Transcript Substance Abuse and Use of Opioids for Low Back Pain

Substance Abuse and Use of Opioids for Low
Back Pain
®
Nabil Aounallah, Sunand Kallumadanda, MD, Sandra Burge, PhD
The University of Texas Health Science Center at San Antonio
Introduction
Results
Low back pain is a highly prevalent health problem
associated with enormous costs worldwide1. In developed
countries, episodes of back pain account for over a quarter
of all conditions involving days away from work2. Back
pain is also the second leading symptom seen by physicians
in the United States3. Chronic back pain occurs in 5% to
8% of people who live in communities and is reported in
nineteen percent of working adults4.
• Figure 1. Patients with a history of drug abuse,
hepatitis C, a positive SOAP score, or any sign of
addiction (all listed + alcohol abuse) reported
significantly higher average pain levels than patients
without those diagnoses.
Effective pain management involves providing appropriate
analgesia for patients with legitimate pain while
simultaneously reducing risks of aberrant drug-related
behaviors and preventing their negative outcomes.
Currently risks for misuse, abuse, or diversion of opioid
medication among patients with chronic low back pain are
not well-known. . Therefore we plan to study how opioid
use correlates with substance abuse as well as risk for
abuse or dependence in a sample of outpatients with
chronic low back pain.
• Figure 3. Patients with a positive SOAP score were
significantly more likely (53.2% vs. 32.3%) to use
opioid medication daily.
Figure 2. Daily Opioid Use
Percent Using Opioids Daily
Clinicians treating chronic back pain have a range of
options, including exercise therapy, non-steroidal antiinflammatory medications (NSAIDs), tricyclic
antidepressants, acupuncture, and electrical stimulation.
Although these treatments may be effective, patients often
experience continued pain and concerns over NSAIDs
which have led clinicians to consider opioid treatments5.
However, over the last two decades, increased opioid
prescriptions have been accompanied by increases in
opioid misuse, abuse, and diversion6. The societal and
economic costs of opioid abuse are considerable.
Compared with non-abusers, opioid-abusers use
significantly more medical services, experience far greater
numbers of opioid and non-opioid related adverse events,
and are at high risk for abuse-related diseases7.
• Figure 2. Although statistically insignificant, patients
with a history of drug abuse or hepatitis C were more
likely to be taking opioid medication on a daily basis.
70%
40%
Reported Pain Level
10
9
8
7
6
5
4
3
2
1
0
No
Yes
p = 0.003
p = 0.001
Drug Abuse
Hepatitis C
6.1846
7.8
5.9752
9.0769
p = 0.002
Positive
SOAP
5.5677
7.4286
p = 0.003
Addiction
Signs
5.3353
7.4189
Acknowledgements
This study was conducted in the Residency Research Network of
Texas (RRNeT) with support from the Dean’s Office, School of
Medicine, UTHSCSA; the Texas Academy of Family Physicians;
the South Texas Area Health Education Center; the National Center
for Research Resources (Award # UL 1RR025767); and the Health
Resources and Services Administration (Award # D54HP16444).
The content is solely the responsibility of the authors and does not
necessarily represent the official views of the National Center for
Research Resources of the National Institutes of Health.
40%39%38%
38%
30%
Alcoholism
Drug
Abuse
Hepatitis
C
20%
p = 0.277
p = 0.346
p = 0.894
10%
0%
No Dx
Yes Dx
Figure 3. Opioids & SOAP Score
(N=155)
100%
90%
80%
Subjects. Student research assistants enrolled 258 adult
70%
patients with low back pain from 9 outpatient clinics across 60%
Texas, and completed followup data collection one year
50%
later with 159 patients (62% followup rate). Patients were
40%
30%
eligible if they had low back pain for 3 months or longer,
and were excluded if they were pregnant or had a diagnosis 20%
10%
of cancer.
0%
Figure 1. Average Pain (N = 159)
54%
50%
Materials and Methods
Procedure and Measurement. Students gathered data from
patient surveys and medical records at enrollment and
followup. A 6-page patient survey addressed demographic
characteristics, pain duration, frequency and severity,
physical functioning and general health, anxiety,
depression, substance abuse, and risk for opioid
misuse. Patients reported pain severity using a 10-point
scale. To assess “risk for opioid misuse,” investigators used
the 5-item SOAPP scale (Screener and Opioid Assessment
for Patients with Pain). Items addressed mood swings,
early morning tobacco use, medication misuse, illegal drug
use, and legal problems. The SOAPP score is a sum of item
responses, with higher scores indicated higher risk. From
participants’ medical records, students gathered information
about causes of low back pain, treatments for pain
(including medications, procedures, and surgeries),
comorbidities, and Body Mass Index (BMI).
60%
60%
32.3
53.2
Positive
SOAP
67.7
46.8
No
Yes
Use Opioids Daily
Negative
SOAP
p=0.009
Conclusions
Opioid therapy is an important element in pain
management programs for patients with legitimate chronic
pain that does not respond to preliminary treatments. Our
research shows that patients with a history of drug abuse
are more likely to use opioids for treatment of chronic low
back pain. We observed the same trend among patients
with positive SOAP scores. Our research also
demonstrates a correlation between substance abuse and
average pain levels. Are patients with substance abuse
more sensitive to pain? Or, are they more likely to
exaggerate their pain?
Unlike previous studies8, substance abuse disorders were
not common in patients taking opioids for low back pain.
In our patient population, few had diagnoses of alcohol
abuse, drug abuse, or hepatitis C although the results could
be biased by exaggerated self-reported pain levels or our
patient population could be very different than other
researchers.
While opioid therapy is useful for pain management, a
balance is essential to prevent opioid abuse and diversion.
Our findings suggest that patients being treated with opioid
therapy for chronic low back pain do indeed have an
increased self-reported pain level and show few signs of
addiction. When treating patients with chronic low back
pain, risk stratification and regular monitoring appear to be
effective in managing patients.
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