Correlates of high-dose opioid medication use for low back pain in primary care

Abstract

Little is known about patients who are prescribed high doses of opioid medication for the treatment of chronic non-cancer pain. We sought to determine the prevalence of high-dose opioid therapy, as well as associated demographic, clinical, and utilization correlates. Study was conducted in the Kaiser Permanente Northwest health system in Portland, Oregon. Participants were ambulatory adults, age 18 or above. Using electronic medical records, we chose as an index visit, the first visit in 2004 associated with an ICD-9 code for back pain. We assessed data six-months previous and subsequent care around this index date for a total of 26,000 participants. Patients prescribed high-dose opioids (> 100 mg/day morphine equivalent at last dispensing) for 90+ consecutive days were compared to two groups with back pain: Traditional-dose (1- 99 mg/day) or no opioids. Demographic and clinical data were analyzed using Chi-squares for categorical variables and Kruskall-Wallis nonparametric test for continuous variables. A multivariate logistic regression was performed to evaluate characteristics associated with high-dose opioids. High-dose opioid therapy was prescribed to 8.6% of back pain patients who were prescribed opioids long-term. The average patient was female (55.63%), aged 54.76 (SD = 14.97), non-Hispanic white (79.91%), and overweight (mean BMI = 31.0, SD = 7.48). Patients in the high-dose group had higher rates of psychiatric and substance use disorder diagnoses, comorbidity, concurrent sedative-hypnotics (60.5%), and higher utilization. After controlling for select demographic, medical/psychiatric, and utilization factors, male gender, higher comorbidity, medicare, mental health/substance use diagnosis, co-prescriptions of sedative-hypnotics, ED visits, pain clinic visits were associated with increased likelihood of high-dose prescriptions. High-dose opioid therapy is being prescribed to substantial proportion of back pain patients who are also prescribed opioids long-term. These patients were also found to have greater psychopathology, co-morbidity, and co-prescriptions of sedative-hypnotics raising significant safety concerns. Little is known about patients who are prescribed high doses of opioid medication for the treatment of chronic non-cancer pain. We sought to determine the prevalence of high-dose opioid therapy, as well as associated demographic, clinical, and utilization correlates. Study was conducted in the Kaiser Permanente Northwest health system in Portland, Oregon. Participants were ambulatory adults, age 18 or above. Using electronic medical records, we chose as an index visit, the first visit in 2004 associated with an ICD-9 code for back pain. We assessed data six-months previous and subsequent care around this index date for a total of 26,000 participants. Patients prescribed high-dose opioids (> 100 mg/day morphine equivalent at last dispensing) for 90+ consecutive days were compared to two groups with back pain: Traditional-dose (1- 99 mg/day) or no opioids. Demographic and clinical data were analyzed using Chi-squares for categorical variables and Kruskall-Wallis nonparametric test for continuous variables. A multivariate logistic regression was performed to evaluate characteristics associated with high-dose opioids. High-dose opioid therapy was prescribed to 8.6% of back pain patients who were prescribed opioids long-term. The average patient was female (55.63%), aged 54.76 (SD = 14.97), non-Hispanic white (79.91%), and overweight (mean BMI = 31.0, SD = 7.48). Patients in the high-dose group had higher rates of psychiatric and substance use disorder diagnoses, comorbidity, concurrent sedative-hypnotics (60.5%), and higher utilization. After controlling for select demographic, medical/psychiatric, and utilization factors, male gender, higher comorbidity, medicare, mental health/substance use diagnosis, co-prescriptions of sedative-hypnotics, ED visits, pain clinic visits were associated with increased likelihood of high-dose prescriptions. High-dose opioid therapy is being prescribed to substantial proportion of back pain patients who are also prescribed opioids long-term. These patients were also found to have greater psychopathology, co-morbidity, and co-prescriptions of sedative-hypnotics raising significant safety concerns.