Cover StoryPerspective

Study links chronic low back pain and illicit drug use in patients in community setting

Adults with chronic low back pain in the United States were more likely to use marijuana, cocaine, heroin and methamphetamine and were also more likely to have a current prescription for pain-relieving opioid analgesics than adults without chronic low back pain, according to investigators.

Anna Shmagel, MD, MS, and colleagues found more than twice as many individuals with chronic low back pain used heroin than individuals who did not have this pain.

Image: Shmagel A

However, the nature of the relationship between chronic low back pain (LBP) and illicit drug use warrants further investigation, they noted. The study, which was published in Spine, is among the first to focus on rates of illicit drug use among Americans with chronic LBP, according to a press release from the journal.

“[Americans] with chronic low back pain are more likely to use illicit drugs than the general population, particularly the ‘hard’ drugs like cocaine, heroin and methamphetamine,” Anna Shmagel, MD, MS, the study’s first author, told Spine Surgery Today. “There are several ways to interpret this relationship. It is possible that illicit drug use makes chronic pain more likely or leads individuals to seek a chronic pain diagnosis to obtain prescription narcotics. Alternatively, chronic pain patients may be ‘self-medicating’ with illicit drugs. It is also possible there is a unifying risk factor or mediator for both chronic low back pain and illicit drug use, such as depression, for example,” she said.

Shmagel, assistant professor of medicine in the Division of Rheumatic and Autoimmune Diseases at the University of Minnesota, and colleagues used data from responses to a back pain survey from more than 5,000 U.S. adults aged 20 years to 69 years to identify adult patients with chronic LBP. For the study, the definition of chronic LBP was back pain that was present for 3 months or longer, according to the release.

Marijuana, cocaine use

Individuals were given a self-administered questionnaire about drug use to determine data on lifetime and current use of marijuana or hashish, cocaine, heroin and methamphetamine. Using these results, investigators compared adults with chronic LBP and those without this pain.

Findings showed 46.5% of community-based U.S. adults with chronic LBP used marijuana compared with 42% of adults without pain. There were 22% of adults with chronic LBP who used cocaine compared with 14% of adults without LBP who reported cocaine use. Investigators also noted 9% of adults with LBP used methamphetamine vs. 5% of adults without pain, and 5% of adults with chronic LBP used heroin compared with 2% of adults without chronic LBP.

Choll W. Kim

Adults with chronic LBP who said they had lifetime illicit drug use had a higher chance of having an active prescription for opioid analgesics at 22.5% than patients who did not have a history of illicit drug use at 15.3%. This was a statistically significant difference, according to the results. Some 25.7% of adults with chronic LBP who currently used illicit drugs had an active prescription for opioid analgesics compared to 17.7% for adults without chronic LBP.

The authors noted the strength of the study included the sample used, which was large and nationally representative, and that the drug-use questionnaire was private, which helped reduce the chances of reporting bias. Among the study’s limitations, which the authors noted, were that it did not include institutionalized individuals and that residual confounding could have occurred due to the observational nature of the study.

“Despite the limitations, our study offers insights into an important public health problem of drug abuse in the chronic low back pain population, and has the advantage of using a nationally representative sample of community-dwelling adults,” Shmagel and colleagues wrote.

Physicians should be on alert

Choll W. Kim, MD, PhD, of the Spine Institute of San Diego, was not surprised by the findings because the way that patients with chronic LBP respond to pain is highly variable and these patients are also more challenging to treat.

“We should be careful about prescribing narcotic pain medicines that are habit-forming and build up tolerance in a group of patients that is going to have long-standing pain,” he told Spine Surgery Today.

Kim does a number of things when dealing with patients with chronic LBP. He assesses their affect when he takes their history to get a sense of whether they are significantly depress-ed and also provides patients with a handout that discusses opioid-induced hyperalgesia, which is a heightened pain sensitivity caused by opioid pain medication.

“An important component of dealing with this issue is patient education, but that conversation tends to be awkward to broach because patients think you are accusing them of either being pain intolerant or being a drug abuser or a combination of both,” he said, noting the handout is perceived as a more formal approach to the topic and helps complete what can be an awkward conversation.

Get buy-in for prescribed opioids

When Kim prescribes high-dose narcotics prior to surgery for his patients with chronic LBP, he also gets them to agree to the plan for using these medications at the outset. He tells them the pain medications will make their surgery harder overall but, once the surgery is complete, they must be weaned off them.

“It is important to have the buy-in of the patient. Without that,” he said, “they will resist you. We have a responsibility to try to help our patients do this.”

Overall, this study makes it easier for spine surgeons to explain to their patients why prescribing more pain medication is not a good option, according to Kim.

“I think the take-home message from this is there is more information that should put physicians on alert that patients with chronic LBP are at risk for chronic narcotic dependence and abuse. We should continue to be careful about long-term narcotic management in these patients,” Kim said. — by Susan M. Rapp and Monica Jaramillo

Disclosures: Kim and Shmagel report no relevant financial disclosures.

Adults with chronic low back pain in the United States were more likely to use marijuana, cocaine, heroin and methamphetamine and were also more likely to have a current prescription for pain-relieving opioid analgesics than adults without chronic low back pain, according to investigators.

Anna Shmagel, MD, MS, and colleagues found more than twice as many individuals with chronic low back pain used heroin than individuals who did not have this pain.

Image: Shmagel A

However, the nature of the relationship between chronic low back pain (LBP) and illicit drug use warrants further investigation, they noted. The study, which was published in Spine, is among the first to focus on rates of illicit drug use among Americans with chronic LBP, according to a press release from the journal.

“[Americans] with chronic low back pain are more likely to use illicit drugs than the general population, particularly the ‘hard’ drugs like cocaine, heroin and methamphetamine,” Anna Shmagel, MD, MS, the study’s first author, told Spine Surgery Today. “There are several ways to interpret this relationship. It is possible that illicit drug use makes chronic pain more likely or leads individuals to seek a chronic pain diagnosis to obtain prescription narcotics. Alternatively, chronic pain patients may be ‘self-medicating’ with illicit drugs. It is also possible there is a unifying risk factor or mediator for both chronic low back pain and illicit drug use, such as depression, for example,” she said.

Shmagel, assistant professor of medicine in the Division of Rheumatic and Autoimmune Diseases at the University of Minnesota, and colleagues used data from responses to a back pain survey from more than 5,000 U.S. adults aged 20 years to 69 years to identify adult patients with chronic LBP. For the study, the definition of chronic LBP was back pain that was present for 3 months or longer, according to the release.

Marijuana, cocaine use

Individuals were given a self-administered questionnaire about drug use to determine data on lifetime and current use of marijuana or hashish, cocaine, heroin and methamphetamine. Using these results, investigators compared adults with chronic LBP and those without this pain.

Findings showed 46.5% of community-based U.S. adults with chronic LBP used marijuana compared with 42% of adults without pain. There were 22% of adults with chronic LBP who used cocaine compared with 14% of adults without LBP who reported cocaine use. Investigators also noted 9% of adults with LBP used methamphetamine vs. 5% of adults without pain, and 5% of adults with chronic LBP used heroin compared with 2% of adults without chronic LBP.

Choll W. Kim

Adults with chronic LBP who said they had lifetime illicit drug use had a higher chance of having an active prescription for opioid analgesics at 22.5% than patients who did not have a history of illicit drug use at 15.3%. This was a statistically significant difference, according to the results. Some 25.7% of adults with chronic LBP who currently used illicit drugs had an active prescription for opioid analgesics compared to 17.7% for adults without chronic LBP.

The authors noted the strength of the study included the sample used, which was large and nationally representative, and that the drug-use questionnaire was private, which helped reduce the chances of reporting bias. Among the study’s limitations, which the authors noted, were that it did not include institutionalized individuals and that residual confounding could have occurred due to the observational nature of the study.

“Despite the limitations, our study offers insights into an important public health problem of drug abuse in the chronic low back pain population, and has the advantage of using a nationally representative sample of community-dwelling adults,” Shmagel and colleagues wrote.

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Physicians should be on alert

Choll W. Kim, MD, PhD, of the Spine Institute of San Diego, was not surprised by the findings because the way that patients with chronic LBP respond to pain is highly variable and these patients are also more challenging to treat.

“We should be careful about prescribing narcotic pain medicines that are habit-forming and build up tolerance in a group of patients that is going to have long-standing pain,” he told Spine Surgery Today.

Kim does a number of things when dealing with patients with chronic LBP. He assesses their affect when he takes their history to get a sense of whether they are significantly depress-ed and also provides patients with a handout that discusses opioid-induced hyperalgesia, which is a heightened pain sensitivity caused by opioid pain medication.

“An important component of dealing with this issue is patient education, but that conversation tends to be awkward to broach because patients think you are accusing them of either being pain intolerant or being a drug abuser or a combination of both,” he said, noting the handout is perceived as a more formal approach to the topic and helps complete what can be an awkward conversation.

Get buy-in for prescribed opioids

When Kim prescribes high-dose narcotics prior to surgery for his patients with chronic LBP, he also gets them to agree to the plan for using these medications at the outset. He tells them the pain medications will make their surgery harder overall but, once the surgery is complete, they must be weaned off them.

“It is important to have the buy-in of the patient. Without that,” he said, “they will resist you. We have a responsibility to try to help our patients do this.”

Overall, this study makes it easier for spine surgeons to explain to their patients why prescribing more pain medication is not a good option, according to Kim.

“I think the take-home message from this is there is more information that should put physicians on alert that patients with chronic LBP are at risk for chronic narcotic dependence and abuse. We should continue to be careful about long-term narcotic management in these patients,” Kim said. — by Susan M. Rapp and Monica Jaramillo

Disclosures: Kim and Shmagel report no relevant financial disclosures.

    Perspective
    Kern  Singh

    Kern Singh

    This study was an interesting retrospective review of 5,103 patients from the 2009 to 2010 National Health and Nutrition Examination Survey cycle who took a self-administered drug-use questionnaire. Respondents with chronic low back pain (cLBP) had higher rates of lifetime and current illicit drug use. Interestingly, those respondents who reported lifetime illicit drug use also were more likely to have active opioid prescriptions.

    Kern Singh

    The implications of this study are two-fold. First, the results of this study suggest patients with cLBP should be carefully monitored for signs of illicit drug use and misuse. Second, the increased risk for illicit drug use among those with opioid prescriptions demonstrates another risk of liberal opioid prescription practices. This further emphasizes the need for more judicious practices in terms of patient selection for opioid prescription.

    • Kern Singh, MD
    • Spine Surgery Today Editorial Board member Chicago