UMEM Educational Pearls

The OPAL trial attempted to investigate the effectiveness of opioids in the acute management of neck and back pain.

346 adults presenting to the Emergency department or primary care provider with 12 weeks or less of lower back pain, neck pain or both (of at least moderate intensity).

51% male. 49% female.

Location: Sydney, Australia

All participants received guideline care (advice to stay active, reassurance of a positive prognosis, avoidance of bed rest, and, if required, other non-opioid analgesics).

Patients were then randomly assigned to an opioid (oxycodone, up to 20 mg PO qD) or and an identical placebo, for up to 6 weeks*.

         *Trial used a combination oxycodone/naloxone to reduce risk of opioid induced constipation and assist with blinding.

         *Trial used a modified release formulation that could be dosed q12h rather than q4-6h to increase adherence.

*Recommended regimen was oxycodone 5mg every 12 hours, with titration as necessary, max dose 20mg total per day. 

*Trial physicians were able to individualize the prescription to suit the patient’s needs. 

* Mean prescribed dose was approx. oxycodone 10mg total daily.

*Most patients only treated for 2 weeks

Primary outcome: Pain severity at 6 weeks

Results: Mean pain score at 6 weeks was identical between groups.

Trend towards faster recovery in the placebo group in the first 2 weeks.

Take home: Consider the likely benefit vs harm of prescribing opioids for acute back and neck pain in the ED.


Friedman BW, Irizarry E, Chertoff A, Feliciano C, Solorzano C, Zias E, Gallagher EJ. Ibuprofen Plus Acetaminophen Versus Ibuprofen Alone for Acute Low Back Pain: An Emergency Department-based Randomized Study. Acad Emerg Med. 2020 Mar;27(3):229-235.