The Sydney Health Partners Emergency Department (SHaPED) trial significantly reduced the rate of opioid prescriptions for acute back pain by encouraging clinicians to adopt evidence-based clinical guidelines that recommend patients receive non-pharmacological treatments in the first instance.

The SHaPED trial, which was run in four Emergency Departments (EDs) at Sydney Local Health District (SLHD) and Dubbo Health Service, tested methods to encourage busy doctors and nurses to follow the clinical guidelines of the Agency for Clinical Innovation (ACI).

Led by Dr Gustavo Machado and Dr Danielle Coombs from Sydney Musculoskeletal Health (SMH), SHaPED showed that an implementation strategy combining clinician education, education resources, and audit and feedback avoided use of opioids in 12 per cent of patients who presented to an ED with back pain.

The treatment did not negatively affect the patients’ satisfaction with care, pain scores or the impact of the back pain on their physical ability.

SMH Director, Professor Chris Maher, said opioid use for musculoskeletal conditions should be minimised where possible.

“While there is no evidence that opioids are an effective treatment for acute lower back pain, we have plenty of evidence about the harms caused by opioid use,” he said.

“Most of the thousands of people who have died in the United States from prescription opioid consumption, started taking the drugs because they had back pain.”

The SHaPED trial found that the key to changing the treatment approach of doctors and nurses was presenting data about the scale of the opioid problem.

“As a part of the trial we accessed almost real time data on the number of opioids prescribed for low back pain and presented it to the ED clinicians using data visualisation in the form of a dashboard,” said Professor Maher.

“When we showed them the data, they said ‘oh no that’s not us, that’s another hospital’”.

“So, the doctors and nurses, because they were very busy, didn’t realise the scale of the problem, but when it was presented to them, they wanted to be part of the solution.”

Winning clinical trial team: (L-R) Dr Bethan Richards, Dr James Edwards, Hannah Storey, Dr Gustavo Machado, Dr Danielle Coombs, Dr Chris Needs

The ACI model of care for low back pain suggests that patients should not be prescribed strong harmful medications before safer alternatives are tried.

“Emergency Department clinicians should use non-pharmacological strategies such as heat packs first, simple pharmacological strategies such as analgesics second, and only then in selected people might they have to prescribe an opioid in the lowest dose for the shortest period possible,” said Professor Maher.

A follow-up study showed that the effect of the SHaPED trial on the behaviour of ED doctors and nurses was sustained for up to 30 months after the implementation of the clinical guidelines. There was also a significant improvement in the clinicians’ knowledge and beliefs about lower back pain.

“Back pain is one of the top ten conditions seen in Emergency Departments, but most ED clinicians are not taught the best way to manage it,” said Professor Maher.
The SHaPED trial demonstrated it is possible to change clinical practice at scale - and by doing so benefit many patients.

“We had four hospitals, 269 clinicians and 4,491 patients involved in the trial,” said Professor Maher.

“It was also very much real world. Sometimes, for example, we had to reschedule training as the ED was full of emergency cases and staff were literally run off their feet. If you can work in partnership with the staff to improve care in a less than ideal environment, then it is possible in other settings.”

“The SHaPED trial also demonstrated that if we can get researchers and clinicians working together and moving between the two worlds, we will get research into practice more quickly.”

The impact of the trial on clinical practice and policy has been recognised in several ways.

A team of clinician-researchers at Royal Brisbane and Women's Hospital is now testing the SHaPED intervention in their Emergency Department.

In addition to the 2022 award from the Australia and New Zealand Musculoskeletal Clinical Trials Network, the SHaPED trial won the 2018 NPS MedicineWise Award for Excellence in eHealth Resources, the 2018 Lyn March Award for Excellence from the ACI, was a finalist in the 2019 NSW Health Awards, and was highly commended at the 2019 Sydney Local Health District Quality Awards.