Vulnerability to Opioid Withdrawal Symptoms Among Chronic Low Back Pain Patients

1. Vulnerability to Opioid Withdrawal Symptoms Among Chronic Low Back Pain Patients Nayeli Rodulfo, Sandra Burge, Ph.D. Darryl White, M.D. The University of Texas Health Science Center at San Antonio Valley Baptist Family Medicine Residency Training Program Figure 4 BACKGROUND The consequences of opioid misuse among patients with chronic low back pain are a rising concern in the medical community. Past research has examined opioid misuse in the context of drug overdoses in emergency settings. The Drug Abuse Warning Network examined 1.3 million emergency department visits in 2005 that involved drug misuse or abuse; over 196,000 visits were opioid-related, an increase over 2004 of 24%.1 Studies have shown that common side effects of opioids fall into two categories: non-life threatening or life threatening. Examples are constipation, pruritus, respiratory depression, nausea, vomiting, among others.1 In a study focusing on chronic injury among workers, opioid misuse risk factors included demographics, employment, and psychosocial domains. 2However, few studies have studied opioid misuse in primary care settings; and few have identified risk factors that make chronic pain patients more susceptible to opioid dependence and withdrawal symptoms. The purpose of this study is to examine factors which might make patients more vulnerable to withdrawal symptoms, including opioid medication dose, pain severity, and problems with mental health. RESULTS • Out of 137 patients, 101 were female (73.7%). 49.3% were White, 34.3% Hispanic, and 14.6% African American. Most of these patients had government insurance (60.6%). Out of this patient sample, 69 were currently taking opioid medications; 22 reported early withdrawal symptoms and 21 reported late withdrawal symptoms. Thirteen reported both early and late withdrawal symptoms. • Figure 1 describes the chief withdrawal symptoms reported. Increased back pain, higher pain sensitivity, and irritability were the most common. • Figure 2 shows that pain is perceived significantly higher in those with late opioid withdrawal, especially true when not taking medicines (p-value: 0.037). Withdrawal symptoms were not associated with depression in this particular group of patients. • Figure 3 depicts the presence of panic among patients in with early and late withdrawal symptoms, which is significantly higher than patients with no panic. • Figure 4 demonstrates that patients with higher opioid dosages are more likely to experience late withdrawal symptoms in comparison to those without symptoms. Differences were not significant in patients with/ without early withdrawal symptoms. # # P-Values # 0.037 METHODS Subjects.  In 2008, student research assistants consented and enrolled 213 outpatients with chronic low back pain from six family medicine residency programs in five Texas cities. Patients were included if they were visiting their family physician for routine care and had low back pain for 3 months or longer. Investigators excluded pregnant women and patients with cancer. In 2009, student research assistants conducted one-year follow up data collection from medical records of 204 patients (96% follow up), and from surveys of 137 patients (64% follow up).  Measurement. From participants’ medical records, students gathered information about causes of low back pain, treatments for pain, co-morbidities, and BMI.  A 5-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.  Early withdrawal symptoms included: anxiety, cravings, depression, restlessness, irritability, runny nose, sweating, or yawning. Late withdrawal symptoms included rapid heart rate, fever, hypertension, muscle spasms, seizures, cramps, tremors, insomnia, or vomiting. Analysis.  In this analysis, we examine the 137 patients from 2009 with complete data from surveys and medical record reviews. To compare groups with or without withdrawal symptoms, we examined only those 69 who used opioid medications. ● p = .027 ♦ p = .064 ♦ DISCUSSION ♦ Our findings indicated that opioid withdrawal symptoms are found in patients who experience more severe pain, panic, and who take higher dosages of opioids. This information is pertinent for primary care physicians in order to monitor their patients neurological symptoms as well as their dosage in relation to their lower back pain. REFERENCES ACKNOWLEDGEMENTS • Trescot AM, Helm S, Hansen H, Benyamin R, Glaser SE, Adlaka R, et al. Opioids in the management of chronic non-cancer pain: an update of American Society of the Interventional Pain Physicians' (ASIPP) Guidelines. Pain Physician. 2008 Mar;11(2 Suppl):S5-S62. Review. • Franklin GM, Stover BD, Turner JA, Fulton-Kehoe D, Wickizer TM, et al. Early opioid prescription and subsequent disability among workers with back injuries: the Disability Risk Identification Study Cohort. • Disability Risk Identification Study Cohort. Spine (Phila Pa 1976). 2008 Jan 15;33(2):199-204. This study was conducted in the Residency Research Network of Texas (RRNeT) with support from the Texas Academy of Family Physicians, the South Texas Area Health Education Center, and the Dean’s Office, School of Medicine, UTHSCSA.