Prevalence, predictors and trends of opioid prescribing for lower back pain in United States emergency departments

Abstract

What is known and objective: Current evidence-based guidelines for the treatment of acute low back pain (ALBP) recommend the use of opioid medications only after failure of nonpharmacological therapy, non-steroidal anti-inflammatory drugs and skeletal muscle relaxants and after thorough evaluation of risks and benefits. Despite this recommendation and the state of the opioid epidemic in the United States (US), opioids remain a common drug of choice for ALBP in the emergency department (ED). The purpose of this study was to quantify the prevalence and identify predictors of opioid prescribing for acute lower back pain (ALBP) in emergency departments (EDs) in the United States.Methods: This was a national, cross-sectional study of the National Hospital Ambulatory Care Survey from 2013-2016. ED visits for patients aged ≥18 years treated for ALBP were included. Patients presenting with specified reasons that an opioid may be indicated were excluded. The primary endpoint was frequency of opioids prescribed. A multivariate logistic regression model identified patient-and provider-level predictors of opioid use. Results and discussion:This analysis included 2260 visits for ALBP. Opioids were prescribed in 32.3% of visits. Positive predictors of opioid prescribing were pain score of 7-10 (OR 1.85; 95% CI 1.26-2.70), and patients seen in the Southern (OR 2.53; 95% CI 1.47-4.36) or Western US (OR 2.10; 95% CI 1.19-3.70). Opioids were prescribed less often to patients who received a NSAID or acetaminophen (OR 0.38; 95% CI 0.28-0.52 and OR 0.03; 95% CI 0.01-0.10, respectively). What is new and conclusion:Opioid prescribing rates for ALBP remain high and the predictors identified demonstrate that this prescribing pattern is not uniformly distributed across the patient and provider characteristics studied. K E Y W O R D S low back pain, opioid, opioid prescribing, pain | 699 WALKERLY Et AL. Received an NSAID a 0.36 0.25-0.51 Received acetaminophen a 0.03 0.01-0.10 History of alcohol use disorder 0.51 0.19-1.35a Indicates a statistically significant predictor of receiving an opioid via the logistic regression model.

Emergency Department Management of Low Back Pain: A Comparative Review of Guidelines and Practices

“…There was no consensus on the additional benefit of combining other medications with NSAIDs. One study reported decreased opioid prescribing for patients who received either acetaminophen or NSAIDs [ 18 ], while other studies found no benefit from acetaminophen for the treatment of low back pain [ 12 , 22 ]. There was a similar disagreement on the effectiveness of muscle relaxants.…”

“…There is widespread agreement on the limited use of opioids and their detrimental long-term effects. Despite recommendations against first-line use of opioids, however, there is a broad acknowledgment of overprescription and chronic use of opioids for patients in emergency departments [ 18 ] and following discharge [ 26 ]. We found no consensus on the reason for this discrepancy.…”

“…Recommendations are aligned in suggesting acetaminophen, NSAIDs, and muscle relaxants for short-term relief, while opioids are suggested only for severe refractory pain [13,14,16]. However, the studies were consistent in reporting frequent prescriptions of opioids in the ED for low back pain [17,18] and their detrimental effects on patient outcomes [19,20]. Extracorporeal pharmacologic interventions, chiefly topical lidocaine, are generally recommended for acute back pain and have, in some cases, demonstrated greater effectiveness than neuropathic medications [21].…”

Critical Appraisal of Current Acute LBP Management and the Role of a Multimodal Approach

“…Over time, multimodal analgesia has become more a standard to manage pain as effectively as possible, also reducing opioid exposure [91], without sacrificing patient comfort or impeding rehabilitation [92]. This is relevant if one considers that opioids remain a common drug of choice for acute LBP in the emergency department (ED) [93] and their use in ED has been associated with an increased length of stay [94].…”