Opioid use among low back pain patients in primary care: Is opioid prescription associated with disability at 6-month follow-up?

Impact of Prescription Medicines on Work-Related Outcomes in Workers with Musculoskeletal Disorders or Injuries: A Systematic Scoping Review

PURPOSE

Medicines are often prescribed to workers with musculoskeletal disorders (MSDs) and injuries to relieve pain and facilitate their recovery and return to work. However, there is a growing concern that prescription medicines may have adverse effects on work function. This scoping review aimed to summarize the existing empirical evidence on prescription medicine use by workers with MSD or injury and its relationship with work-related outcomes.

METHODS

We identified studies through structured searching of MEDLINE, EMBASE, PsycINFO, CINAHL Plus, Scopus, Web of Science and Cochrane library databases, and via searching of dissertations, theses, and grey literature databases. Studies that examined the association between prescription medicine and work-related outcomes in working age people with injury or MSDs, and were published in English after the year 2000 were eligible.

RESULTS

From the 4884 records identified, 65 studies were included for review. Back disorders and opioids were the most commonly studied musculoskeletal conditions and prescription medicines, respectively. Most studies showed a negative relationship between prescription medicines and work outcomes. Opioids, psychotropics and their combination were the most common medicines associated with adverse work outcomes. Opioid prescriptions with early initiation, long-term use, strong and/or high dose and extended pre- and post-operative use in workers' compensation setting were consistently associated with adverse work function. We found emerging but inconsistent evidence that skeletal muscle relaxants and non-steroidal anti-inflammatory drugs were associated with unfavorable work outcomes.

CONCLUSION

Opioids and other prescription medicines might be associated with adverse work outcomes. However, the evidence is conflicting and there were relatively fewer studies on non-opioid medicines. Further studies with more robust design are required to enable more definitive exploration of causal relationships and settle inconsistent evidence.

Comparative Review of the Socioeconomic Burden of Lower Back Pain in the United States and Globally

Internationally, the United States (U.S.) cites the highest cost burden of low back pain (LBP). The cost continues to rise, faster than the rate of inflation and overall growth of health expenditures. We performed a comprehensive literature review of peer-reviewed and non- peer-reviewed literature from PubMed, Scopus, and Google Scholar for contemporary data on prevalence, cost, and projected future costs. Policymakers in the U.S. have long attempted to address the high-cost burden of LBP through limiting low-value services and early imaging. Despite these efforts, costs (~$40 billion; ~$2,000/patient/yr) continue to rise with increasing rates of unindicated imaging, high rates of surgery, and subsequent revision surgery without proper trial of non-pharmacologic measures and no corresponding reduction in LBP prevalence. Globally, the overall prevalence of LBP continues to rise largely secondary to a growing aging population. Cost containment methods should focus on careful and comprehensive clinical assessment of patients to better understand when more resource-intensive interventions are indicated.

Postoperative analgesic options after spine surgery: finding the optimal treatment strategies

INTRODUCTION

Spine surgery is one of the most common types of surgeries performed in the United States; however, managing postoperative pain following spine surgery has proven to be challenging. Patients with spine pathologies have higher incidences of chronic pain and resultant opioid use and potential for tolerance. Implementing a multimodal plan for postoperative analgesia after spine surgery can lead to enhanced recovery and outcomes.

AREAS COVERED

This review presents several options for analgesia following spine surgery with an emphasis on multimodal techniques to best aid this specific patient population. In addition to traditional therapeutics, such as acetaminophen, non-steroidal anti-inflammatory medications, and opioids, we discuss intrathecal morphine administration and emerging regional anesthesia techniques.

EXPERT OPINION

Several adjuncts to improve analgesia following spine surgery are efficacious in the postoperative period. Intrathecal morphine provides sustained analgesia and can be instilled intraoperatively by the surgical team under direct visualization. Local anesthetics deposited under ultrasound guidance by an anesthesiologist trained in regional techniques also provide the opportunity for single injections or continuous analgesia via an indwelling catheter.

Patient Motivation to Reduce or Discontinue Opioids for Chronic Pain: Self-efficacy, Barriers, and Readiness to Change

OBJECTIVES

This study aimed to assess levels and predictors of self-efficacy and motivation to change opioid use among a community sample of patients using opioids for chronic pain, as well as patient-reported barriers to pursuing opioid discontinuation.

METHODS

Participants with a variety of chronic pain conditions, recruited from ResearchMatch.org , completed a battery of electronic, self-report questionnaires assessing demographic and medical characteristics, pain treatment history, and levels of readiness, self-efficacy, and other attitudes toward reducing or discontinuing opioid use. Multiple regression analyses and analyses of variance were conducted to examine predictors of readiness and self-efficacy to change opioid use. A modified version of rapid qualitative analysis was utilized to analyze themes in participant responses to an open-ended item about "what it would take" to consider opioid discontinuation.

RESULTS

The final sample included N=119 participants, the majority of whom were female (78.2%), Caucasian (77.3%), and well-educated. Readiness and self-efficacy to decrease or stop opioid use were fairly low on a 0 to 10 Visual Analog Scale (2.6 to 3.8) and significantly higher to decrease than stop ( P <0.01). Higher readiness to change was predicted by lower pain severity and higher concern about opioids, whereas higher self-efficacy was predicted by shorter pain duration. Results from the qualitative analyses revealed that the availability of an alternative treatment option was the most commonly cited requirement to consider opioid discontinuation.

DISCUSSION

Patients with lower pain severity, shorter duration of pain, and higher concerns about opioids may be a prime target from a motivation standpoint for interventions addressing opioid tapering and discontinuation.

Up-and-coming Radiotracers for Imaging Pain Generators

Chronic musculoskeletal pain is among the most highly prevalent diseases worldwide. Managing patients with chronic pain remains very challenging because current imaging techniques focus on morphological causes of pain that can be inaccurate and misleading. Moving away from anatomical constructs of disease, molecular imaging has emerged as a method to identify diseases according to their molecular, physiologic, or cellular signatures that can be applied to the variety of biomolecular changes that occur in nociception and pain processing and therefore have tremendous potential for precisely pinpointing the source of a patient's pain. Several molecular imaging approaches to image the painful process are now available, including imaging of voltage-gated sodium channels, calcium channels, hypermetabolic processes, the substance P receptor, the sigma-1 receptor, and imaging of macrophage trafficking. This article provides an overview of promising molecular imaging approaches for the imaging of musculoskeletal pain with a focus on preclinical methods.

A Practical Guide to Sigma-1 Receptor Positron Emission Tomography/Magnetic Resonance Imaging: A New Clinical Molecular Imaging Method to Identify Peripheral Pain Generators in Patients with Chronic Pain

Accurately identifying the peripheral pain generator in patients with chronic pain remains a major challenge for modern medicine. Millions of patients around the world suffer endlessly from difficult-to-manage debilitating pain because of very limited diagnostic tests and a paucity of pain therapies. To help these patients, we have developed a novel clinical molecular imaging approach, and, in its early stages, it has been shown to accurately identify the exact site of pain generation using an imaging biomarker for the sigma-1 receptor and positron emission tomography/magnetic resonance imaging. We hope the description of the work in this article can help others begin their own pain imaging programs at their respective institutions.

Mortality among older adults with osteoporotic vertebral fracture

We evaluated whether older adults who received kyphoplasty had reduced risk of mortality compared to those who did not. In unmatched analyses, those receiving kyphoplasty were at reduced risk of death but after matching on age and medical complications, patients who received kyphoplasty were at increased risk of death.

PURPOSE

In previous observational studies, kyphoplasty for treatment of osteoporotic vertebral fractures has been associated with decreased mortality compared to conservative management. The purpose of this research was to determine whether older adults who received kyphoplasty had reduced risk of mortality compared to matched patients who did not.

METHODS

Retrospective cohort study of US Medicare enrollees with osteoporotic vertebral fractures between 2017-2019 comparing patients who underwent kyphoplasty to those who did not. We identified 2 control groups a priori: 1) non-augmented patients who met inclusion criteria (group 1); 2) propensity-matched patients on demographic and clinical variables (group 2). We then identified additional control groups using matching for medical complications (group 3) and age + comorbidities (group 4). We calculated hazard ratios (HRs) and 95% confidence intervals (95% CIs) associated with mortality.

RESULTS

A total of 235,317 patients (mean (± standard deviation) age 81.1 ± 8.3 years; 85.8% female) were analyzed. In the primary analyses, those who received kyphoplasty were at reduced risk of death compared to those who did not: adjusted HR (95% CI) in group 1 = 0.84 (0.82, 0.87); and in group 2 = 0.88 (0.85, 0.91). However, in post hoc analyses, patients who received kyphoplasty were at increased risk of death: adjusted HR (95% CI) in group 3 = 1.32 (1.25, 1.41) and 1.81 (1.58, 2.09) in group 4.

CONCLUSION

An apparent benefit of kyphoplasty on mortality among patients with vertebral fractures was not present after rigorous propensity matching, illustrating the importance of comparing similar individuals when evaluating observational data.

Referrals, Symptoms and Treatment of Patients Referred to a Secondary Spine Centre-How Can We Help?

INTRODUCTION

Spinal disorders are amongst the conditions with the highest burden of disease. To limit the increase of healthcare-related costs in the ageing population, the selection of different types of care for patients with spinal disorders should be optimized. The first step is to investigate the characteristics of these patients and the relationship with treatment.

RESEARCH QUESTION

The primary aim of this study was to provide insights in the characteristics, symptoms, diagnosis and treatment of patients referred to a specialized spinal health care centre. The secondary aim was to perform an in-depth analysis of resource utilization for a representative subgroup of patients.

METHODS

This study describes the characteristics of 4855 patients referred to a secondary spine centre. Moreover, an extensive analysis of a representative subgroup of patients (~20%) is performed.

RESULTS

The mean age was 58.1, 56% of patients were female, and the mean BMI was 28. In addition, 28% of patients used opioids. Mean self-reported health status was 53.3 (EuroQol 5D Visual Analogue Scale), and pain ranged from 5.8 to 6.7 (Visual Analogue Scale neck/back/arm/leg). Additional imaging was received by 67.7% of patients. Surgical treatment was indicated for 4.9% of patients. The majority (83%) of non-surgically treated patients received out-of-hospital treatment; 25% of patients received no additional imaging or in-hospital treatment.

CONCLUSION

The vast majority of patients received non-surgical treatments. We observed that ~10% of patients did not receive in-hospital imaging or treatment and had acceptable or good questionnaire scores at the time of referral. These findings suggest that there is potential for improvement in efficacy of referral, diagnosis, and treatment. Future studies should aim to develop an evidence base for improved patient selection for clinical pathways. The efficacy of chosen treatments requires investigation of large cohorts.

Treatment With Opioids Is Not Associated With Poor Outcomes Among Older Adults With Lumbar Spinal Stenosis Receiving Epidural Injections

STUDY DESIGN

Secondary analysis of a randomized controlled trial.

OBJECTIVE

To assess how baseline treatment with opioids is associated with pain and function in older adults with lumbar spinal stenosis who receive epidural injections.

SUMMARY OF BACKGROUND DATA

Data were obtained from the Lumbar Epidural Steroid injections for Spinal Stenosis trial, a double-blind, multisite, randomized controlled trial.

METHODS

Baseline treatment with opioids was assessed from electronic medical record prescription pharmacy data or from health utilization records collected from patients. We calculated adjusted changes in back pain numerical rating scale, leg pain numerical rating scale, and back-related disability (Roland Morris Disability Questionnaire scores) from baseline to three weeks and to six weeks among patients treated and not treated with opioids at baseline using generalized linear regression.

RESULTS

Baseline treatment with opioids was not significantly associated with back pain intensity (adjusted difference in means at three weeks of follow-up between patients treated with opioids at baseline versus not [±95% CI, 0.1 (-0.7, 0.7)], leg pain intensity [-0.2 (-0.9, 0.4)], or back-related function [-0.8 (-2.1, 0.4)]. We found similar results at six weeks of follow-up.

CONCLUSIONS

Among older adults with lumbar spinal stenosis who are receiving epidural injections, those treated with opioids at baseline had similar outcomes to those who were not.

Emergency Department Alternatives to Opioids: Adapting and Implementing Proven Therapies in Practice

The use of opioids to treat pain can increase the risk of long-term opioid dependency and is associated with negative patient outcomes. The objective of this study was to present the initial results following the implementation of Emergency-Department Alternatives to Opioids (ED-ALTO), a program that encourages the use of non-narcotic medications and procedures to treat pain in the Emergency Department (ED). We used a pre- and post-implementation study design to compare in-ED opioid utilization, as well as ED-ALTO medication and procedure use in the year before and after the program's implementation. After ED-ALTO's implementation, there was a decrease in opioid utilization in the ED and an increase in ED-ALTO medication use. Additionally, there was an increase in ED-ALTO procedure utilization and the complexity of conditions treated with ED-ALTO procedures, including the use of regional nerve blocks for shoulder dislocations and hip and rib fractures. In 8 of the 12 months following ED-ALTO's implementation, a lower proportion of patients receiving ED-ALTO procedures received an opioid, and the opioid dosage was lower compared to patients with the same diagnoses who received standard care. The continued expansion of ED-ALTO programs across the US may serve as a mechanism to reduce opioid utilization and safely and successfully treat pain in ED settings.

Influence of Initial Health Care Provider on Subsequent Health Care Utilization for Patients With a New Onset of Low Back Pain: A Scoping Review

OBJECTIVE

The aim of this research was to examine the scope of evidence for the influence of a nonmedical initial provider on health care utilization and outcomes in people with low back pain (LBP).

METHODS

Using scoping review methodology, we conducted an electronic search of 4 databases from inception to June 2021. Studies investigating the management of patients with a new onset of LBP by a nonmedical initial health care provider were identified. Pairs of reviewers screened titles, abstracts, and eligible full-text studies. We extracted health care utilization and patient outcomes and assessed the methodological quality of the included studies using the Joanna Briggs Institute checklist. Two reviewers descriptively analyzed the data and categorized findings by outcome measure.

RESULTS

A total of 26,462 citations were screened, and 11 studies were eligible. Studies were primarily retrospective cohort designs using claims-based data. Four studies had a low risk of bias. Five health care outcomes were identified: medication, imaging, care seeking, cost of care, and health care procedures. Patient outcomes included patient satisfaction and functional recovery. Compared with patients initiating care with medical providers, those initiating care with a nonmedical provider showed associations with reduced opioid prescribing and imaging ordering rates but increased rates of care seeking. Results for cost of care, health care procedures, and patient outcomes were inconsistent.

CONCLUSIONS

Prioritizing nonmedical providers at the first point of care may decrease the use of low-value care, such as opioid prescribing and imaging referral, but may lead to an increased number of health care visits in the care of people with LBP. High-quality randomized controlled trials are needed to confirm our findings.

IMPACT

This scoping review provides preliminary evidence that nonmedical practitioners, as initial providers, may help reduce opioid prescription and selective imaging in people with LBP. The trend observed in this scoping review has important implications for pathways of care and the role of nonmedical providers, such as physical therapists, within primary health care systems.

LAY SUMMARY

This scoping review provides preliminary evidence that nonmedical practitioners, as initial providers, might help reduce opioid prescription and selective imaging in people with LBP. High-quality randomized controlled trials are needed to confirm these findings.

The Association between Early Opioids Prescribing and the Length of Disability in Acute Lower Back Pain: A Systematic Review and Narrative Synthesis

BACKGROUND

There is conflicting evidence with respect to whether early opioid prescribing (EOP) within the first two weeks of acute Low Back Pain (LBP) onset is associated with the length of disability (LOD). The aim of this systematic review was to examine the relationship between EOP and LOD in individuals with acute LBP.

METHODS

A systematic search of Medline, EMBASE, and CINAHL was conducted. The Newcastle-Ottawa scale was used to assess the methodological quality of included studies. A narrative synthesis of findings was used owing to between-study heterogeneity.

RESULTS

Six cohort studies using workers' compensation administrative data on 178,130 adults with LBP were included. Most studies were of good methodological quality. One study reported that LBP cases with EOP had higher LOD by 4 days than cases without EOP. Two studies reported that each 100 mg morphine equivalent amount (MEA) was associated with an increase in mean LOD by 0.4 day (95% confidence interval (CI): 0.3, 0.5) and 0.4 day (95% CI: 0.3, 0.4). One study showed that LBP cases with EOP had a higher hazard of continuation of time loss benefits by 1.94 (95% CI 1.86, 2.02). One study reported a dose-response relationship between MEA of EOP and LOD ranging between 5.2 days (95% CI 14.6, 25.0) for 1-140 mg MEA and 69.1 (95% CI 49.3, 89.0) for 450+ mg MEA. One study reported that LBP cases with EOP had a higher mean LOD by 3.8 days, but there was no statistically significant relationship between EOP and LOD (Hazard ratio 1.02; 95% CI 0.91, 1.13).

CONCLUSIONS

The use of early opioid in the management of acute uncomplicated LBP is associated with prolonged disability duration. Further research on factors influencing inadequate adherence to evidence-based guidelines and optimal strategies to modify such factors may improve disability outcomes among patients presenting with acute LBP.

Nerve Growth Factor (NGF) Inhibitors and Related Agents for Chronic Musculoskeletal Pain: A Comprehensive Review

Musculoskeletal pain such as osteoarthritis (OA) and low back pain (LBP) are very common and contribute to enormous burden and societal costs, despite dramatic therapeutic advances over recent decades. Novel approaches and targeted therapies are required to satisfy the urgent unmet medical need of musculoskeletal pain relief in both conditions. Nerve growth factor (NGF) inhibitors have utilized novel mechanisms different from conventional drugs, which have a variety of gastrointestinal, cardiac, or renal adverse effects. Several phase 2/3 studies have been accomplished for these drugs, such as tanezumab, fasinumab, and tyrosine receptor kinase A (TrkA) inhibitors. We searched the literature using the PubMed database and clinical trials using ClinicalTrials.gov to identify original papers, meta-analyses as well as ongoing clinical trials assessing the efficacy and safety profile of these drugs. In this narrative review, we briefly overview the disease burden of musculoskeletal pain, the role of NGF signaling and its receptors in the genesis of pain, and the mechanisms of action of inhibitors of NGF signaling and downstream pathways, and then discuss the efficacy and safety of each investigational drug in OA and LBP. Finally, we briefly review two serious adverse effects of NGF inhibitors, namely rapidly progressive OA and sympathetic system effects, and conclude with possible barriers and potential research directions to overcome these.

Tanezumab for chronic low back pain: a long-term, randomized, celecoxib-controlled Japanese Phase III safety study

Aim & methods: This trial investigated long-term (56-week treatment/24-week follow-up) use of subcutaneous tanezumab (5 or 10 mg every 8 weeks) or oral celecoxib (200 mg/day) in Japanese patients with chronic low back pain. Results & conclusion: Tanezumab safety was consistent with previous studies, except overall adverse events (tanezumab 5 mg = 63.0%, tanezumab 10 mg = 54.8%, celecoxib = 67.4%) and events of abnormal peripheral sensation (tanezumab 5 mg = 9.8%, tanezumab 10 mg = 4.3%, celecoxib = 4.3%) were more frequent with 5 mg than 10 mg tanezumab. Joint safety event rates were 1.1% for tanezumab 5 mg, 2.2% for tanezumab 10 mg and 0% for celecoxib. All treatments improved pain and function throughout the treatment period. Clinical trial registration number: NCT02725411.

Treatment Patterns in Patients with Diagnostic Imaging for Low Back Pain: A Retrospective Observational Study

Purpose

Low back pain (LBP) is one of the most frequent reasons for medical consultations. Literature suggests a large evidence-performance gap, especially regarding pain management. Therefore, the monitoring of treatment patterns is important to ensure high quality of treatment. This study aimed to describe treatment patterns specific to patients with diagnostic imaging of the spine for LBP.

Patients and Methods

The study was retrospective observational and based on health claims data from 2015 to 2019 provided by a Swiss health insurance company covering around 12% of the population. Patients, ≥18 years of age, with diagnostic imaging of the spine were included and observed 12 months before and after imaging. Patients with back surgery or comorbidities associated with the use of pain medications were excluded.

Results

In total, 60,822 patients (mean age: 53.5 y, 56.1% female) were included and 85% received at least one pain medication. Of these, non-steroidal anti-inflammatory drugs, paracetamol, or opioids were prescribed in 88.6%, 70.7%, and 40.3% of patients, respectively. Strong opioids were used in 17% of patients given opioids. Patients with combinations of diagnostic imaging methods had the highest odds of receiving pain medication prescriptions (1.81, 95% CI: 1.66, 1.96, P < 0.001). Prescribed defined daily doses corresponded to short-term therapies.

Conclusion

Although the majority of patients received non-opioid short-term therapies, we found a substantial use of opioids, and in particular, a relative high usage of strong opioids. Our results highlighted the importance of both patient and healthcare provider awareness regarding the prudent treatment of LBP.

Trends and risk factors for opioid administration for non-emergent lower back pain

BACKGROUND

Non-emergent low-back pain (LBP) is one of the most prevalent presenting complaints to the emergency department (ED) and has been shown to contribute to overcrowding in the ED as well as diverting attention away from more serious complaints. There has been an increasing focus in current literature regarding ED admission and opioid prescriptions for general complaints of pain, however, there is limited data concerning the trends over the last decade in ED admissions for non-emergent LBP as well as any subsequent opioid prescriptions by the ED for this complaint.

AIM

To determine trends in non-emergent ED visits for back pain; annual trends in opioid administration for patients presenting to the ED for back pain; and factors associated with receiving an opioid-based medication for non-emergent LBP in the ED

METHODS

Patients presenting to the ED for non-emergent LBP from 2010 to 2017 were retrospectively identified from the National Hospital Ambulatory Medical Care Survey database. The “year” variable was transformed to two-year intervals, and a weighted survey analysis was conducted utilizing the weighted variables to generate incidence estimates. Bivariate statistics were used to assess differences in count data, and logistic regression was performed to identify factors associated with patients being discharged from the ED with narcotics. Statistical significance was set to a P value of 0.05.

RESULTS

Out of a total of 41658475 total ED visits, 3.8% (7726) met our inclusion and exclusion criteria. There was a decrease in the rates of non-emergent back pain to the ED from 4.05% of all cases during 2010 and 2011 to 3.56% during 2016 and 2017. The most common opioids prescribed over the period included hydrocodone-based medications (49.1%) and tramadol-based medications (16.9), with the combination of all other opioid types contributing to 35.7% of total opioids prescribed. Factors significantly associated with being prescribed narcotics included age over 43.84-years-old, higher income, private insurance, the obtainment of radiographic imaging in the ED, and region of the United States (all, P < 0.05). Emergency departments located in the Midwest [odds ratio (OR): 2.42, P < 0.001], South (OR: 2.35, < 0.001), and West (OR: 2.57, P < 0.001) were more likely to prescribe opioid-based medications for non-emergent LBP compared to EDs in the Northeast.

CONCLUSION

From 2010 to 2017, there was a significant decrease in the number of non-emergent LBP ED visits, as well as a decrease in opioids prescribed at these visits. These findings may be attributed to the increased focus and regulatory guidelines on opioid prescription practices at both the federal and state levels. Since non-emergent LBP is still a highly common ED presentation, conclusions drawn from opioid prescription practices within this cohort is necessary for limiting unnecessary ED opioid prescriptions.

Physiotherapists' Experiences with and Perspectives on Implementing an Evidence-Based, Chronic Pain Self-Management Programme in Primary Health Care: A Qualitative Study

Purpose: Evidence suggests that a physiotherapist-led chronic pain self-management programme in primary health care (PHC) improves function for people living with chronic pain; however, implementing a new approach to care can be difficult. In this study, we sought to understand the experiences of physiotherapists who had implemented the ChrOnic pain self-ManageMent support with pain science EducatioN and exerCisE (COMMENCE) programme; its perceived barriers, facilitators, benefits, and drawbacks; and how the physiotherapists tailored the programme to their own clinical contexts. Method: This interpretive description qualitative study used semi-structured interviews with physiotherapists who had implemented the COMMENCE programme in PHC. Results: Themes from 11 interviews included experiences of personal and professional growth, increasing confidence with experience, and changing the culture of pain management. Barriers and drawbacks to implementation included resource intensiveness, balancing programme demands with other clinical work, and challenges with patient attendance and participation. Facilitators included training, programme design and materials, supportive teams, and previous knowledge. Benefits included offering group and individualized support, evidence-based content, and sparking interest in learning more about pain management. The participants made small changes to tailor the programme content and delivery to their context. Conclusions: This study provides a rich understanding of the experiences, barriers, facilitators, benefits, drawbacks, and tailoring related to the COMMENCE programme in PHC. The results will facilitate future implementation of this intervention in PHC settings.

Opioid use as a predictor of pain outcomes in Iraq and Afghanistan Veterans with chronic pain: Analysis of a randomized controlled trial

OBJECTIVE

Our objectives were to: 1) assess the relationship between self-reported opioid use and baseline demographics, clinical characteristics and pain outcomes; and 2) examine whether baseline opioid use moderated the intervention effect on outcomes at 9 months.

DESIGN

We conducted a secondary analysis of data from the Evaluation of Stepped Care for Chronic Pain (ESCAPE) trial, which found stepped-care to be effective for chronic pain in military veterans.

SETTING

A post-deployment clinic and 5 general medicine clinics at a Veteran Affairs Medical Center.

SUBJECTS

241 veterans with chronic musculoskeletal pain; 220 with complete data at 9 months.

METHODS

Examination of baseline relationships and multivariable linear regression to examine baseline opioid use as a moderator of pain-related outcomes including Roland Morris Disability Questionnaire (RMDQ), Brief Pain Inventory (BPI) Interference scale, and Graded Chronic Pain Scale (GCPS) at 9 months.

RESULTS

Veterans reporting baseline opioid use (n = 80) had significantly worse RMDQ (16.0 ± 4.9 vs. 13.4 ± 4.2, P < 0.0001), GCPS (68.7 ± 12.0 vs. 65.0 ± 14.4, p = 0.049), BPI Interference (6.2 ± 2.2 vs. 5.0 ± 2.1, P < 0.0001), and depression (PHQ-9 12.5 ± 6.2 vs. 10.6 ± 5.7, p = 0.016) compared to veterans not reporting baseline opioid use. Using multivariable modeling we found that baseline opioid use moderated the intervention effect on pain-related disability (RMDQ) at 9 months (interaction Beta = -3.88, p = 0.0064), but not pain intensity or interference.

CONCLUSIONS

In a stepped-care trial for pain, patients reporting baseline opioid use had greater improvement in pain disability at 9 months compared to patients not reporting opioid use.

Association between opioid-related deaths and persistent opioid prescribing in primary care in England: a nested case-control study

AIM

This study aimed to evaluate the association between opioid-related deaths and persistent opioid utilisation in the United Kingdom (UK).

METHODS

This nested case-control study used the UK Clinical Practice Research Datalink, linking the Office for National Statistics death registration. Adult opioid users with recorded opioid-related death between 2000 and 2015 were included and matched to four opioid users (controls) based on a disease risk score. Persistent opioid utilisation (opioid prescriptions ≥3 quarters/year and oral morphine equivalent dose ≥4500 mg/year) and psychotropic prescriptions were identified annually during the three patient-years before the date of opioid-related death. Conditional logistic regression was used to assess the association between persistent opioid utilisation and opioid-related death, and the results were reported as adjusted odds ratios (aOR) and 95% confidence intervals (95%CI).

RESULTS

Of the 902,149 opioid users, 230 opioid-related deaths (cases) and 920 controls were identified. Persistent opioid utilisation was significantly associated with an increased risk of opioid-related deaths (aOR: 1.9; 95%CI: 1.2, 2.9) when persistent opioid utilisation was defined by both annual dose and number of quarters. Concurrent prescription of opioids and tricyclic antidepressants (aOR: 2.0; 95%CI: 1.2, 3.5) or higher dose of benzodiazepine (aOR: 6.5; 95%CI: 4.0, 10.4) or gabapentinoids (aOR: 6.2; 95%CI: 2.9, 13.5) were associated with opioid-related death.

CONCLUSION

Persistent opioid prescribing and concurrent prescribing of psychotropics were associated with a higher risk of opioid-related death and should be avoided in clinical practice. An evidence-based indicator to monitor the safety of prescribed opioids during opioid de-prescribing is needed.

Psychosocial, Functional, and Emotional Correlates of Long-Term Opioid Use in Patients with Chronic Back Pain: A Cross-Sectional Case-Control Study

INTRODUCTION

The opiate epidemic has severe medical and social consequences. Opioids are commonly prescribed in patients with chronic pain, and are a main contributor to the opiate epidemic. The adverse effects of long-term opioid usage have been studied primarily in dependence/addiction disorders, but not in chronic pain. Here, we examine the added iatrogenic effects, psychology, and brain morphology of long-term opioid use in matched patients with chronic pain with and without opioid use (case-controlled design).

METHODS

We compared psychosocial, functional, and psychological measures between patients with chronic back pain (CBP) who were managing their pain with or without opioids, thereby controlling for the effect of pain on these outcomes. In addition, we investigated brain morphological differences associated with long-term opioid usage. We recruited 58 patients with CBP, 29 of them on long-term opioids and 29 who did not use opioids, and who were matched in terms of age, sex, pain intensity, and pain duration. Questionnaires were used to assess pain quality, pain psychology, negative and positive emotions, physical, cognitive, sensory, and motor functions, quality of life, and personality traits.

RESULTS

Patients with CBP on opioids displayed more negative emotion, poorer physical function, and more pain interference (p < 0.001), whereas there were no statistical differences in cognitive and motor functions and personality traits. Voxel-based morphometry using structural brain imaging data identified decreased gray matter density of the dorsal paracingulate cortex (family-wise error-corrected p < 0.05) in patients with opioids, which was associated with negative emotion (p = 0.03). Finally, a volumetric analysis of hippocampal subfields identified lower volume of the left presubiculum in patients on opioids (p < 0.001).

CONCLUSION

Long-term opioid use in chronic pain is associated with adverse negative emotion and disabilities, as well as decreased gray matter volumes of specific brain regions.

Prolonged opioid use among opioid-naive individuals after prescription for nonspecific low back pain in the emergency department

ABSTRACT

Low back pain is a leading cause of disability globally. It is a common reason for presentation to the emergency department where opioids are commonly prescribed. This is a retrospective cohort study of opioid-naive adults with low back pain presenting to 1 of 4 emergency departments in Nova Scotia. We use routinely collected administrative clinical and drug-use data (July 2010-November 2017) to investigate the prevalence of prolonged opioid use and associated individual and prescription characteristics. In total, 23,559 eligible individuals presented with nonspecific low back pain, with 84.4% being opioid-naive. Our study population included 4023 opioid-naive individuals who filled a new opioid prescription within 7 days after their index emergency department visit (24.4%). The prevalence of prolonged opioid use after a new opioid prescription for low back pain (filling an opioid prescription 8-90 days after the emergency department visit and filling a subsequent prescription ±30 days of 6 months) was 4.6% (185 individuals). Older age and female sex were associated with clinically important increased odds of prolonged opioid use. First prescription average >90 morphine milligram equivalents/day (odds ratio 1.6, 95% confidence interval 1.0-2.6) and greater than 7-day supply (1.9, 1.1-3.1) were associated with prolonged opioid use in adjusted models. We found evidence of declining opioid prescriptions over the study period, but that 24.3% of first opioid prescriptions in 2016 would not have aligned with current guideline recommendations. Our study provides evidence to support a cautious approach to prescribing in opioid-naive populations.

Tanezumab for chronic low back pain: a randomized, double-blind, placebo- and active-controlled, phase 3 study of efficacy and safety

Supplemental Digital Content is Available in the Text.

Placebo and tramadol-controlled study assessing long-term safety and efficacy of tanezumab in patients with chronic low back pain and inadequate response to standard analgesics.

This randomized, double-blind, phase 3 study (56-week treatment; 24-week follow-up) assessed tanezumab in patients with chronic low back pain and history of inadequate response to standard-of-care analgesics (NCT02528253). Patients received placebo, subcutaneous tanezumab (5 or 10 mg every 8 weeks), or oral tramadol prolonged-release (100-300 mg/day). Primary endpoint was change in low back pain intensity (LBPI) at week 16 for tanezumab vs placebo. Key secondary endpoints were proportion of patients with ≥50% decrease in LBPI at week 16, change in Roland Morris Disability Questionnaire at week 16, and change in LBPI at week 2 for tanezumab vs placebo. Adverse events and joint safety were assessed through weeks 56 and 80, respectively. Tanezumab 10 mg met the primary endpoint by significantly improving LBPI at week 16 vs placebo; least squares (LS) mean (95% CI) difference = −0.40 (−0.76 to −0.04; P = 0.0281). Tanezumab 10 mg significantly improved all key secondary endpoints. Tanezumab 5 mg did not meet the primary endpoint (LS mean [95% CI] treatment difference vs placebo = −0.30 [−0.66 to 0.07; P = 0.1117]), preventing formal testing of key secondary endpoints for this dose. The proportion of patients with ≥50% improvement in LBPI at week 16 was 37.4% in the placebo group, 43.3% in the tanezumab 5 mg group (Odds ratio [95% CI] vs placebo = 1.28 [0.97 to 1.70; P = 0.0846]), and 46.3% in the tanezumab 10 mg group (Odds ratio [95% CI] vs placebo = 1.45 [1.09 to 1.91; P = 0.0101]). Prespecified joint safety events were more frequent with tanezumab 10 mg (2.6%) than tanezumab 5 mg (1.0%), tramadol (0.2%), or placebo (0%). Seven patients, all in the tanezumab 10 mg group (1.4%), underwent total joint replacement. In conclusion, tanezumab 10 mg significantly improved pain and function vs placebo in patients with difficult-to-treat chronic low back pain. Tanezumab was associated with a low rate of joint safety events, some requiring joint replacement.

Long-term improvements following a residential combined physical and psychological programme for chronic low back pain

OBJECTIVES

Evaluate the outcomes and explore experiences of patients undergoing a residential combined physical and psychological programme (CPPP) for chronic low back pain.

DESIGN

A longitudinal observational cohort design, with a parallel qualitative design using semistructured interviews.

SETTING

Residential, multimodal rehabilitation.

PARTICIPANTS

136 adults (62 male/74 female) referred to the CPPP, 100 (44 male/56 female) of whom completed the programme, during the term of the study. Ten (2 male/8 female) participated in the qualitative evaluation.

INTERVENTION

A 3-week residential CPPP.

OUTCOME MEASURES

Primary outcome measures were the STarT Back screening tool score; pain intensity-11-point Numerical Rating Scale; function-Oswestry Disability Index (ODI); health status/quality of life-EQ-5D-5L EuroQol five-Dimension-five level; anxiety-Generalised Anxiety Disorder-7; depression-Patient Health Questionnaire-9. Secondary outcome measures were the Global Subjective Outcome Scale; National Health Service Friends and Family Test;.

RESULTS

At discharge, 6 and 12 months follow ups, there were improvements from baseline that were greater than minimum clinically important differences in each of the outcomes (with the sole exception of ODI at discharge). At 12 months, the majority of people considered themselves a lot better (57%) and were extremely likely (86%) to recommend the programme to a friend. The qualitative data showed praise for the residential nature of the intervention and the opportunities for interaction with peers and peer support. There were testimonies of improvements in understanding of pain and how to manage it better. Some participants said they had reduced, or stopped, medication they had been taking to manage their pain.

CONCLUSIONS

Participants improved, and maintained long term, beyond minimum clinically important differences on a wide range of outcomes. Participants reported an enhanced ability to self-manage their back pain and support for the residential setting.

Prognostic factors for pain chronicity in low back pain: a systematic review

Supplemental Digital Content is Available in the Text.

Several prognostic factors are related to low back pain chronicity, and these should be taken into account when planning more comprehensive models in its prevention.

Low back pain is the leading cause for years lived in disability. Most people with acute low back pain improve rapidly, but 4% to 25% of patients become chronic. Since the previous systematic reviews on the subject, a large number of new studies have been conducted. The objective of this article was to review the evidence of the prognostic factors behind nonspecific chronic low back pain. A systematic literature search was performed without date limitation from the MEDLINE, Cochrane library, and Medic databases. Specific inclusion criteria were used, and risk factors before the onset of chronic symptoms were searched. Study quality was assessed by 2 independent reviewers. One hundred eleven full articles were read for potential inclusion, and 25 articles met all the inclusion criteria. One study was rated as good quality, 19 studies were rated as fair quality, and 5 articles were rated as poor quality. Higher pain intensity, higher body weight, carrying heavy loads at work, difficult working positions, and depression were the most frequently observed risk factors for chronic low back pain. Maladaptive behavior strategies, general anxiety, functional limitation during the episode, smoking, and particularly physical work were also explicitly predictive of chronicity. According to this systematic review, several prognostic factors from the biomechanical, psychological and psychosocial point of view are significant for chronicity in low back pain.

Prescribing Patterns of Pain Medications in Unspecific Low Back Pain in Primary Care: A Retrospective Analysis

Acute low back pain (LBP) is one of the most prevalent diseases worldwide. Since there is evidence of excessive prescriptions of analgesics, i.e., opioids, the aim of this study was to describe the use of pain medications in patients with LBP in the Swiss primary care setting. A retrospective, observational study was performed using medical prescriptions of 180 general practitioners (GP) during years 2009–2020. Patterns of pain medications (nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol, and opioids) as well as co-medications were analyzed in patients with a LBP diagnosis. Univariable and multivariable regression analyses assessed GP and patient characteristics associated with the prescription of pain medication. Patients included were 10,331 (mean age 51.7 years, 51.2% female); 6449 (62.4%) received at least one pain medication and of these 86% receive NSAIDs and 22% opioids. GP characteristics (i.e., self-employment status) and patient characteristics (male gender and number of consultations) were associated with significantly higher odds of receiving any pain medication in multivariable analysis. 3719 patients (36%) received co-medications. Proton-pump-inhibitors and muscle relaxants were the most commonly used co-medications. In conclusion, two-thirds of LBP patients were treated with pain medications. Prescribing patterns were conservative, with little use of strong opioids and co-medications.

Use of healthcare services and therapeutic measures associated with new episodes of acute low back pain-related disability among elderly people: a cross-sectional study on the Back Complaints in the Elders - Brazil cohort

BACKGROUND

Patients with low back pain frequently undergo a variety of diagnostic and therapeutic interventions, but some of these have uncertain effectiveness. This highlights the importance of the association of healthcare services and therapeutic measures relating to disability.

OBJECTIVE

To analyze the use of healthcare services and therapeutic measures among Brazilian older adults with disability-related low back pain.

DESIGN AND SETTING

Observational cross-sectional study on baseline assessment data from the Back Complaints in the Elders - Brazil (BACE-B) cohort.

METHODS

The main analyses were based on a consecutive sample of 602 older adult participants in BACE-B (60 years of age and over). The main outcome measurement for disability-related low back pain was defined as a score of 14 points or more in the Roland Morris Questionnaire.

RESULTS

Visits to doctors in the previous six weeks (odds ratio, OR = 1.82; 95% confidence interval, CI 1.22-2.71) and use of analgesics in the previous three months (OR = 1.57; 95% CI 1.07-2.31) showed statistically significant associations with disability-related low back pain. The probability of disability-related low back pain had an additive effect to the combination of use of healthcare services and therapeutic measures (OR = 2.57; 95% CI 1.52-4.36). The analyses showed that this association was significant among women, but not among men.

CONCLUSIONS

Occurrence of the combined of consultations and medication use was correlated with higher chance of severe disability among these elderly people with nonspecific low back pain. This suggested that overuse and "crowding-in" effects were present in medical services for elderly people.

Association Between Chiropractic Use and Opioid Receipt Among Patients with Spinal Pain: A Systematic Review and Meta-analysis

OBJECTIVE

To investigate the current evidence to determine if there is an association between chiropractic use and opioid receipt.

DESIGN

Systematic review and meta-analysis.

METHODS

The protocol for this review was registered on PROSPERO (CRD42018095128). The MEDLINE, PubMed, EMBASE, AMED, CINAHL, and Web of Science databases were searched for relevant articles from database inception through April 18, 2018. Controlled studies, cohort studies, and case-control studies including adults with noncancer pain were eligible for inclusion. Studies reporting opioid receipt for both subjects who used chiropractic care and nonusers were included. Data extraction and risk of bias assessment were completed independently by pairs of reviewers. Meta-analysis was performed and presented as an odds ratio with 95% confidence interval.

RESULTS

In all, 874 articles were identified. After detailed selection, 26 articles were reviewed in full, and six met the inclusion criteria. Five studies focused on back pain and one on neck pain. The prevalence of chiropractic care among patients with spinal pain varied between 11.3% and 51.3%. The proportion of patients receiving an opioid prescription was lower for chiropractic users (range = 12.3-57.6%) than nonusers (range = 31.2-65.9%). In a random-effects analysis, chiropractic users had a 64% lower odds of receiving an opioid prescription than nonusers (odds ratio = 0.36, 95% confidence interval = 0.30-0.43, P < 0.001, I2 = 92.8%).

CONCLUSIONS

This review demonstrated an inverse association between chiropractic use and opioid receipt among patients with spinal pain. Further research is warranted to assess this association and the implications it may have for case management strategies to decrease opioid use.

From Tramadol to Methadone: Opioids in the Treatment of Pain and Dyspnea in Pediatric Palliative Care

BACKGROUND

More than 15,000 children die annually in the United States due to an underlying life-limiting disease and the majority of those children experience distressing symptoms, which are not adequately relieved, such as pain and dyspnea. Multimodal analgesia, that is multiple agents, interventions, rehabilitation, psychological modalities, and integrative (nonpharmacologic) therapies, act synergistically for more effective pediatric pain and symptom control with fewer side effects than a single analgesic or modality. However, opioids, such as morphine, fentanyl, hydromorphone, oxycodone, and methadone (in the United Kingdom: diamorphine) remain the mainstay medication to effectively treat pain and dyspnea in children with serious illness.

METHODS

This article reviews commonly used opioids in Pediatric Palliative Care, which a special emphasis on 2 potentially particularly effective multimechanistic opioids: tramadol and methadone.

RESULTS

Methadone, due to its multimechanistic action profile, is possibly among the most effective and most underutilized opioid analgesics in children with severe unrelieved pain at end of life. However, methadone should not be prescribed by those unfamiliar with its use: Its effects should be closely monitored for several days, particularly when it is first started and after any dose changes.

CONCLUSIONS

Tramadol appears to play a key role in treating episodes of inconsolability in children with progressive neurologic, metabolic, or chromosomally based condition with impairment of the central nervous system. However, the recent 2017 United States Food and Drug Administration (FDA) warning against pediatric use of tramadol does not seem to be based on clinical evidence, and therefore puts children at risk for unrelieved pain or increased respiratory depression.

Pain rehabilitation's dual power: Treatment for chronic pain and prevention of opioid-related risks

The purpose of this article is to provide a data-driven exploration of an interdisciplinary pain rehabilitation program (PRP) as a viable option for addressing the dual crises of chronic pain and opioid use. Psychologists are crucial providers in the PRP, in both intervention and leadership roles. There is well-established literature supporting pain rehabilitation as an effective treatment for chronic pain and functioning, but there are few studies examining the effects of pain rehabilitation on opioid misuse risk. We evaluated data from 60 patients with diverse chronic pain conditions who completed an interdisciplinary PRP to evaluate changes in pain, functioning (self-report and objective physical measure), psychological symptoms, and health-related quality of life. To evaluate the effect of pain rehabilitation on opioid-related risks, we examined opioid use and opioid misuse behaviors (measured by the Current Opioid Misuse Measure; COMM) pre- and posttreatment. Results demonstrated statistically significant improvements in all outcomes, with medium effect sizes for pain severity and large effect sizes for functioning, psychological symptoms, and emotional quality of life. Fifty-eight percent of patients were on opioid medications at entry compared with 15% at discharge. Among patients who entered on opioids, mean COMM scores were significantly reduced from above the cutoff for misuse risk (M = 13.57) to below the cutoff (M = 5.86). Overall, this study provided strong support for pain rehabilitation as an effective treatment for chronic pain and related suffering, while also providing a prevention-based opportunity for reducing opioid-related risk. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Predicting the Transition to Chronic Pain 6 Months After an Emergency Department Visit for Acute Pain: A Prospective Cohort Study

BACKGROUND

Acute pain can transition to chronic pain, a potentially debilitating illness.

OBJECTIVE

We determined how often acute pain transitions to chronic pain among patients in the emergency department (ED) and whether persistent pain 1 week after the ED visit was associated with chronic pain.

METHODS

An observational cohort study conducted in two EDs. We included adults with acute pain (≤10 days) if an oral opioid was prescribed. Exclusion criteria were recent opioid use and use of any analgesics regularly prior to onset of the pain. Research associates interviewed patients during the ED visit and 1 week and 6 months later. The primary outcome, chronic pain, was defined as pain on > 50% of days since ED discharge. We constructed logistic regression models to evaluate the association between persistent pain 1 week after an ED visit and chronic pain, while adjusting for demographic and treatment variables.

RESULTS

During a 9-month period, we approached 733 patients for participation and enrolled 484; 450 of 484 (93%) provided 1-week outcomes data and 410 of 484 (85%) provided 6-month outcomes data. One week after the ED visit, 348 of 453 (77%; 95% confidence interval [CI] 73-80%) patients reported pain in the affected area. New-onset chronic pain at 6 months was reported by 110 of 408 (27%; 95% CI 23-31%) patients. Presence of pain 1 week after ED visit was associated with chronic pain (odds ratio 3.6; 95% CI 1.6-8.5).

CONCLUSIONS

About one-quarter of ED patients with acute pain transition to chronic pain within 6 months. Persistence of pain 1 week after the ED visit can identify patients at risk of transition.

Relationship Between Opioid Analgesic Prescription and Unemployment in Patients Seeking Acupuncture for Chronic Pain in Urban Primary Care

OBJECTIVE

The widespread use of opioid analgesics to treat chronic nonmalignant pain has contributed to the ongoing epidemic of opioid-related morbidity and mortality. Previous studies have also demonstrated a relationship between opioid analgesic use and unemployment due to disability. These studies have been limited to mainly white European and North American populations. The objective of this study is to explore the relationship between opioid analgesic use for chronic nonmalignant pain in an urban, mainly black and Hispanic, low-income population.

DESIGN

This is a cross-sectional observational study.

SETTING

Subjects were recruited from six urban primary care health centers.

SUBJECTS

Adults with chronic neck, back, or osteoarthritis pain participating in an acupuncture trial were included.

METHODS

Survey data were collected as a part of the Acupuncture Approaches to Decrease Disparities in Pain Treatment two-arm (AADDOPT-2) comparative effectiveness trial. Participants completed a baseline survey including employment status, opioid analgesic use, the Brief Pain Inventory, the global Patient Reported Outcomes Measurement Information Systems quality of life measure, the Patient Health Questionnaire-9 (PHQ-9), and demographic information. A multivariable logistic regression model was built to examine the association between opioid analgesic use and unemployment.

RESULTS

Opioid analgesic use was associated with three times the odds of unemployment due to disability while controlling for potential confounders, including depression, pain severity, pain interference, global physical and mental functioning, and demographic characteristics.

CONCLUSIONS

This study adds to the growing body of evidence that opioid analgesics should be used with caution in chronic nonmalignant pain.

Chronic pain care: time for excellence

The current health system aims to cope with the epidemic of chronic pain. The narrative urgently needs to be reset to one that strives for excellence. This reflection illustrates what excellence may look like and also highlights where system biases are preventing positive change from occurring.

What proportion of patients with chronic noncancer pain are prescribed an opioid medicine? Systematic review and meta-regression of observational studies

Guidelines now discourage opioid analgesics for chronic noncancer pain because the benefits frequently do not outweigh the harms. We aimed to determine the proportion of patients with chronic noncancer pain who are prescribed an opioid, the types prescribed and factors associated with prescribing. Database searches were conducted from inception to 29 October 2018 without language restrictions. We included observational studies of adults with chronic noncancer pain measuring opioid prescribing. Opioids were categorized as weak (e.g. codeine) or strong (e.g. oxycodone). Study quality was assessed using a risk of bias tool designed for observational studies measuring prevalence. Individual study results were pooled using a random-effects model. Meta-regression investigated study-level factors associated with prescribing (e.g. sampling year, geographic region as per World Health Organization). The overall evidence quality was assessed using Grading of Recommendations Assessment, Development and Evaluation criteria. Of the 42 studies (5,059,098 participants) identified, the majority (n = 28) were from the United States of America. Eleven studies were at low risk of bias. The pooled estimate of the proportion of patients with chronic noncancer pain prescribed opioids was 30.7% (95% CI 28.7% to 32.7%, n = 42 studies, moderate-quality evidence). Strong opioids were more frequently prescribed than weak (18.4% (95% CI 16.0-21.0%, n = 15 studies, low-quality evidence), versus 8.5% (95% CI 7.2-9.9%, n = 15 studies, low-quality evidence)). Meta-regression determined that opioid prescribing was associated with year of sampling (more prescribing in recent years) (P = 0.014) and not geographic region (P = 0.056). Opioid prescribing for patients with chronic noncancer pain is common and has increased over time.

Development of an in vitro intervertebral disc innervation model to screen neuroinhibitory biomaterials

Pain originating from an intervertebral disc (discogenic pain) is a major source of chronic low back pain. Pathological innervation of the disc by pain-sensing nerve fibers is thought to be a key component of discogenic pain, so treatment with biomaterials that have the ability to inhibit neurite growth will greatly benefit novel disc therapeutics. Currently, disc therapeutic biomaterials are rarely screened for their ability to modulate nerve growth, mainly due to a lack of models to screen neuromodulation. To address this deficit, our lab has engineered a three dimensional in vitro disc innervation model that mimics the interface between primary sensory nerves and the intervertebral disc. Further, herein we have demonstrated the utility of this model to screen the efficacy of chondroitin sulfate biomaterials to inhibit nerve fiber invasion into the model disc. Biomaterials containing chondroitin-4-sulfate (CS-A) decrease neurite growth in a uniform gel and at an interface between a growth-permissive and a growth-inhibitory gel, while chondroitin-6-sulfate (CS-C) is less neuroinhibitory. This in vitro model holds great potential for screening inhibitors of nerve fiber growth to further improve intervertebral disc replacements and therapeutics. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:1016-1026, 2020.

Opioid Fills for Lumbar Facet Radiofrequency Ablation Associated with New Persistent Opioid Use

Background

Zygapophyseal (facet) joint interventions are the second most common interventional procedure in pain medicine. Opioid exposure after surgery is a significant risk factor for chronic opioid use. The aim of this study was to determine the incidence of new persistent use of opioids after lumbar facet radiofrequency ablation and to assess the effect of postprocedural opioid prescribing on the development of new persistent opioid use.

Methods

The authors conducted a retrospective cohort study using claims from the Clinformatics Data Mart Database (OptumInsight, USA) to identify opioid-naïve patients between 18 and 64 yr old who had lumbar radiofrequency ablation. Patients who had either subsequent radiofrequency ablation 15 to 180 days or subsequent surgery within 180 days after the primary procedure were excluded from the analysis. The primary outcome was new persistent opioid use, defined as opioid prescription fulfillment within the 8 to 90 and 91 to 180 day periods after radiofrequency ablation. The authors then assessed patient-level risk factors for new persistent opioid use.

Results

A total of 2,887 patients met the inclusion criteria. Of those patients, 2,277 (78.9%) had radiofrequency ablation without a perioperative opioid fill, and 610 (21.1%) patients had the procedure with a perioperative opioid fill. The unadjusted rate of new persistent opioid use was 5.6% (34 patients) in the group with a perioperative opioid fill versus 2.8% (63 patients) for those without an opioid fill. Periprocedural opioid prescription fill was independently associated with increased odds of new persistent use (adjusted odds ratio, 2.35; 95% CI, 1.51 to 3.66; P &lt; 0.001).

Conclusions

Periprocedural opioid use after lumbar radiofrequency ablation was associated with new persistent use in previously opioid-naïve patients, suggesting that new exposure to opioids is an independent risk factor for persistent use in patients having radiofrequency ablation for chronic back pain. Opioid prescribing after radiofrequency ablation should be reevaluated and likely discontinued in this population.

Editor’s Perspective

What We Already Know about This Topic

What This Article Tells Us That Is New

Basic Opioid Pharmacology - An Update

Opioids are a group of analgesic agents commonly used in clinical practice. The three classical opioid receptors are MOP, DOP and KOP. The NOP (N/OFQ) receptor is considered to be a non-opioid branch of the opioid receptor family. Opioid receptors are G-protein-coupled receptors which cause cellular hyperpolarisation when bound to opioid agonists. Opioids may be classified according to their mode of synthesis into alkaloids, semi-synthetic and synthetic compounds. Opioid use disorder (OUD) is an emerging issue and important lessons can be learnt from the United States where opioid epidemic was declared as a national emergency in 2017.

Opioid Prescriptions and Short-Term Mortality: a U.S. National Study

BACKGROUND

Opioid-related mortality continues to rise. Though risks of prescription opioid misuse and abuse are well known, short-term mortality across a range of prescription opioid exposure is unclear.

OBJECTIVE

This study was conducted in order to assess the short-term mortality associated with quantity of reported opioid prescriptions, DESIGN: An observational analysis was performed using data from the Medical Expenditure Panel Survey, years 2005-2015, a population-based, nationally representative household survey.

PARTICIPANTS

This study included adults (age 18+) with prescription data and death status reported during their 2-year survey participation.

MAIN MEASURES

Key exposure is the number of opioid prescriptions (0, 1-5, 6 or more) in year 1 of survey participation. The main outcome is all-cause mortality reported during the 2-year survey participation.

KEY RESULTS

Of 90,622 participants, 14% reported at least 1 opioid prescription. There were 774 (0.9%) deaths during the survey period, 551 (0.7%) among those not reporting opioids, 127 (1.2%) among those reporting 1-5 opioid prescriptions, and 96 (3.9%) among those reporting 6 or more opioid prescriptions. After adjusting for sociodemographics, health status, and utilization, there was no significant association between category of opioid prescriptions and death during the study period; adjusted odds ratios = 0.86 (95% CI = 0.66, 1.22, p = 0.27) and 0.99 (95% CI = 0.74, 1.34, p = 0.96), respectively, for 1-5 prescriptions and 6 or more prescriptions.

CONCLUSIONS

In a nationally representative sample, opioid prescriptions were associated with increased short-term mortality only without adjustment for sociodemographics, health status, or utilization. The relationship between prescription opioid use and mortality risk is more complex than previously reported, meriting further examination.

Increased overall and cause-specific mortality associated with disability among workers' compensation claimants with low back injuries

BACKGROUND

Mortality tends to be higher among people who do not work than among workers, but the impact of work-related disability on mortality has not been well studied.

METHODS

The vital status through 2015 was ascertained for 14 219 workers with an accepted workers' compensation claim in West Virginia for a low back injury in 1998 or 1999. Mortality among the cohort compared with the West Virginia general population was assessed using standard life table techniques. Associations of mortality and disability-related factors within the cohort were evaluated using Cox proportional hazards regression.

RESULTS

Compared to the general population, mortality from accidental poisoning was significantly elevated among the overall cohort and lost-time claimants. Most deaths from accidental poisoning in the cohort were due to drug overdoses involving opioids. Mortality from intentional self-harm was also significantly elevated among lost-time claimants. In internal analyses, overall mortality and mortality from cancer, heart disease, intentional self-harm, and drug overdoses involving opioids was significantly associated with lost time. Overall mortality and mortality from drug overdoses involving opioids were also significantly associated with amount of lost time, permanent partial disability, and percent permanent disability. Heart disease mortality was also significantly associated with the amount of lost time.

CONCLUSIONS

The results suggest that disability itself may impact mortality risks. If confirmed, these results reinforce the importance of return to work and other efforts to reduce disability.

Promoting Participation in Physical Activity and Exercise Among People Living with Chronic Pain: A Qualitative Study of Strategies Used by People with Pain and Their Recommendations for Health Care Providers

OBJECTIVE

To explore strategies used by people living with chronic pain when participating in physical activity and exercise and their recommendations for health care providers when promoting participation in physical activity and exercise.

DESIGN

Interpretive description qualitative study.

SETTING

Participants were recruited from primary care sites and a hospital-based chronic pain clinic in Kingston, Ontario, Canada.

SUBJECTS

Adults (>18 years of age) who self-identified as experiencing chronic pain (three months' duration) were interviewed.

METHODS

In-depth semistructured interviews were conducted with participants. Interviews were audio-recorded, transcribed verbatim, and reviewed for accuracy by the interviewer. Transcripts were analyzed using thematic analysis. Peer debriefing, reflexivity, and multiple in-person meetings were used to establish trustworthiness.

RESULTS

Sixteen adults (five men, 11 women) with a median age of 53 years were interviewed. Strategies used by people living with chronic pain to participate in physical activity and exercise included 1) finding the motivation, 2) setting up for success, 3) leveraging social support, and 4) managing pain and discomfort during activity. Recommendations for health care providers when promoting participation in physical activity and exercise for people living with chronic pain included 1) the importance of listening, 2) providing tailored advice, 3) being supportive, and 4) making physical activity and exercise programming accessible.

CONCLUSIONS

People living with chronic pain reported using multiple strategies to participate in physical activity and exercise. Recommendations for health care providers centered on the importance of listening and taking a supportive approach when promoting engagement in physical activity and exercise for this population.

Cancer Screening Among Women Prescribed Opioids: A National Study

PURPOSE

Prior work suggests that there are competing demands between addressing pain and other issues in primary care, potentially lessening delivery of evidence-based cancer screening. We assessed the association between opioid therapy and cancer screening among women in a nationally representative US sample.

METHODS

We conducted an observational analysis of the 2005-2015 Medical Expenditure Panel Surveys. We included all women aged ≥18 years without cancer and with opioid prescription and preventive care services data. Logistic regression analyses examined associations between receipt of opioid prescription (any vs none) and receipt of breast, cervical, and colorectal cancer screenings. Analyses were adjusted for sociodemographic characteristics, health status, health conditions, and usual source of care, as well as health care utilization.

RESULTS

Of 53,982 participants, 15.8% reported ≥1 opioid prescription. Compared with women not prescribed opioids, those prescribed opioids were more likely to visit their doctor (median number of visits per year = 5, vs 1). Without adjustment for number of visits, women prescribed opioids were more likely to receive all 3 cancer screenings; the adjusted odds ratio for breast cancer screening was 1.26 (95% CI, 1.16-1.38), that for cervical cancer screening was 1.22 (95% CI, 1.13-1.33), and that for colorectal cancer screening was 1.22 (95% CI, 1.12-1.33). With adjustment for number of visits, adjusted odds ratios decreased (breast 1.07 [95% CI, 0.98-1.18]; cervical 1.01 [95% CI, 0.93-1.09]; colorectal 1.04 [95% CI, 0.95-1.14]).

CONCLUSIONS

In a nationally representative sample, receipt of opioid prescriptions was not associated with less recommended cancer screenings. Rather, women receiving opioids had greater adjusted odds of receiving breast, cervical, and colorectal cancer screening, although the associations were attenuated by adjusting for their more frequent office visits relative to women not receiving opioids.

Gender differences in association of prescription opioid use and mortality: A propensity-matched analysis from the REasons for Geographic And Racial Differences in Stroke (REGARDS) prospective cohort

BACKGROUND

Prescription opioids (PO) have been widely used for chronic non-cancer pain, with commensurate concerns for overdose. The long-term effect of these medications on non-overdose mortality in the general population remains poorly understood. This study's objective was to examine the association of prescription opioid use and mortality in a large cohort, accounting for gender differences and concurrent benzodiazepine use, and using propensity score matching. Methods: 29,025 US community-dwellers were enrolled in the REasons for Geographic And Racial Differences in Stroke (REGARDS) cohort between 2003 and 2007, and followed through December 31, 2012. At baseline there were 1907 participants with PO; 1864 of them were matched to participants without PO, based on the model-derived propensity to receive opioid prescriptions. Causes of death were expert-adjudicated. Results: Over median follow-up of 6 years there were 4428 deaths (413 among persons with PO). The risk for all-cause mortality was 12% higher, in absolute terms, for persons with PO compared to those without PO in the overall sample, with gender differences (interaction p = .0008). The risk of death was increased for women with PO (hazard ratio [HR] 1.21 [95% Confidence Interval (CI) 1.04-1.40]), but not men (HR 0.92 [95% CI 0.77-1.10]). Women with PO were at higher risk of cardiovascular disease (CVD) death (HR 1.43 [95% CI 1.12-1.84]), sudden death (HR 2.02 [95% CI 1.29-3.15]) (a subset of CVD death), and accidents (HR 2.18 [95% CI 1.03-4.60]). These risks were not observed for men with PO. Conclusion: Over 6 years of follow-up, women but not men who had opioid prescriptions were at higher risk of all-cause mortality, CVD death, sudden death, and accidents. Special caution in prescribing opioids for women may be warranted until these findings are confirmed.

Individual recovery expectations and prognosis of outcomes in non-specific low back pain: prognostic factor review

BACKGROUND

Low back pain is costly and disabling. Prognostic factor evidence can help healthcare providers and patients understand likely prognosis, inform the development of prediction models to identify subgroups, and may inform new treatment strategies. Recent studies have suggested that people who have poor expectations for recovery experience more back pain disability, but study results have differed.

OBJECTIVES

To synthesise evidence on the association between recovery expectations and disability outcomes in adults with low back pain, and explore sources of heterogeneity.

SEARCH METHODS

The search strategy included broad and focused electronic searches of MEDLINE, Embase, CINAHL, and PsycINFO to 12 March 2019, reference list searches of relevant reviews and included studies, and citation searches of relevant expectation measurement tools.

SELECTION CRITERIA

We included low back pain prognosis studies from any setting assessing general, self-efficacy, and treatment expectations (measured dichotomously and continuously on a 0 - 10 scale), and their association with work participation, clinically important recovery, functional limitations, or pain intensity outcomes at short (3 months), medium (6 months), long (12 months), and very long (> 16 months) follow-up.

DATA COLLECTION AND ANALYSIS

We extracted study characteristics and all reported estimates of unadjusted and adjusted associations between expectations and related outcomes. Two review authors independently assessed risks of bias using the Quality in Prognosis Studies (QUIPS) tool. We conducted narrative syntheses and meta-analyses when appropriate unadjusted or adjusted estimates were available. Two review authors independently graded and reported the overall quality of evidence.

MAIN RESULTS

We screened 4635 unique citations to include 60 studies (30,530 participants). Thirty-five studies were conducted in Europe, 21 in North America, and four in Australia. Study populations were mostly chronic (37%), from healthcare (62%) or occupational settings (26%). General expectation was the most common type of recovery expectation measured (70%); 16 studies measured more than one type of expectation. Usable data for syntheses were available for 52 studies (87% of studies; 28,885 participants). We found moderate-quality evidence that positive recovery expectations are strongly associated with better work participation (narrative synthesis: 21 studies; meta-analysis: 12 studies, 4777 participants: odds ratio (OR) 2.43, 95% confidence interval (CI) 1.64 to 3.62), and low-quality evidence for clinically important recovery outcomes (narrative synthesis: 12 studies; meta-analysis: 5 studies, 1820 participants: OR 1.89, 95% CI 1.49 to 2.41), both at follow-up times closest to 12 months, using adjusted data. The association of recovery expectations with other outcomes of interest, including functional limitations (narrative synthesis: 10 studies; meta-analysis: 3 studies, 1435 participants: OR 1.40, 95% CI 0.85 to 2.31) and pain intensity (narrative synthesis: 9 studies; meta-analysis: 3 studies, 1555 participants: OR 1.15, 95% CI 1.08 to 1.23) outcomes at follow-up times closest to 12 months using adjusted data, is less certain, achieving very low- and low-quality evidence, respectively. No studies reported statistically significant or clinically important negative associations between recovery expectations and any low back pain outcome.

AUTHORS' CONCLUSIONS

We found that individual recovery expectations are probably strongly associated with future work participation (moderate-quality evidence) and may be associated with clinically important recovery outcomes (low-quality evidence). The association of recovery expectations with other outcomes of interest is less certain. Our findings suggest that recovery expectations should be considered in future studies, to improve prognosis and management of low back pain.

Subdissociative-dose Ketamine Is Effective for Treating Acute Exacerbations of Chronic Pain

BACKGROUND

Subdissociative-dose ketamine (SDDK) is used to treat acute pain. We sought to determine if SDDK is effective in relieving acute exacerbations of chronic pain.

METHODS

This study was a randomized double-blind placebo-controlled trial conducted May 2017 to June 2018 at a public teaching hospital (ClinicalTrials.gov #NCT02920528). The primary endpoint was a 20-mm decrease on a 100-mm visual analog scale (VAS) at 60 minutes. Power analysis using three groups (0.5 mg/kg ketamine, 0.25 mg/kg ketamine, or placebo infused over 20 minutes) estimated that 96 subjects were needed for 90% power. Inclusion criteria included age > 18 years, chronic pain > 3 months, and acute exacerbation (VAS ≥ 70 mm). Pain, agitation, and sedation were assessed by VAS at baseline and 20, 40, and 60 minutes after initiation of study drug. Telephone follow-up at 24 to 48 hours used a 10-point numeric rating scale for pain.

RESULTS

A total of 106 subjects were recruited, with three excluded for baseline pain < 70 mm. After randomization, 35 received 0.5 mg/kg ketamine, 36 received 0.25 mg/kg ketamine, and 35 received placebo. Three subjects receiving 0.5 mg/kg withdrew during the infusion due to adverse effects, and one subject in each group had incomplete data, leaving 97 for analysis. Initial pain scores (91.9 ± 8.9 mm), age (46.5 ± 12.6 years), sex distribution, and types of pain reported were similar. Primary endpoint analysis found that 25 of 30 (83%) improved with 0.5 mg/kg ketamine, 28 of 35 (80%) with 0.25 mg/kg ketamine, and 13 of 32 (41%) with placebo (p = 0.001). More adverse effects occurred in the ketamine groups with one subject in the 0.25 mg/kg group requiring a restraint code for agitation. A total of 89% of subjects were contacted at 24 to 48 hours, and no difference in pain level was detected between groups.

CONCLUSION

Ketamine infusions at both 0.5 and 0.25 mg/kg over 20 minutes were effective in treating acute exacerbations of chronic pain but resulted in more adverse effects compared to placebo. Ketamine did not demonstrate longer-term pain control over the next 24 to 48 hours.

The World Health Organization Disability Assessment Schedule-2.0 (WHODAS 2.0) in a chronic pain population being considered for chronic opioid therapy

Purpose

To examine the validity of the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) for the assessment of function in a community-based sample of patients with chronic pain conditions undergoing evaluation for chronic opioid therapy.

Patients and methods

One hundred nine of 124 patients were evaluated for a chronic opioid therapy program between December 1, 2014 and April 10, 2015, inclusive, at one community-based interdisciplinary pain management practice. Measures included: demographic data; the WHODAS 2.0; a modified version of the Roland Morris Disability Questionnaire (RMDQ-m); the Patient Health Questionnaire-9 item (PHQ-9); the Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R); the Current Opioid Misuse Measure (COMM), the Opioid Risk Tool (ORT); opioid dose. These data were collected as part of routine care, and this retrospective chart review study examined the data from this convenience sample, comparing the results of each assessment tool to the results of the WHODAS 2.0.

Results

Median score on the WHODAS 2.0 was 25.69 (IQR=16.01 to 35.28). WHODAS 2.0 score was significantly correlated with the RMDQ-m (r_s=0.69, p<0.001), the PHQ-9 (r_s=0.68, p<0.001), the COMM (r_s=0.52, p<0.001) and the SOAPP-R (r_s=0.51, p<0.001). There was no significant correlation between the WHODAS 2.0 and the ORT (r_s=0.14, p=0.12) or opioid dose (r_s=0.07, p=0.47).

Conclusions

The WHODAS 2.0 was significantly positively correlated with other measures, including measures of disability, risk of opioid misuse, and depression among patients being evaluated for chronic opioid therapy. The WHODAS 2.0 may be a useful measure of disability across a number of important domains when discussing expectations of both patients and providers at initiation of opioid therapy for chronic pain management. This assessment and discussion is crucial, particularly given the focus on function, rather than analgesia alone, when evaluating the effectiveness of opioid treatment.

Associations of Early Opioid Use With Patient-reported Outcomes and Health Care Utilization Among Older Adults With Low Back Pain

OBJECTIVES

The objective of this study was to compare outcomes and health care utilization of older patients who did versus did not fill opioid prescriptions within 90 days of initiating care for low back pain.

MATERIALS AND METHODS

For patients ≥65 years with new back pain visits, we used propensity scores to match those who filled no opioid prescriptions to those who filled ≥2 opioid prescriptions within 90 days (and the first opioid prescription within 30 d) of the index visit. Over 24 months, we examined patient-reported outcomes, health care utilization, and subsequent opioid prescription fills.

RESULTS

Among 1954 patients eligible for matching, 238 (12%) filled ≥2 opioid prescriptions within 90 days; 200 of these were matched to controls. Patients with versus without early opioid prescriptions had similar patient-reported outcomes but were more likely to have filled ≥1 opioid prescription 18 to 24 months after the index visit (odds ratio [95% confidence interval]=2.4 [1.5-3.9]) and to have had ≥1 visit to the emergency department in the subsequent 24 months (OR, 1.6; 95% confidence interval, 1.0-2.5).

DISCUSSION

Among older patients with new back pain visits, filling ≥2 opioid prescriptions within 90 days of the visit was associated with similar back pain-related outcomes but increased likelihood of filling opioid prescriptions 18 to 24 months later compared with matched patients who did not fill early opioid prescriptions.

Disability Benefits and Change in Prescription Opioid Dose

Among chronic low back pain (CLBP) patients, workers' compensation is associated with longer term prescription opioid analgesic use (OAU). The aim was to study the association between receiving Social Security Disability Insurance (SSDI) benefits and course of OAU. This prospective cohort study utilized data from primary care patients diagnosed with non-cancer CLBP. The outcomes were morphine equivalent dose (MED) - categorized as no OAU, 1-50mg MED, or >50mg MED - and change in MED over time using mixed multinomial logistic regression models. Covariates included sociodemographics, pain severity, pain management characteristics, continuity of care with their physician, health-related quality of life, number of comorbid health conditions, obesity, depression, and anxiety. In adjusted analysis, SSDI vs. non-SSDI patients were more likely to be receiving >50mg MED vs. no OAU at baseline (OR = 10.19; 95% CI:1.51-68.83). Differences in OAU trajectory between SSDI groups were nonsignificant (P = 0.204). Collection of SSDI benefits was an independent predictor of higher MED at baseline and persistently higher MED during 2 years of follow-up. Providers should consider the risk of persistent, high-dose opioid use in patients receiving SSDI benefits.

Initial Provider Specialty Is Associated With Long-term Opiate Use in Patients With Newly Diagnosed Low Back and Lower Extremity Pain

STUDY DESIGN

Retrospective longitudinal cohort analysis of patients diagnosed in 2010, with continuous enrollment 6 months prior to and 12 months following the initial visit.

OBJECTIVE

To determine whether provider specialty influences patterns of opiate utilization long after initial diagnosis.

SUMMARY OF BACKGROUND DATA

Patients with low back pain present to a variety of providers and receive a spectrum of treatments, including opiate medications. The impact of initial provider type on opiate use in this population is uncertain.

METHODS

We performed a retrospective analysis of opiate-naïve adult patients in the United States with newly diagnosed low back or lower extremity pain. We estimated the risk of early opiate prescription (≤14 d from diagnosis) and long-term opiate use (≥six prescriptions in 12 mo) based on the provider type at initial diagnosis using multivariable logistic regression, adjusting for patient demographics and comorbidities.

RESULTS

We identified 478,981 newly diagnosed opiate-naïve patients. Of these, 40.4% received an opiate prescription within 1 year and 4.0% met criteria for long-term use. The most common initial provider type was family practice, associated with a 24.4% risk of early opiate prescription (95% CI, 24.1-24.6) and a 2.0% risk of long-term opiate use (95% CI, 2.0-2.1). Risk of receiving an early opiate prescription was higher among patients initially diagnosed by emergency medicine (43.1%; 95% CI, 41.6-44.5) or at an urgent care facility (40.8%; 95% CI, 39.4-42.3). Risk of long-term opiate use was highest for patients initially diagnosed by pain management/anesthesia (6.7%; 95% CI, 6.0-7.3) or physical medicine and rehabilitation (3.4%; 95% CI, 3.1-3.8) providers.

CONCLUSION

Initial provider type influences early opiate prescription and long-term opiate use among opiate-naïve patients with newly diagnosed low back and lower extremity pain.

LEVEL OF EVIDENCE

3.