Interesting....
The opioid group first tier was characterized by short-acting pain killers, then escalated to longer acting agents, and finally capped out with transdermal fentanyl.
The non-opioid regimen was a bit more clever, in my opinion. Tier 1 was acetaminophen and NSAIDs. Providers could then escalate to other oral meds (I particularly like the underused amitriptyline appearing in this tier) and topicals, and finally capped out with tramadol.
Now, I know what you're thinking. Isn't tramadol an opioid? I asked lead author Dr. Erin Krebs that very question. She reminded me that this trial started in 2010: "This was before all the concerns about opioid overdose and addiction and back then a big concern was is it ethical to deprive patients of opioids if they fail all these non-opioid medications."
Times have certainly changed. But regardless, only 13 patients in the non-opioid group ever required escalation all the way to tramadol.
And the results did not look good for opioids. The primary outcome was pain-related function which improved substantially in both groups but did not differ between the groups. Raw pain scores ended up being a bit better in the non-opioid arm.