Introduction

1. Back Pain Flare Ups, Physical Function, and Opioid Use Adriana Gonzalez, Darryl White MD, Sandra Burge PhD The University of Texas Health Science Center at San Antonio Introduction Materials and Methods -Chronic low back pain (LBP) is disabling, expensive, and becoming increasingly common. Recent work by a research group in North Carolina has indicated that the prevalence of chronic LBP has increased over the past 10 to 15 years, from 3.9% to 10.2% of the adult population. The North Carolina researchers also found that the proportion of those who seek care has also modestly increased.1 -McGorry conducted a study on how the intensity and episodic nature of low back pain is related to disability and medication use. He found that during an episode of intense pain participants had significantly greater disability and medication use.2 -The study we conducted further explores the relationship between disabling flare-ups, physical functioning, and medication use. Specifically, this analysis examines the relationship between pain flare-ups, average pain severity, physical function, and opioid use in patients with chronic low back pain Subjects.  Student research assistants enrolled 367 adult patients from 9 outpatient clinics across Texas.  Patients were eligible if they had low back pain for 3 months or longer, and were excluded if they were pregnant or had a diagnosis of cancer. Procedure and Measurement.  Students gathered data from patient surveys and medical records.  A 6-page patient survey addressed demographic characteristics, pain duration, frequency and severity, physical functioning and general health, anxiety, depression, substance abuse, and risk for opioid misuse.  Patients reported pain severity using  a 10-point scale.  Two items addressed pain flare-ups, addressing their frequency and their effect on one’s life. Investigators assessed physical function, role function, and general health using composite scores based on  items from the MOS Short Form-36.  Ten items addressed physical function (ability to perform physical activities);  four items addressed role function (ability to perform daily work); and four items addressed general health (feelings of wellness versus illness). In all 3 scales, a higher score indicated higher function or better health.  From participants’ medical records, students gathered information about causes of low back pain, treatments for pain (including medications, procedures, and surgeries), co-morbidities, and Body Mass Index (BMI).  Worst Pain =10 Results p=0.0 -In this study,367 subjects participated. 71.9% of the sample were female, 29.2% were Hispanic, 45.2% were White, 22.6% were African American, 3% were Asian and 0 .8% were mixed. -Figure 1 demonstrates the number of flare ups people had during a 12 month period.-Table 1. demonstrates the correlations between pain flare ups and pain effect, pain severity physical function and role function. More frequent flare-ups were associated with worse effects, more severe pain, and poorer physical and role function. - In the past 12 months , 58% of the subjects reported using opioids for pain. Figure 2 demonstrates people who had more frequent flare ups were more likely to take opioids for pain. -Figure 3 demonstrates the relationships between frequency of flare ups and pain severity, physical role, and physical function Best physical and role function =3 Your Image Here No Pain=0 worst physical And role Function = 0 p=0.0 % of People Number of Flare Ups in the past 12 months X 16.501, p=0.006 Number of Flare Ups in past 12 months 4.1% 5.2% 24.5% 14.0% 16.3% 35.8% Figure 1: NUMBER OF FLARE UPS p=0.0 Conclusions Acknowledgments This study was conducted in the Residency Research Network of Texas (RRNeT) with support from the Dean’s Office, School of Medicine, UTHSCSA;  the Texas Academy of Family Physicians; the South Texas Area Health Education Center; the National Center for Research Resources (Award # UL 1RR025767); and the Health Resources and Services Administration (Award # D54HP16444).  The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center for Research Resources of the National Institutes of Health. •  Patients with more frequent flare-ups reported more severe pain, worse physical and role functioning, and were more likely to take opioid medicines. • The association between opioid use and frequent flare-ups is consistent with McGorry’s findings.2 It is likely that sudden flare-ups induce patients to seek ‘stronger’ medicines to alleviate the pain. • Given concerns about opioid misuse, can non-pharmaceutical interventions be helpful ? Moorea’s study of a Self Care intervention showed significant reductions in average back pain intensity and interference with activities.3 • Pain flare-ups may be driving disability and medicine-seeking in patients with chronic low back pain.  • Physicians should work hard to find non-narcotic treatment modalities to improve daily pain and function, with a specific plan for managing flare-ups when they occur. References 1. Carey TS, Freburger JK, Holmes GM, Castel L, Darter J, Agans R, Kalsbeek W, Jackman A. A long way to go: practice patterns and evidence in chronic low back pain care. SPINE 2009; 34: 718-724. 2. McGorry R, Barbara S ,Snook SH, Hsiang SM. The Relation Between Pain Intensity, Disability, and the Episodic Nature of Chronic and Recurrent Low Back Pain. SPINE 2000;25:834-841 3. Moorea, JE, Korffb MV, Cherkinb D, Saundersb K, Lorigc K. A randomized trial of a cognitive-behavioral program for enhancing back pain self care in a primary care setting. Pain 2000; 88: 145-153.