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Prescription Medication Use Among Community-Based U.S. Adults With Chronic Low Back Pain: A Cross-Sectional Population Based Study

  • Anna Shmagel
    Correspondence
    Address reprint requests to Anna Shmagel, MD, Division of Rheumatic and Autoimmune Diseases at the University of Minnesota, Division of Rheumatic and Autoimmune Diseases, 420 Delaware Street SE, MMC 108, Minneapolis, MN 55455.
    Affiliations
    Division of Rheumatic and Autoimmune Diseases, University of Minnesota, Minneapolis, Minnesota
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  • Linh Ngo
    Affiliations
    Division of Rheumatic and Autoimmune Diseases, University of Minnesota, Minneapolis, Minnesota
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  • Kristine Ensrud
    Affiliations
    Medicine and Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota

    Chronic Disease Outcomes Research, Minneapolis VA Center, Minneapolis, Minnesota
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  • Robert Foley
    Affiliations
    Division of Renal Diseases and Hypertension, University of Minnesota, Minneapolis, Minnesota
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      Highlights

      • Opioids were the most common prescription pain medications among U.S. adults with chronic low back pain.
      • Opioids were typically used long-term, and combined with other central nervous system-active agents.
      • Low level of education was strongly associated with opioid use in a chronic low back pain population.

      Abstract

      Many classes of medications have been evaluated in chronic low back pain (cLBP), however their utilization in the community remains unclear. We examined patterns of prescription medication use among Americans with cLBP in a nationally representative, community-based sample. The Back Pain Survey was administered to a representative sample of U.S. adults aged 20 to 69 years (N = 5,103) during the 2009 to 2010 cycle of the National Health and Nutrition Examination Survey. cLBP was defined as self-reported pain in the area between the lower posterior margin of the ribcage and the horizontal gluteal fold on most days for at least 3 months (N = 700). Home-based interviews with pill bottle verification were used to capture commonly prescribed medications for chronic pain. Among the sample of U.S. adults with cLBP aged 20 to 69 years, 36.9% took at least 1 prescription pain medication in the past 30 days; of them, 18.8% used opioids, 9.7% nonsteroidal anti-inflammatory drugs, 8.5% muscle relaxants, and 6.9% gabapentin or pregabalin. Nonpain antidepressants and hypnotics were used by 17.8% and 4.7%, respectively. Opioids were used long-term in 76.9% of cases (median = 2 years) and were frequently coadministered with antidepressants, benzodiazepines, or hypnotics. Ninety-four percent of prescription opioids in the cLBP population were used by individuals with less than a college education. Opioids were the most widely used prescription analgesic class in community-based U.S. adults with cLBP and were often coadministered with other central nervous system-active medications. Opioid use was highly prevalent among less educated Americans with cLBP.

      Perspective

      Because prescription opioid use is an issue of national concern, we examined pain-related prescription medication use in community-dwelling U.S. adults with cLBP. Opioids were the most common prescription pain medication, typically used long-term, in combination with other central nervous system-active agents, and disproportionately among individuals with less than a college education.

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      References

        • Berthelot J.M.
        • Darrieutort-Lafitte C.
        • Le Goff B.
        • Maugars Y.
        Strong opioids for noncancer pain due to musculoskeletal diseases: Not more effective than acetaminophen or NSAIDs.
        Joint Bone Spine. 2015; 82: 397-401
        • Braden J.B.
        • Sullivan M.D.
        • Ray G.T.
        • Saunders K.
        • Merrill J.
        • Silverberg M.J.
        • Rutter C.M.
        • Weisner C.
        • Banta-Green C.
        • Campbell C.
        • Von Korff M.
        Trends in long-term opioid therapy for noncancer pain among persons with a history of depression.
        Gen Hosp Psychiatry. 2009; 31: 564-570
        • Chelminski P.R.
        • Ives T.J.
        • Felix K.M.
        • Prakken S.D.
        • Miller T.M.
        • Perhac J.S.
        • Malone R.M.
        • Bryant M.E.
        • DeWalt D.A.
        • Pignone M.P.
        A primary care, multi-disciplinary disease management program for opioid-treated patients with chronic non-cancer pain and a high burden of psychiatric comorbidity.
        BMC Health Serv Res. 2005; 5: 3
        • Chou R.
        • Qaseem A.
        • Snow V.
        • Casey D.
        • Cross J.T.
        • Shekelle P.
        • Owens D.K.
        • Clinical Efficacy Assessment Subcommittee of the American College of Physicians, American College of Physicians, American Pain Society Low Back Pain Guidelines Panel
        Diagnosis and treatment of low back pain: A joint clinical practice guideline from the American College of Physicians and the American Pain Society.
        Ann Intern Med. 2007; 147: 478-491
        • Chou R.
        • Turner J.A.
        • Devine E.B.
        • Hansen R.N.
        • Sullivan S.D.
        • Blazina I.
        • Dana T.
        • Bougatsos C.
        • Deyo R.A.
        The effectiveness and risks of long-term opioid therapy for chronic pain: A systematic review for a National Institutes of Health Pathways to Prevention Workshop.
        Ann Intern Med. 2015; 162: 276-286
        • Chu L.F.
        • D'Arcy N.
        • Brady C.
        • Zamora A.K.
        • Young C.A.
        • Kim J.E.
        • Clemenson A.M.
        • Angst M.S.
        • Clark J.D.
        Analgesic tolerance without demonstrable opioid-induced hyperalgesia: A double-blinded, randomized, placebo-controlled trial of sustained-release morphine for treatment of chronic nonradicular low-back pain.
        Pain. 2012; 153: 1583-1592
        • Dart R.C.
        • Surratt H.L.
        • Cicero T.J.
        • Parrino M.W.
        • Severtson S.G.
        • Bucher-Bartelson B.
        • Green J.L.
        Trends in opioid analgesic abuse and mortality in the United States.
        N Engl J Med. 2015; 372: 241-248
        • Deyo R.A.
        • Dworkin S.F.
        • Amtmann D.
        • Andersson G.
        • Borenstein D.
        • Carragee E.
        • Carrino J.
        • Chou R.
        • Cook K.
        • DeLitto A.
        • Goertz C.
        • Khalsa P.
        • Loeser J.
        • Mackey S.
        • Panagis J.
        • Rainville J.
        • Tosteson T.
        • Turk D.
        • Von Korff M.
        • Weiner D.K.
        Report of the NIH task force on research standards for chronic low back pain.
        J Pain. 2014; 15: 569-585
        • Deyo R.A.
        • Smith D.H.
        • Johnson E.S.
        • Donovan M.
        • Tillotson C.J.
        • Yang X.
        • Petrik A.F.
        • Dobscha S.K.
        Opioids for back pain patients: Primary care prescribing patterns and use of services.
        J Am Board Fam Med. 2011; 24: 717-727
        • Di Cesare M.
        • Khang Y.H.
        • Asaria P.
        • Blakely T.
        • Cowan M.J.
        • Farzadfar F.
        • Guerrero R.
        • Ikeda N.
        • Kyobutungi C.
        • Msyamboza K.P.
        • Oum S.
        • Lynch J.W.
        • Marmot M.G.
        • Ezzati M.
        Inequalities in non-communicable diseases and effective responses.
        Lancet. 2013; 381: 585-597
        • Donovan H.S.
        • Ward S.E.
        • Song M.K.
        • Heidrich S.M.
        • Gunnarsdottir S.
        • Phillips C.M.
        An update on the representational approach to patient education.
        J Nurs Scholarsh. 2007; 39: 259-265
        • Dowell D.
        • Haegerich T.M.
        • Chou R.
        CDC guideline for prescribing opioids for chronic pain–United States, 2016.
        JAMA. 2016; 315: 1624-1645
        • Drwecki B.B.
        Education to identify and combat racial bias in pain treatment.
        AMA J Ethics. 2015; 17: 221-228
        • Drwecki B.B.
        • Moore C.F.
        • Ward S.E.
        • Prkachin K.M.
        Reducing racial disparities in pain treatment: the role of empathy and perspective-taking.
        Pain. 2011; 152: 1001-1006
        • Edlund M.J.
        • Martin B.C.
        • Fan M.Y.
        • Braden J.B.
        • Devries A.
        • Sullivan M.D.
        An analysis of heavy utilizers of opioids for chronic noncancer pain in the TROUP study.
        J Pain Symptom Manage. 2010; 40: 279-289
        • Eken C.
        • Serinken M.
        • Elicabuk H.
        • Uyanik E.
        • Erdal M.
        Intravenous paracetamol versus dexketoprofen versus morphine in acute mechanical low back pain in the emergency department: a randomised double-blind controlled trial.
        Emerg Med J. 2014; 31: 177-181
        • Enthoven W.T.
        • Roelofs P.D.
        • Deyo R.A.
        • van Tulder M.W.
        • Koes B.W.
        Non-steroidal anti-inflammatory drugs for chronic low back pain.
        Cochrane Database Syst Rev. 2016; (CD012087)
        • Frampton J.E.
        • Keating G.M.
        Celecoxib: a review of its use in the management of arthritis and acute pain.
        Drugs. 2007; 67: 2433-2472
        • Furlan A.D.
        • Sandoval J.A.
        • Mailis-Gagnon A.
        • Tunks E.
        Opioids for chronic noncancer pain: a meta-analysis of effectiveness and side effects.
        CMAJ. 2006; 174: 1589-1594
        • Gouveia N.
        • Rodrigues A.
        • Ramiro S.
        • Eusébio M.
        • Machado P.M.
        • Canhão H.
        • Branco J.C.
        The use of analgesic and other pain-relief drugs to manage chronic low back pain: Results from a national survey.
        Pain Pract. 2016; 17: 353-365
        • Green C.R.
        • Anderson K.O.
        • Baker T.A.
        • Campbell L.C.
        • Decker S.
        • Fillingim R.B.
        • Kaloukalani D.A.
        • Lasch K.E.
        • Myers C.
        • Tait R.C.
        • Todd K.H.
        • Vallerand A.H.
        The unequal burden of pain: Confronting racial and ethnic disparities in pain.
        Pain Med. 2003; 4: 277-294
        • Guy G.P.
        • Zhang K.
        • Bohm M.K.
        • Losby J.
        • Lewis B.
        • Young R.
        • Murphy L.B.
        • Dowell D.
        Vital signs: Changes in opioid prescribing in the United States, 2006–2015.
        MMWR Morb Mortal Wkly Rep. 2017; 66: 697-704
        • Kalita J.
        • Kohat A.K.
        • Misra U.K.
        • Bhoi S.K.
        An open labeled randomized controlled trial of pregabalin versus amitriptyline in chronic low backache.
        J Neurol Sci. 2014; 342: 127-132
        • Khoromi S.
        • Cui L.
        • Nackers L.
        • Max M.B.
        Morphine, nortriptyline and their combination vs. placebo in patients with chronic lumbar root pain.
        Pain. 2007; 130: 66-75
        • King N.B.
        • Fraser V.
        • Boikos C.
        • Richardson R.
        • Harper S.
        Determinants of increased opioid-related mortality in the United States and Canada, 1990–2013: A systematic review.
        Am J Public Health. 2014; 104: e32-e42
        • Lehrer H.M.
        • Dubois S.K.
        • Brown S.A.
        • Steinhardt M.A.
        Resilience-based diabetes self-management education: Perspectives from African American participants, community leaders, and healthcare providers.
        Diabetes Educ. 2017; 43: 367-377
        • Luo X.
        • Pietrobon R.
        • Hey L.
        Patterns and trends in opioid use among individuals with back pain in the United States.
        Spine. 2004; 29 (discussion 891): 884-890
        • Martin B.I.
        • Deyo R.A.
        • Mirza S.K.
        • Turner J.A.
        • Comstock B.A.
        • Hollingworth W.
        • Sullivan S.D.
        Expenditures and health status among adults with back and neck problems.
        JAMA. 2008; 299: 656-664
        • McCarthy D.M.
        • Cameron K.A.
        • King J.P.
        • Mullen R.J.
        • Bailey S.C.
        • Jacobson K.L.
        • Di Francesco L.
        • Davis T.C.
        • Parker R.M.
        • Wolf M.S.
        Patient recall of health care provider counseling for opioid-acetaminophen prescriptions.
        Pain Med. 2014; 15: 1750-1756
        • McCauley J.L.
        • Back S.E.
        • Brady K.T.
        Pilot of a brief, Web-based educational intervention targeting safe storage and disposal of prescription opioids.
        Addict Behav. 2013; 38: 2230-2235
        • Nissen S.E.
        • Yeomans N.D.
        • Solomon D.H.
        • Lüscher T.F.
        • Libby P.
        • Husni M.E.
        • Graham D.Y.
        • Borer J.S.
        • Wisniewski L.M.
        • Wolski K.E.
        • Wang Q.
        • Menon V.
        • Ruschitzka F.
        • Gaffney M.
        • Beckerman B.
        • Berger M.F.
        • Bao W.
        • Lincoff A.M.
        • PRECISION Trial Investigators
        Cardiovascular safety of celecoxib, naproxen, or ibuprofen for arthritis.
        N Engl J Med. 2016; 375: 2519-2529
        • Noble M.
        • Treadwell J.R.
        • Tregear S.J.
        • Coates V.H.
        • Wiffen P.J.
        • Akafomo C.
        • Schoelles K.M.
        • Chou R.
        Long-term opioid management for chronic noncancer pain.
        Cochrane Database Syst Rev. 2010; (CD006605)
        • O'Donnell J.B.
        • Ekman E.F.
        • Spalding W.M.
        • Bhadra P.
        • McCabe D.
        • Berger M.F.
        The effectiveness of a weak opioid medication versus a cyclo-oxygenase-2 (COX-2) selective non-steroidal anti-inflammatory drug in treating flare-up of chronic low-back pain: Results from two randomized, double-blind, 6-week studies.
        J Int Med Res. 2009; 37: 1789-1802
        • Qaseem A.
        • Wilt T.J.
        • McLean R.M.
        • Forciea M.A.
        • for the Clinical Guidelines Committee of the American College of Physicians
        Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain. A Clinical Practice Guideline From the American College of Physicians.
        Ann Intern Med. 2017; 166: 514-530
        • Raffa R.B.
        Pharmacology of oral combination analgesics: Rational therapy for pain.
        J Clin Pharm Ther. 2001; 26: 257-264
        • Remy C.
        • Marret E.
        • Bonnet F.
        Effects of acetaminophen on morphine side-effects and consumption after major surgery: Meta-analysis of randomized controlled trials.
        Br J Anaesth. 2005; 94: 505-513
        • Richardson R.
        • Charters T.
        • King N.
        • Harper S.
        Trends in educational inequalities in drug poisoning mortality: United States, 1994–2010.
        Am J Public Health. 2015; 105: 1859-1865
        • Riley J.L.
        • Wade J.B.
        • Myers C.D.
        • Sheffield D.
        • Papas R.K.
        • Price D.D.
        Racial/ethnic differences in the experience of chronic pain.
        Pain. 2002; 100: 291-298
        • Rimer B.K.
        • Kedziera P.
        • Levy M.H.
        The role of patient education in cancer pain control.
        Hosp J. 1992; 8: 171-191
        • Shmagel A.
        • Foley R.
        • Ibrahim H.
        Epidemiology of chronic low back pain in US adults: Data from the 2009–2010 National Health and Nutrition Examination Survey.
        Arthritis Care Res (Hoboken). 2016; 68: 1688-1694
        • Skljarevski V.
        • Desaiah D.
        • Liu-Seifert H.
        • Zhang Q.
        • Chappell A.S.
        • Detke M.J.
        • Iyengar S.
        • Atkinson J.H.
        • Backonja M.
        Efficacy and safety of duloxetine in patients with chronic low back pain.
        Spine. 2010; 35: E578-E585
        • Staiger T.O.
        • Gaster B.
        • Sullivan M.D.
        • Deyo R.A.
        Systematic review of antidepressants in the treatment of chronic low back pain.
        Spine. 2003; 28: 2540-2545
        • Stein C.
        • Reinecke H.
        • Sorgatz H.
        Opioid use in chronic noncancer pain: Guidelines revisited.
        Curr Opin Anaesthesiol. 2010; 23: 598-601
        • Torke A.M.
        • Corbie-Smith G.M.
        • Branch W.T.
        African American patients' perspectives on medical decision making.
        Arch Intern Med. 2004; 164: 525-530
        • Turner B.J.
        • Liang Y.
        Drug overdose in a retrospective cohort with non-cancer pain treated with opioids, antidepressants, and/or sedative-hypnotics: Interactions with mental health disorders.
        J Gen Intern Med. 2015; 30: 1081-1096
        • Ungprasert P.
        • Cheungpasitporn W.
        • Crowson C.S.
        • Matteson E.L.
        Individual non-steroidal anti-inflammatory drugs and risk of acute kidney injury: A systematic review and meta-analysis of observational studies.
        Eur J Intern Med. 2015; 26: 285-291
        • Vogt M.T.
        • Kwoh C.K.
        • Cope D.K.
        • Osial T.A.
        • Culyba M.
        • Starz T.W.
        Analgesic usage for low back pain: Impact on health care costs and service use.
        Spine. 2005; 30: 1075-1081
        • Walls C.T.
        • Zarit S.H.
        Informal support from black churches and the well-being of elderly blacks.
        Gerontologist. 1991; 31: 490-495
        • Weeks J.
        Influential U.S. medical organizations call for insurance coverage of non-pharmacologic approaches to pain.
        J Altern Complement Med. 2016; 22: 947-949
        • Weisman M.H.
        • Witter J.P.
        • Reveille J.D.
        The prevalence of inflammatory back pain: Population-based estimates from the US National Health and Nutrition Examination Survey, 2009–10.
        Ann Rheum Dis. 2013; 72: 369-373
        • Wielage R.C.
        • Bansal M.
        • Andrews J.S.
        • Wohlreich M.M.
        • Klein R.W.
        • Happich M.
        The cost-effectiveness of duloxetine in chronic low back pain: A US private payer perspective.
        Value Health. 2013; 16: 334-344
        • Willy M.
        • Kelly J.P.
        • Nourjah P.
        • Kaufman D.W.
        • Budnitz D.S.
        • Staffa J.
        Emergency department visits attributed to selected analgesics, United States, 2004–2005.
        Pharmacoepidem Drug Safe. 2009; 18: 188-195
        • Wm H.
        • Tj L.
        • Twyner C.
        Opioid-induced hyperalgesia in community-dwelling adults with chronic pain.
        Pain. 2015; 156: 1145-1152
        • Minnesota Department of Human Services
        Minnesota State Targeted Response to the Opioid Crisis.
        (Available at:)
        • Palmer College of Chiropractic
        The Gallup-Palmer College Annual Report.
        (Available at:)
        • Chicago Urban League Research and Policy Center
        Whitewashed AA Opioid Crisis 11-15-17_EMBARGOED_ FINAL.pdf.
        (Available at:)