High-Dose Opioids in Low Back Pain Flag Mental Health Issues

Alice Goodman

May 14, 2013

New Orleans, Louisiana — Patients prescribed high-dose opioids for low back pain have higher rates of psychiatric diagnoses, including substance use disorders, anxiety, and depression, as well as concurrent use of sedative-hypnotics and greater healthcare resource utilization than those using low-dose opioids or no opioids, according to a retrospective analysis of a large database from Kaiser Permanente Northwest Health System in Portland, Oregon.

The findings were presented here at the American Pain Society (APS) 32nd Annual Scientific Meeting.

"We saw increased opioid prescriptions for chronic pain, specifically low back pain, and high-dose use was more prevalent. These patients also had higher rates of psychiatric diagnoses, including depression, anxiety, substance use disorders, and higher service utilization, as well as more long-term use," said Amy Kobus, PhD, Oregon Health & Science University in Portland. "These are patients least appropriate for high-dose opioids, but they are getting these drugs that can worsen the psychiatric diagnosis and exacerbate substance use disorder. This raises significant safety concerns."

The study included 26,000 participants with an index visit for low back pain. Fifty-five percent were female, the median age was about 55 years, and about 80% were non-Hispanic white. Patients tended to be overweight.

In a cohort of 15,452 patients, the investigators assessed care for the previous 6 months and 6 months after the index visit. Patients prescribed high-dose opioids ( > 100 mg/day morphine equivalent at last dispensing) were compared with those receiving traditional-dose opioids (1 to 99 mg/day morphine equivalent) and no opioids. High-dose opioids were prescribed to 8.6% of patients with low back pain who were receiving long-term opioid treatment.

Patients prescribed high-dose opioids had higher rates of psychiatric and substance use disorder diagnoses, comorbidity, concurrent sedative-hypnotic use (60.5%), and higher resource utilization (including emergency department [ED] and pain clinic visits) than those receiving low-dose opioids and those taking no opioids.

In an adjusted analysis, male sex, higher comorbidity, Medicare, mental health/substance use diagnosis, co-prescription of sedative-hypnotics, ED visits, and pain clinic visits were associated with the likelihood of being prescribed high-dose opioids.

Table. Psychiatric Diagnosis Among 15,452 Persons with Low Back Pain

Psychiatric Diagnosis No Opioids Low-Dose Opioids High-Dose Opioids P Value for Low Dose vs High Dose
Depression (%) 12.2 29.6 41.9 .001
Anxiety (%) 4.4 10.5 19.6 .001
Substance use disorder (%) 9.2 23.8 31.3 .001
Post-traumatic stress disorder (%) 0.53 1.9 4.4 .001


"Because of safety concerns, we need to continue to assess the efficacy and safety of high-dose opioids for patients with chronic pain," Dr. Kobus stated.

In an interview with Medscape Medical News, Brett Stacey, MD, also from the University of Oregon Health & Science Center but not involved in this study, said, "This study shows us what we know already: higher rates of psychiatric diagnoses predict opioid prescriptions in patients with pain. This study of real-life patients suggests that the reasons for prescription of high-dose opioids may not be driven by pain alone but by a constellation of factors."

Dr. Stacey said that his guess is that prescribers are not assessing these psychiatric comorbid conditions. "Prescribers need to increase their awareness of these psychiatric and other comorbid conditions and perform a comprehensive assessment of the patient before prescribing increased doses of opioids," he said.

Dr. Kobus has disclosed no relevant financial relationships. Dr. Stacey has received funding from Pfizer Inc.

American Pain Society (APS) 32nd Annual Scientific Meeting. Abstract 405. Presented May 9, 2013.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as: