Comparative benefits and harms of individual opioids for chronic non-cancer pain: a systematic review and network meta-analysis of randomised trials

Atefeh Noori; Behnam Sadeghirad; Li Wang; Reed A C Siemieniuk; Mostafa Shokoohi; Elena Kum; Mark Jeddi; Luis Montoya; Patrick J Hong; Edward Zhou; Rachel J Couban; David N Juurlink; Lehana Thabane; Mohit Bhandari; Gordon H Guyatt; Jason W Busse

doi:10.1016/j.bja.2022.05.031

Comparative benefits and harms of individual opioids for chronic non-cancer pain: a systematic review and network meta-analysis of randomised trials

Br J Anaesth. 2022 Sep;129(3):394-406. doi: 10.1016/j.bja.2022.05.031. Epub 2022 Jul 9.

Authors

Affiliations

¹ Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada; The Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, ON, Canada.
² Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada; The Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, ON, Canada; Department of Anesthesia, McMaster University, Hamilton, ON, Canada.
³ Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada.
⁴ Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
⁵ Krembil Research Institute-University Health Network-Orthopaedic Surgery Arthritis Program, Toronto, Ontario, Canada.
⁶ Department of Anesthesia, University of Toronto, Toronto, ON, Canada.
⁷ Department of Family Medicine, McMaster University, Hamilton, ON, Canada.
⁸ Department of Medicine, University of Toronto, Toronto, ON, Canada.
⁹ Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada; The Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, ON, Canada; Department of Anesthesia, McMaster University, Hamilton, ON, Canada; The Chronic Pain Centre of Excellence for Canadian Veterans, Hamilton, ON, Canada. Electronic address: bussejw@mcmaster.ca.

PMID: 35817616
DOI: 10.1016/j.bja.2022.05.031

Abstract

Background: Most systematic reviews of opioids for chronic pain have pooled treatment effects across individual opioids under the assumption they provide similar benefits and harms. We examined the comparative effects of individual opioids for chronic non-cancer pain through a network meta-analysis of randomised controlled trials.

Methods: We searched MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials to March 2021 for studies that enrolled patients with chronic non-cancer pain, randomised them to receive different opioids, or opioids vs placebo, and followed them for at least 4 weeks. Certainty of evidence was evaluated using the GRADE approach.

Results: We identified 82 eligible trials (22 619 participants) that evaluated 14 opioids. Compared with placebo, several opioids showed superiority to others for analgesia and improvement in physical function; however, when restricted to pooled-effect estimates supported by moderate certainty evidence, no differences between opioids were evident. Among opioids with moderate certainty evidence, all increased the risk of gastrointestinal adverse events compared with placebo, although no opioids were more harmful than others. Low to very low certainty evidence suggests that extended-release vs immediate-release opioids may provide similar benefits for pain relief and physical functioning, and gastrointestinal harms.

Conclusions: Our findings support the pooling of effect estimates across different types and formulations of opioids to inform effectiveness for chronic non-cancer pain.

Keywords: benefits; chronic non-cancer pain; harms; network meta-analysis; opioids; systematic review.

Publication types

Meta-Analysis
Review
Systematic Review

MeSH terms

Analgesics, Opioid* / adverse effects
Chronic Pain* / drug therapy
Humans
Network Meta-Analysis
Pain Management
Randomized Controlled Trials as Topic

Substances

Analgesics, Opioid