North American Spine Society

View all recommendations from this society

April 8, 2019

Don’t prescribe opioids for acute or chronic low back pain before a thorough evaluation, consideration of a trial of alternative medications and treatments, and discussion of the risks of opioid therapy.

The use of opioids is not recommended without a thorough evaluation, consideration of alternative medications, treatments, review of all current medications and discussions of risks of opioid therapy and potential interactions with current medications for other conditions. Opioid prescriptions should be for a limited period with the lowest effective dose that provides meaningful pain relief and improved function with manageable side effects.


These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

THIS CHOOSING WISELY DOCUMENT DOES NOT REPRESENT A “STANDARD OF CARE,” nor is it intended as a fixed treatment protocol. It is anticipated that there will be patients who will require less or more treatment than the average. It is also acknowledged that in atypical cases, treatment falling outside this recommendation list will sometimes be necessary. This document should not be seen as prescribing the type, frequency or duration of intervention. Treatment should be based on the individual patient’s need and physician’s professional judgment. This document is designed to function as a guide and should not be used as the sole reason for denial of treatment and services. This document is not intended to expand or restrict a health care provider’s scope of practice or to supersede applicable ethical standards or provisions of law, but to encourage discussion of these issues between physician and patient, encourage active patient participation in health care decision-making, and foster greater mutual understanding.

How The List Was Created

The North American Spine Society (NASS) appointed a multidisciplinary task force in 2012 to identify five areas in which to make recommendations. Based on the scientific evidence, existing clinical practice recommendations and expert opinion, the task force collaboratively identified a draft list of nine recommendations that was subsequently submitted to the NASS Board of Directors for review and ranking. After further refinement, the final list was reviewed and approved by the NASS Board of Directors and released in October 2013. In 2018, a multidisciplinary task force was established to review and revise the existing recommendations. The final revision list was reviewed and approved by the NASS Executive Committee.

NASS’ disclosure and conflict of interest policy can be found at: https://www.spine.org/Documents/WhoWeAre/DisclosurePolicy.pdf

Sources

Krebs EE, Gravely A, Nugent S, et al. Effect of opioid vs nonopioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain: the SPACE randomized clinical trial. JAMA. 2018;319(9):872-882.

Webster BS. Verma SK. Gatchel RJ. Relationship between early opioid prescribing for acute occupational low back pain and disability duration, medical costs, subsequent surgery and late opioid use. Spine. 2007 Sep 1;32(19):2127–32.

Dowell D, Haegrich TM, Chou R. CDC guideline for prescribing opioids for chronic pain – United Stated, 2016. MMWR Recomm Rep. 2016;65(1):1-49.

Qaseem A, Wilt TJ, McLean RM, Forciea MA. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Annals of Internal Medicine. 2017;166(7):514-530.

CDC Guideline for Prescribing Opioids for Chronic Pain. United States 2016. MMWR Recomm Rep. 2016; 65(RR-1):1-49.

Centers for Disease Control and Prevention. 2018 Annual Surveillance Report of Drug-Related Risks and Outcomes — United States. Surveillance Special Report 2. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. Published August 31, 2018.