Health

Opioid dependence linked to worse outcomes in back injury patients

Problems may stem from treatment. Experts say a new study offers another warning to use these drugs judiciously.

By Victoria Stagg Elliott — Posted Oct. 23, 2006

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Patients with chronic back injuries who become dependent on opioids during the course of their treatments use far more health care services and are less likely to return to work than are those who do not abuse these drugs, according to a study presented at the North American Spine Society's annual meeting last month in Seattle.

"Don't be afraid to use opioids early in the course of the disease or for severe exacerbations," said Tom Mayer, MD, lead author and medical director of the PRIDE, Productive Rehabilitation Institute of Dallas for Ergonomics. "But with long-duration use, there are significant risks."

Dr. Mayer and his team followed 1,200 patients who completed the institute's rehabilitation program. They had been treated for an average of a year and a half before starting the program, and 1.3% were opioid-dependent before their injuries. This number increased to 14.3% during initial treatment but prior to entering the program, which requires participants to taper from the medications.

Despite the fact that the patients all finished their rehabilitation off the medications, earlier dependence clearly exacted a price. A year after finishing rehab, those who were dependent were 2.8 times less likely to have returned to work. They were also 2.1 times more likely to have sought additional health care services and 1.8 times more likely to have had additional surgeries.

"Opioid dependence disorder in these patients is almost an entirely iatrogenic issue, and patients may well have a poorer outcome," said Dr. Mayer.

Experts praised this study for quantifying some of the impact of opioid dependence among chronic back pain patients and reinforcing the need for judicious prescription drug use.

"The bottom line is that, socioeconomically, individuals who develop opioid dependence do worse," said Douglas Paauw, MD, a general internist and professor of medicine at the University of Washington. "And this really showed that our interventions can help and they can harm."

Classifying the disorder

While there was praise for this study, there were also concerns about how these patients were classified in terms of opioid dependence disorder. Researchers used DSM-IV criteria, but there is significant agreement that this is not a very sensitive way to detect the problem in patients legitimately prescribed these medications.

"This is a good study with a large sample size," said Ajay Wasan, MD, an instructor of anesthesiology and psychiatry at Harvard Medical School and Brigham and Women's Hospital in Boston. "But DSM-IV criteria falls short for prescription opioids. There is just not enough research. We cannot really say who is addicted."

Many other open questions remain that physicians hope will be answered when the full data are published in a peer-reviewed journal, which is expected within a year. For example, it's unclear why these patients did not do as well, although researchers and others suggested the opioids may reduce a patient's motivation to get better.

"Chronic back pain patients are a tough crowd," said Victor Sierpina, MD, associate professor of family and integrative medicine at the University of Texas Medical Branch. "There's a subset of them who don't want to be well. The desire to be disabled may be there on a subconscious level."

But physicians do hope this line of research will lead to information that allows patients who are at high risk of dependence to be differentiated from those most likely to benefit from such prescriptions.

"It's a problem to determine who is more likely to become opioid dependent than others," said Michael A. Seffinger, DO, associate professor of family medicine at Western University of Health Sciences College of Osteopathic Medicine of the Pacific in California.

This study did suggest some possible hints. Those who were more likely to become dependent were also more likely to have been disabled longer and have had surgery for their back problems. They were also more likely to have had a substance disorder before the injury. Co-morbid mental health issues were also more common.

Some experts, however, questioned whether the blame for the outcomes found by this study can be placed squarely on opioid use. The paper certainly suggests an association, but many wondered whether it was really the cause. Also, patients who attend these types of rehabilitation programs tend to be in worse shape than those with back injuries in the general medical population.

"They might have had bad pain and disability to begin with and not have gone back to work anyway," said Dr. Wasan. "They may have been predisposed to a poor outcome. Also, this is a very selected population of poorly functioning people."

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ADDITIONAL INFORMATION

Long-term impact of opioid use

Objective: In patients with chronic disabling occupational spinal disorders, is opioid dependence associated with worse outcomes a year after treatment?

Participants: A group of 1,200 patients who had an average of 18 months of disability before entering and completing a tertiary rehabilitation program.

Methods: Researchers administered a structured clinical interview one year after discharge to assess patients' ability to return to work, health care utilization and opioid use.

Results: About 1.3% of patients were opioid dependent before their injuries, but 14.3% fit this diagnosis after receiving initial treatment. Those with the disorder were 2.8 times less likely to return to work, 2.1 times more likely to use additional health care services and 1.8 times more likely to have new surgeries to the area originally injured.

Conclusions: Patients who start a tertiary rehab program with a diagnosis of opioid dependence disorder have a lower level of socioeconomic success one year after treatment than do those without this disorder. Opioid dependence disorder may develop after being prescribed these drugs for the injury.

Source: North American Spine Society, 21st annual meeting, Seattle, Sept. 26-30

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External links

American Medical Association online CME series on pain management (link)

AMA Council on Science and Public Health's report on neuropathic pain, June (link)

North American Spine Society, 21st annual meeting, Seattle, Sept. 26-30 (link)

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