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Are Opioids Unhelpful for Acute Neck Pain?

Neck pain is an exceedingly common complaint, with an estimated two-thirds of adults experiencing neck pain at some point in their lives. While neck pain often resolves on its own, the pain and decreased mobility can significantly impact one’s quality of life. When neck pain becomes severe or persistent, many patients turn to opioid medications for relief. However, current evidence suggests opioids provide little benefit for acute neck pain.

Acute neck pain is typically defined as neck pain present for less than 3 months. It often arises from muscle strains or soft tissue injuries to the cervical spine. Poor posture, whiplash injuries, and even stress and anxiety can also contribute to acute neck pain. The natural history of acute neck pain tends to be favorable, with most cases resolving spontaneously within days to weeks. Some patients, however, experience moderate to severe pain that warrants medical treatment.

Opioid medications, such as oxycodone and hydrocodone, have historically been prescribed for many types of acute pain, including neck pain. By binding to opioid receptors, these medications block pain signals and provide analgesia. While potentially effective, opioids carry well-known risks, including sedation, constipation, nausea, and addiction. Given these adverse effects, there has been increasing scrutiny over the appropriateness of opioid prescriptions, especially for acute pain conditions.

Several recent studies have examined the use of opioids specifically for acute neck pain. A 2020 systematic review and meta-analysis published in JAMA looked at 5 randomized controlled trials with a total of 269 patients with acute neck pain. Patients were prescribed opioids such as oxycodone or given placebo pills. When comparing pain scores and functional outcomes, there was no significant difference between the opioid and placebo groups. The opioid groups reported more side effects like nausea and constipation. The study concluded that evidence does not support the use of opioids for acute neck pain.

A large observational study in 2021 had similar findings. Looking at insurance records for over 48,000 patients with new onset neck pain, researchers found those who were prescribed opioids early had worse outcomes. Only 45% of the opioid group reported being pain-free at 12 months, compared to 73% of non-opioid users. The opioid group was also significantly more likely to progress to chronic neck pain lasting over 3 months.

With little evidence of benefit, yet clear risks of harm, clinical guidelines uniformly recommend against opioids for acute neck pain. Both the American College of Physicians and American Chiropractic Association state acute neck pain should be treated first with non-pharmacologic therapies like heat, massage, exercise, and physical therapy. For patients who do not respond adequately to conservative measures, non-opioid medications like NSAIDs, muscle relaxants, or neuropathic agents may be considered. Opioids are only appropriate for the rare patient with severe, debilitating pain that is refractory to all other options.

While some patients still receive opioid prescriptions for acute neck pain, there are safer and more effective alternatives. cervical spine manipulation, acupuncture, massage, and exercise therapy have all shown benefit in clinical trials. Meanwhile, medications like topical NSAIDs and muscle relaxants can provide targeted pain relief with less risk of addiction. With a patient-centered approach focused on shared decision making, most cases of acute neck pain can be managed successfully without resorting to opioids.

In summary, current evidence does not support the routine use of opioids for acute neck pain. Given the lack of demonstrated benefits and known harms, opioids should be prescribed sparingly, if at all, for this condition. For most patients, acute neck pain can be effectively managed with conservative, non-opioid therapies. Avoiding unnecessary opioid prescriptions will lead to better outcomes for patients while also helping to curb the ongoing opioid epidemic.