain. JAMA 2018. 320:506-507.
  12. Singh JA et al. Opioids vs Nonopioids for Chronic Back, Hip, or Knee Pain. JAMA 2018. 320:508.