Risk Factors for Prolonged Opioid Usage in Patients with Low Back Pain in the Civilian and Military Population

Risk Factors for Prolonged Opioid Usage in Patients with Low Back Pain in the Civilian and Military Population

Ali Serrani, SPT, ATC

Background: 

My interest in the management of low back pain and the Opioid Epidemic began during my first clinical at Vidant Medical Center in Greenville, NC. There I observed many patients with a medical history of chronic low back pain and polypharmacy, including opioid prescriptions. These patients were unaware of the potential complications, outcomes, or consequences of high or prolonged opioid usage, and often lived in a state of pain without appropriate intervention. Upon reading about current faculty research projects, I read about the opportunity to participate in a collaboration project between UNC and Duke University, focusing on the differences between opioid naive patients and prior users and downstream opioid use. This project involved Dr. Givens, PhD, PT, DPT from UNC, and Dr. Cook, PhD, PT, FAAOMPT from Duke, as well as my classmate, Greg Howell, and two Duke students, Lindsay DiMarco and Benjamin Ramger.

Purpose: 

The opioid epidemic is growing without hesitation, fueled by the plague of chronic pain and the over-prescription of medications in attempt to treat it.¹ Low back pain is the most common pain condition to receive an opiate prescription. These prescriptions come most often from a primary care physician, contrary to the clinical practice guidelines (CPGs) and the evidence of potential harm and ineffectiveness of these medications on the condition.² In attempt to combat the opioid crisis, the CDC has developed and updated guidelines for prescriptions since the exponential increase of these in 1990. However, these have remained controversial and not consistently adhered to due in part to the lack of consequences for noncompliance.¹

Chronic pain is one of the most common conditions leading to a medical visit in the United States.^3,4 Under the umbrella of chronic pain exists low back pain, a condition affecting 50 million adults in the United States.⁵ Not only does LBP affect the sensory system, it is also a contributor to significant emotional distress in many patients.⁶ In addition, LBP causes significant amounts of disability leading to upwards of 149 million missed days of work in the United States.⁷ There is also an increased risk of suicide in those with chronic LBP, defined as low back pain lasting longer than three months.⁶ Studies have identified professions at great risk of developing low back pain, including driving professionals (taxi, bus, truck, etc.), heavy machinery operators, pilots, and construction workers, to name a few. The physical nature of these professions contributes to the development of low back pain as well as psychosocial health in the work environment. Poor job satisfaction, monotony, stress, and work relations can all contribute to the onset and chronicity of this condition.⁷

Statement of Need:

Although there are studies available that identify risk factors for opioid misuse and poor outcomes due to the use of opioid medication, providers continue to utilize this treatment method inappropriately. The evidence supports nonpharmacologic treatment such as superficial heat, massage, spinal manipulation, exercise intervention, mindfulness-based stress reduction, etc. Should these strategies be inadequate, non-steroidal anti-inflammatory medication can be used as the next line of treatment. Lastly, opioids may be prescribed if all prior interventions are insufficient for pain relief and return to function.

Information, education, and identification of patients that are at a greater risk for opioid misuse is of the utmost importance. As healthcare providers, we must be informed and follow current evidence in order to provide our patients with the best care possible. Continuing to provide opioid prescriptions to patients who may not be appropriate for this intervention could be a significant contributor to the opioid epidemic.

Products:

As my interest in the topic grew greater, I developed multiple products across various courses and experiences. In our Evidence Based Practice II course, I completed a Critically Appraised Topic (CAT) that synthesized multiple studies in the attempt to compare the outcomes of physical therapy intervention to opioid usage in military members with acute low back pain. Concurrently, I began my work as a collaborator on the group research project between UNC and Duke examining the influence of prior opioid use on downstream opioid usage. Through this project, I learned more about analyzing a data set, reading current literature, and writing parts of a manuscript. This paper is currently undergoing final edits before submission for publication. I completed a Literature Review that synthesized evidence regarding risk factors for high or prolonged opioid use in patients with low back pain. This review included studies involving military servicemembers/beneficiaries, as well as the civilian population.

Using the data-set we studied for the collaborative project, with the help of Dr. Cook, a secondary analysis was run to examine the influence of comorbidities on high opioid usage at index date as well as prolonged opioid use after index (12 months post-index date). With this, I created an abstract and poster for presentation at a professional conference. The poster contains sensitive data, therefore cannot be posted on this website until there is copyright protection.

Evaluation:

I have worked very closely with Dr. Givens, Dr. Cook, and Dr. Reiman on this project, leading to a successful completion, even when it didn’t seem possible. Their feedback and advice was crucial as I began this project as a complete novice in the world of research. Each member of the committee was provided an evaluation survey to be completed at their leisure. This evaluation can be found here: https://goo.gl/forms/3FZW2vFaW2u4rTXC2

Reflection:

Self-reflection is imperative to personal and professional growth, no matter how challenging this may be. This project was one of the most academically challenging for me, consuming a considerable amount of time and energy. However, many great accomplishments come from the most uncomfortable of situations and I am proud that I continued to persevere. The meetings, emails, and conversations with committee members, advisors, and classmates were crucial to my success. I learned a great deal about myself as a student, the research process, and also to appraise literature efficiently and effectively. These skills will be incredibly helpful in my career as a physical therapist. I sincerely hope that this project and the group project with Duke can influence provider decisions regarding opioid prescriptions in order to work towards decreasing the opioid epidemic and its impact on the United States population.

Acknowledgements:

Firstly, I want to thank Dr. Givens and Dr. Cook for creating this opportunity for collaboration between UNC and Duke. Fostering these relationships between two schools only separated by approximately 15 miles (and two shades of blue) is important and can positively impact the field of physical therapy. A sincere thanks to Dr. Reiman for stepping in as a member of my Capstone Committee, as well as providing significant feedback and advice throughout the process. The student cohort of this project, Greg, Lindsay, and Ben, for their hard work and patience throughout the project. To Mike McMorris, thank you for providing guidance throughout my experience at UNC, as well as keeping my spirits high through challenging times. To Jon Hacke, although you did not have an assigned role on my Capstone Committee, thank you for being my academic advisor and listening to me when I needed an ear in the stressful times. The entire UNC DPT Program has been incredible. From the faculty, staff, and students, I am forever grateful for these relationships.

I have to send a huge thanks to my family as they have supported me every step of the way, even when I was most likely unbearable. My fiancé, Brad, (and our two Greyhounds!) for allowing me to follow my dreams and to leave the comfort of our home to move to Chapel Hill.

Lastly, I want to acknowledge the loss of my immediate family member to the opioid crisis. Michelle, you have inspired me to educate individuals on the risks of opioid use as well as to support those in need of assistance. I am forever grateful for the time we had together and will miss you always.

Resources:

1. Ballantyne JC, Murinova N, Krashin DL. Opioid guidelines are a necessary response to the opioid crisis. Clin Pharmacol Ther 2018. doi:10.1002/cpt.1063.
2. Gebauer S, Salas J, Scherrer JF. Neighborhood socioeconomic status and receipt of opioid medication for new back pain diagnosis. J Am Board Fam Med 2017;30(6):775-783. doi:10.3122/jabfm.2017.06.170061.
3. Johannes CB, Le TK, Zhou X, Johnston JA, Dworkin RH. The prevalence of chronic pain in United States adults: results of an Internet-based survey. J Pain 2010;11(11):1230-1239. doi:10.1016/j.jpain.2010.07.002.
4. Fritz JM, King JB, McAdams-Marx C. Associations between Early Care Decisions and the Risk for Long-Term Opioid Use for Patients with Low Back Pain with a New Physician Consultation and Initiation of Opioid Therapy. Clin J Pain 2017. doi:10.1097/AJP.0000000000000571.
5. Wasan A, Michna E, Edwards R, et al. Psychiatric comorbidity is associated prospectively with diminished opioid analgesia and increased opioid misuse in patients with chronic low back pain. Anesthesiology. 2015;123(4):861-872
6. Mariano TY, Urman RD, Hutchison CA, Jamison RN, Edwards RR. Cognitive behavioral therapy (CBT) for subacute low back pain: a systematic review. Curr Pain Headache Rep 2018;22(3):15. doi:10.1007/s11916-018-0669-5.
7. Ernat J, Knox J, Orchowski J, Owens B. Incidence and risk factors for acute low back pain in active duty infantry. Mil Med 2012;177(11):1348-1351. doi:10.7205/MILMED-D-12-00183.
8. Qaseem A, Wilt TJ, McLean RM, Forciea MA, Clinical Guidelines Committee of the American College of Physicians. Noninvasive treatments for acute, subacute, and chronic low back pain: A clinical practice guideline from the american college of physicians. Ann Intern Med 2017;166(7):514-530. doi:10.7326/M16-2367.