Investigation of Potential Prognostic Factors for Long-Term Opiate Use in Patients with Low Back Pain

Investigation of Potential Prognostic Factors for Long-Term Opiate Use in Patients with Low Back Pain

Gregory Howell, SPT

Background

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I first became interested in area of prescription opioid use in pain management after my father, a former police officer and army reservist, became dependent on these medications following an elective joint replacement surgery in 2016. Potential issues related to adverse events and dependency continued to present themselves during my clinical experiences, which prompted me to present an in-service regarding the current state of the opioid epidemic, and what physical therapists could do to help. By chance, the opportunity to participate in a research collaborative with students and faculty between the UNC and Duke Doctorate of Physical Therapy (DPT) programs opened up last summer, which aimed to explore and address some of these issues. Joined by the Duke DPT program director Dr. Chad Cook PT, PhD, MBA and our very own UNC DPT program director Dr. Deborah Givens PT, PhD, DPT, our research group set out to explore differences in patient characteristics, comorbidities, and downstream drug use between prior opioid users and opioid naïve individuals with low back pain (LBP).

Dr. Daniel Rhon PT, ScD a clinician and researcher with the Physical Performance Service Line, Office of the Army Surgeon General, provided our research group with a dataset of Department of Defense beneficiaries referred to the physical therapy clinic at Madigan Army Medical Center for LBP. For my Capstone project I elected to explore the literature and perform a secondary analysis on the dataset analyzing potentially prognostic factors for long-term opioid use. This entire process has led to the creation of a variety of products relating to opioid use and LBP, including a research manuscript that our group plans to submit for publication in the near future, a research manuscript abstract for submission to the 2019 American Physical Therapy Association’s Combined Sections Meeting (CSM), a research poster on my secondary analysis of the dataset for presentation at CSM 2019, as well as a poster abstract of this secondary analysis for submission to CSM 2019. Below you will find links to the abstracts, as well as other related products.

Overview

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The opioid epidemic in the United States continues to be a pervasive problem, with prescription opioid related drug overdose deaths quintupling since 1999 ¹. Despite recent clinical practice guidelines ^2,3, which advocate for primarily conservative and non-pharmacologic approaches for longitudinal pain management, long-term prescription of opioids is still prevalent. Long-term opioid use has been found to be associated with a variety of adverse outcomes including drug overdose ^4,5, opioid dependency ^4,6, and development of depression ^4,7.

Opioid prescription is common amongst patients diagnosed with LBP ^8,9, with up to ~19% continuing to use them long-term ⁸. These numbers may be elevated in the military population, with a 2010 study demonstrating that military members with LBP are nearly twice as likely to be prescribed higher doses of opioids ¹⁰. Despite a noted lack of efficacy for achieving clinically significant improvements in pain or function using these medications, prevalence of longitudinal opioid prescription for patients with LBP remains high ¹¹.

Statement of Need

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Despite a recent push promoting physical therapy as an alternative means of pain management in the fight against the opioid epidemic, few clinically useful tools and little information has been presented to help guide clinicians in screening for individuals at increased risk for long-term opioid use. While studies have examined a variety of prognostic factors, surprisingly little to no evidence exists on the influence of prior opioid exposure, the volume of prior opioid exposure, or baseline Oswestry Disability Index (ODI) score for predicting long-term use in patients with LBP. To our knowledge, ours is some of the first research exploring these factors and relationships. Equipping clinicians with information and strategies on how to more easily identify individuals at increased risk for long-term use is important in order to more effectively target these individuals with explicit pain management education and interventions, and to hopefully reduce the impact of the current opioid epidemic.

Products

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Multiple products have been created as a result of my work in this area over the last year. As part of my Evidence Based II class this past fall, I produced a Critically Appraised Topic that explored whether prior opioid use or baseline ODI score was a stronger predictor of increased future opioid use. This winter as a part of an independent research class, I began developing a review of the literature that further explored factors significantly associated with or predictive of long-term opioid use in patients with low back and non-cancer pain, which I continued to add to throughout the spring semester. Additionally, I assisted with the writing and editing of our group’s research manuscript as a middle author, and developed an abstract of this manuscript for submission to CSM 2019. Finally, I developed a research poster and poster abstract for my secondary analysis of the dataset, investigating potentially prognostic factors of long-term opioid use in patients with LBP, which I plan to submit to and present at CSM 2019. Unfortunately due to copyright, I am unable to post the current draft of our group’s research manuscript or my research poster to the page at this time.

For links to the other products see below:

• Critically Appraised Topic
• Literature Review
• Research Manuscript Abstract
• Poster Abstract

Evaluation and Reflection

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In order to evaluate my abstracts, I used the formatting and requirements for submission to CSM. Evaluation of our group’s research manuscript has been primarily through formal discussion and edits by members of our research group and research advisors. For evaluation of my secondary analysis research poster and poster presentation, I intend to use this poster evaluation form ¹², developed through the University of Nevada, Las Vegas’s Graduate and Professional Student Association. Additionally, my capstone advisor and committee members have provided me with invaluable feedback and guidance with regards to the successful completion and refinement of these products.

The experience of being involved in the academic research process over the past two semesters has been both challenging and incredibly rewarding. Having had little research experience prior to becoming involved in this collaborative, I have learned a great deal about the overall research process, and have gained a true appreciation for the amount of time and effort that goes into developing sound research products. By the nature of our research, I have gained a much deeper understanding of statistical analyses, and data interpretation. Additionally, this process has taught me a lot about the value of patience and thoroughness, two things which I intend to carry forward with me into my career as a therapist.

Acknowledgements

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Firstly, I would like to thank both Dr. Givens and Dr. Cook for allowing me to participate in this collaborative, despite my admitted lack of research experience. I have learned so much throughout this process, and will be forever indebted to your grace and support. To Dr. Rhon, thank you so much for providing us with this timely dataset, and for your incredibly helpful and constructive feedback along the way. Without you, none of this would have been possible. To our two Duke counterparts, Lindsay DiMarco BA, MPH, SPT and Benjamin Ramger, BS, SPT, thank you both so much for your continued efforts on the collaborative research manuscript and your newfound friendship. Finally, I would like to formally thank my “partner in crime” Ali Serrani, ATC, BS, SPT. It seems as though we have been paired up as partners for almost every project throughout our DPT curriculum, so it was fitting for us to be paired together as part of this final research collaborative experience. I’m not sure what PT school would have been like without you, but I’m confident that it wouldn’t have been nearly the same. Thank you for your friendship, openness, kindness, and much needed timely humor. You have made this entire experience more enriching for me, and I sincerely thank you for that.

References

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1. Seth P, Rudd RA, Noonan RK, Haegerich TM. Quantifying the epidemic of prescription opioid overdose deaths. Am J Public Health 2018;108(4):500-502. doi:10.2105/AJPH.2017.304265.
2. 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.
3. Rosenberg JM, Bilka BM, Wilson SM, Spevak C. Opioid therapy for chronic pain: overview of the 2017 US department of veterans affairs and US department of defense clinical practice guideline. Pain Med 2017. doi:10.1093/pm/pnx203.
4. Hoffman EM, Watson JC, St Sauver J, Staff NP, Klein CJ. Association of Long-term Opioid Therapy With Functional Status, Adverse Outcomes, and Mortality Among Patients With Polyneuropathy. JAMA Neurol 2017;74(7):773-779. doi:10.1001/jamaneurol.2017.0486.
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7. Scherrer JF, Salas J, Copeland LA, et al. Prescription opioid duration, dose, and increased risk of depression in 3 large patient populations. Ann Fam Med 2016;14(1):54-62. doi:10.1370/afm.1885.
8. Deyo RA, Smith DHM, Johnson ES, et al. Opioids for back pain patients: primary care prescribing patterns and use of services. J Am Board Fam Med 2011;24(6):717-727. doi:10.3122/jabfm.2011.06.100232.
9. Deyo RA, Von Korff M, Duhrkoop D. Opioids for low back pain. BMJ 2015;350:g6380. doi:10.1136/bmj.g6380.
10. Morasco BJ, Duckart JP, Carr TP, Deyo RA, Dobscha SK. Clinical characteristics of veterans prescribed high doses of opioid medications for chronic non-cancer pain. Pain 2010;151(3):625-632. doi:10.1016/j.pain.2010.08.002.
11. Abdel Shaheed C, Maher CG, Williams KA, Day R, McLachlan AJ. Efficacy, Tolerability, and Dose-Dependent Effects of Opioid Analgesics for Low Back Pain: A Systematic Review and Meta-analysis. JAMA Intern Med 2016;176(7):958-968. doi:10.1001/jamainternmed.2016.1251.
12. POSTER EVALUATION FORM. University of Nevada, Las Vegas (UNLV) Graduate and Professional Student Association (GPSA). Available at: https://www.unlv.edu/sites/default/files/24/GPSA-EvaluationFormPoster.pdf. Accessed April 15, 2018.