Opioids don’t work well for managing acute low back pain and are not recommended in guidelines for treatment of low back pain as a first line. (1) There is surprising little to no evidence on the long term effectiveness of the use of opioids for the management of chronic low back. Despite this, many patients are still prescribed opioids for low back pain and many stay on them for years despite little improvements to their function. (2)
These two recently published articles give some small insights into the prescription rates of opioids for chronic low back pain, pointing at two factors that can increase the chances that a patient will be prescribed opioids for their back pain. The articles are both drawing on data from the USA, which don’t necessarily represent other countries prescribing patterns but still give some interesting insights.
The first suggests that presence of higher levels of catastrophising can be seen to be a strong moderating factor as to whether a patient is prescribed opioids or not. This association is seen a lot stronger in women than men. (3). Catastrophising is also known to be a moderating factor in pain intensity. Pain catastrophising is defined as the tendency to dwell on the worse case scenario – a cascade of negative thoughts and emotions. Their presence is known to be an unhelpful response to pain and amplifies both pain and distress.
Another study that was recently published suggests that depression is associated with higher rates of prescription of opioids in people with low back pain. Chronic pain populations tend to have higher levels of depression than the normal population, however people with depression are often excluded from clinical trials. This information informs us that the presence of depression increases the chances that a person will be prescribed, and subsequently remain on opioids for back pain (4).
Both of these articles tell us things that we already know about pain – that our thoughts and emotions have a large role to play in the progression and maintenance of pain. Both catastophising and depression have been long recognised as factors in chronic pain – it seems they also have a role to play in whether opioids are prescribed or not.
1. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain–United States, 2016. JAMA 2016;315:1624-45.
2. Chou R, Turner JA, Devine EB, Hansen RN, Sullivan SD, Blazina I, et al. 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;162:276-86.
3. Sharifzadeh Y, Kao MC, Sturgeon JA, Rico TJ, Mackey S, Darnall BD. Pain Catastrophizing Moderates Relationships between Pain Intensity and Opioid Prescription: Nonlinear Sex Differences Revealed Using a Learning Health System. Anesthesiology 2017;127:136-46.
4. Smith JA, Fuino RL, Pesis-Katz I, Cai X, Powers B, Frazer M, Markman JD. Differences in opioid prescribing in low back pain patients with and without depression. PAIN Reports 2017;2:e606.