Secondary analysis of the SHaPED trial: shifting away from opioids to simple analgesics for emergency care of low back pain

Context: The SHaPED trial implemented a model of care for low back pain in emergency departments and resulted in a 12.3% reduction in the prescription of opioids (OR 0.57, 95% CI 0.38–0.95) without compromising patient outcomes. However, the original analyses did not look if the decrease in opioid use led to a greater use of the recommended analgesics (e.g. non-steroidal anti-inflammatory drugs-NSAIDs).

Objective: To determine the effects of the SHaPED intervention on the use of non-opioid pain medicines in the management of low back pain in emergency departments.

Study Design: This is a secondary analysis of a stepped-wedge cluster-randomised controlled trial.

Setting: SHaPED was a multi-centre trial that took place in four emergency departments of NSW, Australia.

Population Studied: Emergency department clinicians (physicians, nurses and physiotherapists) (n=269) and patients aged 18 years and older who presented to an emergency department with non-specific or radicular low back pain (n=4,625) were included.

Intervention: The SHaPED trial used a multifaceted clinician-targeted 4-week intervention to encourage guideline-adherent care that included educational seminars and materials, provision of non-opioid pain management strategies, education on referral to outpatient services and audit and feedback.

Outcome Measures: The main outcome of this secondary analysis was the proportion of low back pain episodes treated exclusively with NSAIDs, paracetamol, or a combination of the two. Secondary outcomes were the proportion of LBP presentations receiving each class of non-opioid pain medicines (paracetamol, NSAIDs, muscle relaxants, corticosteroids, benzodiazepines, antiepileptics, and antidepressants), administered alone or in combination with opioids and/or non-opioids.

Results: There was a 7.1% absolute increase in the proportion of low back pain episodes treated solely with the combination of NSAIDs and paracetamol (OR 2.05, 95% CI 1.16-3.65), a 1.4% absolute increase in the use of NSAIDs alone (OR 3.05, 95% CI 1.24–7.52), and an absolute decrease of 2.3% in the prescriptions of benzodiazepines (OR 0.42, 95% CI 0.20–0.86).

Conclusions: These secondary analyses of the SHaPED trial provide the first randomised evidence that a shift in the prescribing pattern of pain medicine away from opioids and towards simpler and safer analgesics for the emergency care of low back pain is possible.