By: Jason Lipetz, MD
Long Island Rehabilitation Medicine
When assessing the impact of opioid use in the treatment of low back pain it becomes truly clear that “we have a problem.” In the past 25 years, over one half a million people have died from opioid overdose in the United States. Of all developed nations, the use and abuse of opioids in the United States is by far the most problematic. Musculoskeletal pain has the potential of being a major source of pain that results in the prescription of opioids to manage. Among the wide range of musculoskeletal pain generators, low back pain can result in pain at the higher end of the spectrum and will be the focus of this article.
In 2009, accidental deaths from opioid overdose surpassed motor vehicle accident deaths. Most illegal use of opioids, such as heroin and fentanyl, begins with the legal use of opioid pain medications prescribed by physicians. This reality highlights the responsibility that all prescribers in the healthcare system have when considering opioids as a treatment option. There are three primary scenarios to consider when examining the situations in which opioid prescriptions might be considered for low back pain.
1) Acute Low Back Pain
The first is the patient presenting with an episode of acute low back pain arising from daily activities, sport participation, or a more strenuous or traumatic event. In such instances, there is a role for medications to control pain, often prescribed in conjunction with rehabilitative therapies and alternative medicine techniques such as acupuncture. Most patients presenting with this type of acute pain can be successfully treated with the introduction of anti-inflammatory agents, acetaminophen, and muscle relaxants.
In more severe cases, oral steroids might be prescribed to better control pain and inflammation. Only the minority of these patients will also require a short-term prescription of opioids, such as hydrocodone or oxycodone. A sizable number of patients will not obtain relief from opioid use in these situations and will prefer to avoid their use due to common side effects of drowsiness, nausea, and constipation. In a small but significant subset of patients, the use of opioids for a low back pain episode will unfortunately lead to future opioid dependence and abuse.
2) Following Spine Surgery
Opioids can also be used following spinal surgery for low back pain. In such instances, the use of opioids should be limited in dosing and duration. The most concerning of this group is that subset of patients who will become chronic users. The use of opioids after surgery can also result in medical complications and prolonged hospital stays. Studies show the use of alternative pain control strategies following surgery can reduce the need for opioids and the likelihood of complications from opioid use.
Following spine surgery, the combination of anti-inflammatory medications, non-opioid pain relievers such as acetaminophen, muscle relaxers, and medications that target nerve-related pain can provide adequate pain relief. The local use of anesthetics and nerve blocks can be very impactful in controlling postoperative pain. Also, the evolution of more minimally invasive spine surgery has been shown to reduce the degree of postoperative pain intensity and medication needs.
3) Chronic Low Back Pain
Individuals taking opioids for chronic low back pain, pain lasting beyond three months, represent a particularly challenging patient population. Studies reveal a lack of benefit to long-term opioid use for chronic pain. In these chronic low back pain patients, other medication classes have been shown to provide the same or greater levels of pain relief. In addition, opioids are not shown to improve function or reduce disability. What is known is that these patients are anticipated to suffer from medication side effects, have a greater likelihood of abuse, and have an overall increase in premature death. When attempting to taper opioid use in this chronic pain population, this must be done gradually with dosage reductions of approximately 10% at regular define intervals using an interdisciplinary team of pain specialists and psychologists.
Conclusion
The opioid crisis in the United States has reduced overall population life expectancy for otherwise healthy individuals. In these three clinical situations, we must be very careful when introducing opioids. Most often, adequate pain control can be achieved without the introduction of opioids at all. In other instances, there is a need for the limited use of opioids for pain control. We must remain mindful of the adverse effects which can arise from prescribed opioids, the potential for abuse, and the subset of patients who become chronically dependent on opioids without benefit. Educating patients suffering from low back pain is one of the most effective tools to avoiding adverse outcomes associated with opioids.
