Opioids Linked to Worse Outcomes After Back Injury
New Study Unveiled at North American Spine Society's 21st Annual Meeting
SEATTLE, WA – October 2006 - Recent years have seen a sharp rise in the use of opioid therapy to treat chronic back pain. Although opioids may help some patients, chronic use after a disabling injury can have steep socioeconomic costs, according to new research being unveiled this week at the North American Spine Society’s (NASS) 21st annual meeting in Seattle.
NASS member Tom Mayer, MD, and colleagues studied 1,200 patients who successfully completed an intensive functional rehabilitation program. Although most were using substantial amounts of opioids when they entered the program, all patients had tapered off the drugs by graduation. One year later, however, 15% were opioid-dependent, and that nearly doubled the risk that a patient would be out of work, and doubled the likelihood that a patient had engaged in excessive healthcare-seeking behavior, apparently to find a physician willing to provide opioids.
There is considerable debate in the medical community about the role of opioids in the treatment of chronic, nonmalignant pain. The new report suggests that in certain individuals opioids may cause harm in unexpected ways.
“Giving prescription opioids to patients with chronic disabling back pain is fraught with risk,” said Mayer, of the PRIDE Productive Rehabilitation Institute in Dallas, Texas.
The researchers used a structured clinicial interview based on formal DSM-IV criteria to evaluate patients for opioid dependence before enrollment in the rehabilitation program. (For details of the DSM-IV criteria, see below.) The patients retained severe functional limitations.
Those who became opioid dependent one year after completing the program were burdened by substantial psychosocial and medical problems. Typically they had been disabled a year longer than their nonopioid-dependent counterparts (29 vs. 17 months). They were also 2.5 times more likely to have had prior surgery, 2.6 times more likely to have an antisocial or borderline personality disorder, about twice as likely to have had a pre-injury substance use disorder, and 1.7 times more likely to have a major depressive or anxiety disorder.
Even after controlling for these factors, the researchers found that opioid dependence was an independent risk factor for poorer treatment outcomes. Physicians who treat patients with chronic disabling back pain “must be cautious in prescribing chronic opioid medication, and be alert to the de-motivating effect such medication can have,” advise Mayer and colleagues.
Despite their disability and functional limitations, “Patients found doctors who were willing to give them the opioids and, more importantly, keep them on opioids,” noted Mayer. “Prescription for benign conditions is probably excessive.”
Accumulating evidence from around the world suggests that researchers are still clarifying the long-term risks and benefits of opioid therapy for chronic nonmalignant pain. In a recent population-based study from Denmark that followed more than 10,000 individuals for 10 years, long-term opioid users had significantly lower rates of employment, worse quality of life, and increased healthcare utilization. About 90% continued to have moderate, severe, or very severe pain. (Eriksen J et al., Pain, in press; epub ahead of print 13 July 2006)
Source: Abstract #18. Tom Mayer, MD, et al. “Opioid Dependence is Associated with Worse Socioeconomic Outcomes of Spine Rehabilitation.”
DSM-IV Diagnostic Criteria for Substance Dependence: The DSM-IV defines substance dependence as a “maladaptive pattern of substance use, leading to clinically significant impairment or distress,” as manifested by at least three of seven characteristics associated with tolerance for a substance, withdrawal, consumption, and a variety of occupational, social, physical, and psychological behaviors. For the complete criteria, see: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. American Psychiatric Association, 1994.
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NASS is a multidisciplinary medical organization dedicated to fostering the highest quality, evidence-based, and ethical spine care by promoting education, research, and advocacy. Since its start in 1985, NASS has grown to nearly 4,000 members in 22 spine-related specialties. NASS members are MDs, DOs, and PhDs, including orthopedics, neurosurgery, physiatry, pain management, and other disciplines. Nurse practitioners, physician’s assistants, chiropractors, physical therapists, practice administrators, and other allied health care professionals involved in spine care are also represented as affiliate members.
For further information, contact:
North American Spine Society
Toll-free: (866) 960-6277 Direct: (630) 230-3600
or
Kathleen Hansen
(630) 933-9477