Transcript No Slide Title

Medication Use for Chronic Low Back Pain
Kathryn Schmidt,1 Gerald Kizerian PhD,2 Sandra Burge PhD1
University of Texas Health Science Center at San Antonio
2Corpus Christi Family Medicine Residency Program
INTRODUCTION
45
40
35
Percent
Opioids
Tramadol, Amitriptyline, or Gabapentin
Muscle Relaxants
10
0
10
20
30
40
Percent
50
60
ACKNOWLEDGMENTS
This study was conducted in the Residency Research Network of
Texas (RRNeT) with support from the Texas Academy of Family
Physicians, the South Texas Area Health Education Center, and the
Dean’s Office, School of Medicine, UTHSCSA.
Non-opioid users
20
Benzodiazepines
Opioid users
5
* *
* *
0
+ +
^^ ^
* *
1 doctor in 2-3 doctors 4 or more
clinic
in clinic
doctors in
clinic
Figure 1. Medicine Used to Treat Chronic Low Back Pain.
Pain clinic
doctor
Surgeon
* χ2=79.015 p=.000
^ χ2=10.793 p=.001
+ χ2=4.562 p=.033
Figure 3. Group Differences in Use of Doctors to Manage Pain.
12
50
10
40
20
Subjects. In 2008, student research assistants consented and enrolled
213 outpatients with chronic low back pain from six family medicine
residency programs in five Texas cities. Patients were included if they
were visiting their family physician for routine care and had low back
pain for 3 months or longer. Investigators excluded pregnant women and
patients with cancer. In 2009, student research assistants conducted oneyear follow up data collection from medical records of 204 patients (96%
follow up), and from surveys of 137 patients (64% follow up).
Measurement. From participants’ medical records, students gathered
information about causes of low back pain, treatments for pain, comorbidities, and BMI. A 5-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.
Analysis. In this analysis, the key outcome variables were medications
used to manage chronic low back pain. We compared two groups:
patients using opioids for managing pain and nonusers of
opioids. Predictor variables included number and type of doctors seen
for back pain and pain severity.
25
15
30
MATERIAL and METHODS
30
NSAIDS
Frequency
Low back pain affects 80% of the population within their lifetime.
While most of these cases resolve within six to twelve weeks,
approximately 30% of cases develop into chronic conditions3.
Medications are predominately used to manage chronic low back pain, as
the majority of cases are not candidates for surgery. The most commonly
used medications include non-steroidal ant-inflammatory drugs
(NSAIDS), benzodiazepines, muscle relaxants, and opioid analgesics2.
Opioid medication is increasingly being given to patients with low back
pain; however, their efficacy has yet to be assessed in high quality
research studies3. Additionally, there is little research on what type of
doctors are prescribing medication for chronic low back pain patients.
This study examined the medications patients use for chronic low back
pain and the relationship between the type of medication used, pain
severity, and doctors seen for treatment.
50
Medications Used for Chronic Low
Back Pain
Pain Level
1The
8
6
Opioid users
Non-opioid users
4
2
10
0
Mean =51.54
Std. Dev. =56.41
N =104
0
100
200
300
0
!
!
With Medicine
*
*
Without Medicine
400
! p=.000
*p=.000
sum of all opioid doses, current average daily use
Figure 2. Average Daily Dose of Opioid Medication.
Figure 4. Group Differences in Pain Severity.
RESULTS
CONCLUSIONS
This study enrolled 204 subjects, 70.1 % female and 29.9% male,
with a mean age of 54.62 ranging from 19-90 years. 40.2% of the
subjects were Hispanic, 44.1% were white, and 14.2% were African
American. Of the research subjects, 50.5% of the patients used opioid
medication (Figure 1), with the median daily dose being 30mg
(morphine equivalent), ranging from 10-320mg (Figure 2). Opioidusers saw significantly more family physicians for their back pain, and
were more likely to receive care from a pain clinic doctor or a surgeon,
compared to nonusers. (Figure 3). Who currently prescribed pain
medicines? We found no significant group differences: family
physicians prescribed pain medicines to 85.3% of opioid users and
73.6% of non-users. Patients who used opioid medication reported
more severe pain on a ten point pain analog scale – both “average
pain” and “unmedicated pain” – when compared to patients who did
not use opioid medication (Figure 4).
This study found that pain severity and the number and types of
doctors treating pain were strongly associated with use of opioid
medication. Opioid users saw more doctors for their pain, and
reported significantly more severe pain. These findings differed from
Breckenridge and Clark’s, which found no correlation between pain
severity and the likelihood of being on opioid medication1. A
possible explanation for this discrepancy could be a difference in
patient population. Their sample was drawn from a VA hospital, and
included 95% males, who were older than this sample, and had less
severe pain.
We have observed that patients with higher pain levels are more likely
to seek multiple ways to manage their pain; they visit more physicians
such as pain or rehabilitation specialists, surgeons and primary care
doctors. When procedural treat-ments are not effective, the patient
returns to the primary care doctor who has few remaining options for
controlling severe pain. Thus opioid medications are often used as the
treatment of last resort. When managing a patient with chronic low back
pain, it is important for primary care physicians to provide appropriate
assessments of the condition, offer varying options for managing pain
and improving function, track the patient's use (or misuse) of health
care resources, and understand the benefits and hazards of prescribing
opioid medicines.
REFERENCES
1. Breckenridge J. Clark JD. Journal of Pain. 4(6):344-50, 2003 Aug.
2. Chou R. Huffman LH. Annals of Internal Medicine. 147(7):505-14,
2007 Oct 2.
3. Deshpande A, Furlan A, Mailis-Gagnon A, Atlas S, Turk D. Cochrane
Database of Systematic Reviews. (3):CD004959, 2007.