Opioid Use for Acute Injuries Not Supported By Research

Evidence shows compelling reasons to avoid opioid prescribing for acute musculoskeletal injuries.

Jason Busse, DC, PhD
November 30, 2020

Prescription opioids may provide pain relief, but can also result in addiction, overdose and even death. In the U.S., drug overdose deaths involving prescription opioids rose nearly 400%, from 3,442 in 1999 to 17,029 in 2017, according to the National Institute on Drug Abuse. As such, there is interest in avoiding use of prescription opioids when possible.

Two new evidence reviews related to acute musculoskeletal injuries like strains and sprains suggest other forms of treatments are as effective as opioids and have less risk of harms to patients. They were both published in the Annals of Internal Medicine and funded by the National Safety Council. 

The first review explored the management of acute pain from non-low-back musculoskeletal injuries. Topical nonsteroidal anti-inflammatory drugs (NSAIDs), followed by oral NSAIDs, and then by acetaminophen (the generic name for the over-the-counter drug Tylenol), showed the most convincing and attractive benefit-to-harm ratio for patients. No opioid achieved benefit greater than NSAIDs for non-low-back musculoskeletal injuries, and opioids caused the most harm.

The second review explored prolonged opioid use following initial prescription for acute musculoskeletal injuries in adults. For high-risk patients, including those receiving workers’ compensation benefits, veterans affairs claims or patients with high rates of substance use disorders, prolonged opioid use (one year after an initial injury) was a serious concern. Approximately one in four high-risk patients developed prolonged opioid use, compared to 6% of the general population.

These results provide compelling reasons to avoid prescribing opioids for acute, non-low-back musculoskeletal injuries. If followed, this guidance would result in a substantial change in practice. An analysis of 30,832 U.S. patients who received treatment for acute ankle sprains from 2011 to 2015 found that 25% were prescribed opioids for their pain.

The U.S. is the leading prescriber of opioids in the world, and there have been efforts to curb prescribing in recent years. The results of these recent reviews support continued caution, but there is a balance to be maintained, especially when it comes to long-term opioid therapy for chronic pain where forced tapering is not supported by evidence and may cause more harm than benefit. Opioids may have a role in pain management for some patients, but keeping our patients and communities safe should be the first priority.

Jason Busse, DC, PhD

Jason Busse, DC, PhD, is associate professor, McMaster Faculty of Health Sciences.

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