UMEM Educational Pearls

Category: Pharmacology & Therapeutics

Title: Avoid Opioids for Low Back Pain

Keywords: low back pain, opioids, naproxen, oxycodone, cyclobenzaprine (PubMed Search)

Posted: 10/21/2015 by Bryan Hayes, PharmD (Emailed: 11/7/2015) (Updated: 11/7/2015)
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If there weren't enough reasons to avoid opioids, here is another: opioids don't work for low back pain (LBP).


A well-done, double-blind, randomized controlled trial from JAMA set out to compare functional outcomes and pain at 1 week and 3 months after an ED visit for acute LBP among patients randomized to a 10-day course of (1) naproxen + placebo; (2) naproxen + cyclobenzaprine; or (3) naproxen + oxycodone/acetaminophen.


  • Nontraumatic, nonradicular LBP of 2 weeks’ duration or less
  • All patients were given 20 tablets of naproxen, 500 mg, to be taken twice a day.
    • They were randomized to receive either 60 tablets of placebo; cyclobenzaprine, 5 mg; or oxycodone, 5 mg/acetaminophen, 325 mg. Participants were instructed to take 1 or 2 of these tablets every 8 hours, as needed for LBP.
  • Patients received a standardized 10-minute LBP educational session prior to discharge.


Neither oxycodone/acetaminophen nor cyclobenzaprine improved pain or functional outcomes at 1 week compared to placebo, and more adverse effects were noted.

Application to Clinical Practice

Among patients with acute, nontraumatic, nonradicular LBP presenting to the ED, avoid adding opioids or cyclobenzaprine to the standard NSAID therapy.


Friedman BW, et al. Naproxen with Cyclobenzaprine, Oxycodone/Aceaminophen, or Placebo for Treating Acute Low Back Pain: A Randomized Clinical Trial. JAMA 2015;314(15):1572-80.

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