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.