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Research ArticleOriginal Research

Opioids for Back Pain Patients: Primary Care Prescribing Patterns and Use of Services

Richard A. Deyo, David H. M. Smith, Eric S. Johnson, Marilee Donovan, Carrie J. Tillotson, Xiuhai Yang, Amanda F. Petrik and Steven K. Dobscha
The Journal of the American Board of Family Medicine November 2011, 24 (6) 717-727; DOI: https://doi.org/10.3122/jabfm.2011.06.100232
Richard A. Deyo
MD, MPH
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David H. M. Smith
RPh, PhD
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Eric S. Johnson
PhD
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Marilee Donovan
RN, PhD
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Carrie J. Tillotson
MPH
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Xiuhai Yang
MS
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Amanda F. Petrik
MS
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Steven K. Dobscha
MD
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Figures

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    Figure 1.

    Graphic presentation of proportions of patients with diagnoses of depression (a), any of four mental health diagnoses (b), or sedative hypnotic use (c) as a function of duration of opioid use. PTSD, posttraumatic stress disorder.

Tables

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    Table 1.

    International Classification of Diseases, 9th Revision, Clinical Modification Diagnosis and Procedure Codes Used to Select or Exclude Patients18

    Inclusion codesBack Pain
    721.3Lumbosacral spondylosis without myelopathy
    721.42Spondylogenic compression of lumbar spinal cord
    722.10Displacement of lumbar intervertebral disc without myelopathy
    722.32Schmorl's nodes, lumbar
    722.52Degeneration of lumbar or lumbosacral intervertebral disc
    722.73Intervertebral disc disorder with myelopathy, lumbar
    722.83Postlaminectomy syndrome, lumbar
    722.93Other and unspecified disc disorder, lumbar
    724.02Spinal stenosis, lumbar
    724.2Lumbago; low back pain
    724.3Sciatica
    724.5Backache, unspecified
    724.6Disorders of sacrum
    738.4Acquired spondylolisthesis
    739.3, 739.4Somatic dysfunction, lumbar region or sacral region
    756.11Spondylolysis, lumbosacral region
    756.12Spondylolisthesis
    805.4, 805.6Vertebral fracture without spinal cord injury, closed, lumbar, sacrum, or coccyx
    846.0–846.9Sprains and strains of sacroiliac region
    847.2, 847.3Sprains and strains, lumbar or sacrum
    Exclusion codes
    140–239.9Neoplasms
    324.1Intraspinal abcess
    730–730.99Osteomyelitis
    805.1, 805.3, 805.5, 805.7, 805.9Open vertebral fractures
    03.2–03.29Chordotomy (procedure code)
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    Table 2.

    Classification of Opioid Medications and Morphine Equivalent Conversion Factors per Milligram of Opioid*

    Major GroupType of OpioidMorphine Equivalent Conversion Factor/Milligram of Opioid
    Short-acting, non-schedule IIPropoxyphene (with or without aspirin/acetaminophen/ibuprofen)0.23
    Codeine + acetaminophen, ibuprofen, or aspirin0.15
    Hydrocodone + acetaminophen, ibuprofen, aspirin, or homatropine1.00
    Tramadol with or without aspirin0.10
    Butalbital and codeine (with or without aspirin, ibuprofen, acetaminophen)0.15
    Dihydrocodeine (with or without aspirin, ibuprofen, acetaminophen)0.25
    Pentazocine (with or without aspirin, ibuprofen, acetaminophen)0.37
    Short-acting, schedule IIMorphine sulfate1.00
    Codeine sulfate0.15
    Oxycodone (with or without aspirin, ibuprofen, acetaminophen)1.50
    Hydromorphone4.00
    Meperidine hydrochloride0.10
    Fentanyl citrate transmucosal†0.125
    Oxymorphone3.00
    Long-acting, schedule IIMorphine sulfate sustained release1.00
    Fentanyl transdermal‡2.40
    Levorphanol tartrate11.0
    Oxycodone HCl controlled release1.50
    Methadone3.00
    • ↵* Opioids delivered by pill, capsule, liquid, transdermal patch, and transmucosal administration were included. Opioids formulated for administration by injection or suppository were not included.

    • ↵† Transmucosal fentanyl conversion to morphine equivalents assumes 50% bioavailability of transmucosal fentanyl, and 100-μg transmucosal fentanyl is equivalent to 12.5 to 15 mg of oral morphine.

    • ↵‡ Transdermal fentanyl conversion to morphine equivalent is based on the assumption that one patch delivers the dispensed micrograms/hour over a 24-hour day and remains in place for 3 days.

    • Adapted from Von Korff M, Saunders K, Ray GT, et al. De facto long-term opioid therapy for noncancer pain. Clin J Pain 2008;24:521–7.19.

    • View popup
    Table 3.

    Kaiser Northwest Patient Demographic Characteristics and Comorbid Conditions According to Duration of Opioid Use, 2004*

    CharacteristicNo opioidsAcute opioids only†Episodic opioid use†Chronic opioid use†P
    Patients (n)10,18410,5434044,883—
    Mean age (years)‡49.149.156.654.6<.001
    Women§5,529 (54.3)5,847 (55.5)240 (59.4)3,071 (62.9)<.001
    BMI ≥30§3,490 (36.8)4,525 (45.4)185 (47.2)2,403 (50.0)<.001
    Current or recent smoker§3,538 (37.4)4,620 (45.9)176 (46.3)2,476 (52.6)<.001
    Diagnosis during previous year
    Depression§1,247 (12.2)1,839 (17.4)95 (23.5)1,526 (31.3)<.001
    Anxiety§449 (4.4)594 (5.6)25 (6.2)573 (11.7)<.001
    PTSD§54 (0.5)102 (1.0)1 (0.3)116 (2.4)<.001
    Substance abuse§946 (9.3)1,467 (13.9)60 (14.9)1,233 (25.3)<.001
    Patients with any of the four mental health diagnoses§2,185 (21.5)3,108 (29.5)146 (36.1)2,405 (49.3)<.001
    Median comorbidity score (RxRisk)¶1,2761,5802,4643,366<.001
    • Values provided as n (%) unless otherwise indicated.

    • ↵* Approximately 5% of patients had missing values for body mass index and smoking status; the percentages displayed are calculated for those cases that were not missing.

    • ↵† “Acute” use was defined as use ≥90 days. “Episodic” use was defined as use >90 days but <120 days with fewer than 10 prescription fills. “Chronic” use was ≥120 days, or >90 days with ≥10 prescription fills.

    • ↵‡ Generalized linear model F-test.

    • ↵§ Cochrane-Armitage test for trend.

    • ↵¶ Kruskal-Wallis test.

    • BMI, body mass index; PTSD, posttraumatic stress disorder.

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    Table 4.

    Logistic Regression Models for the Associations of Mental Health Diagnoses With Duration of Prescription Opioid Use*

    DepressionAnxietyPTSDSubstance AbuseSedative-Hypnotic Use
    None (reference category)1.001.001.001.001.00
    Acute†1.15 (1.06–1.25)1.00 (0.88–1.14)1.34 (0.96–1.88)1.44 (1.32–1.57)1.94 (1.79–2.11)
    Episodic†1.35 (1.05–1.74)0.95 (0.62–1.45)0.31 (0.04–2.28)1.56 (1.17–2.08)2.99 (2.38–3.75)
    Chronic†1.49 (1.35–1.64)1.44 (1.24–1.66)2.07 (1.44–2.96)2.77 (2.50–3.08)4.00 (3.65–4.39)
    • Values provided as odds ratios (95% CI).

    • ↵* All models adjusted for age, gender, comorbidity score, and number of hospitalizations in the past year. The models for depression and for substance abuse also adjusted for the use of sedative-hypnotics.

    • ↵† “Acute” was defined as use for ≥90 days. “Episodic” was defined as use for >90days but <120 days with fewer than 10 prescription fills. “Chronic” was defined as use for ≥120 days or >90 days with 10 or more prescription fills.

    • PTSD, posttraumatic stress disorder.

    • View popup
    Table 5.

    Health Care Use and Complications According To Duration of Opioid Use

    Type of Health Care UseNo OpioidsAcute Opioids OnlyEpisodic Opioid UseChronic Opioid UseP
    Patients (n)10,18410,5434044,883
    Opioid dose at last dispensing, morphine equivalent (median)*NA‡30.0 mg20.0 mg30.0 mg<.001
    Opioid prescribers (median)*NA‡123<.001
    Patients receiving sedative-hypnotic prescription during the 6 months before/after index visit (n [%])†1,018 (10.0)2,163 (20.5)134 (33.2)2,166 (44.4)<.001
    Patients with ER visit 6 months before/after index date (n [%])†1,725 (16.9)3,627 (34.4)148 (36.6)1,948 (39.9)<.001
    ER visit with back pain diagnosis, patients with any ER visit (n [%])†405 (23.5)1,246 (34.4)50 (33.8)535 (27.5).66
    Opioid prescription filled within 5 days of ER visit (% of patients with ER visit)†1 (0.1)2,048 (56.5)85 (57.4)1,091 (56.0)<.001
    Clinic visits of any type during the 6 months before/after index date (median)*8111718<.001
    Patients with any pain clinic visit during the 6 months before/after index date (n [%])†99 (1.0)227 (2.2)25 (6.2)585 (12.0)<.001
    Patients with any hospitalization during the 6 months before or after index date (n [%])†364 (3.6)1,126 (10.7)87 (21.5)1,012 (20.7)<.001
    • ↵* aKruskal-Wallis test.

    • ↵† Cochrane-Armitage test for trend.

    • ↵‡ NA, not applicable. This category was not included in tests of statistical significance.

    • ER, emergency room.

    • View popup
    Table 6.

    Use of Long-and Short-Acting Opioids by Duration of Opioid Use

    OpioidAcute Use (n = 10,543)Episodic Use (n = 404)Chronic Use (n = 4,883)
    Short-acting only (%)98.385.259.4
    Long-acting only (%)0.10.71.3
    Both long-and short-acting (%)1.614.139.3
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The Journal of the American Board of Family     Medicine: 24 (6)
The Journal of the American Board of Family Medicine
Vol. 24, Issue 6
November-December 2011
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Opioids for Back Pain Patients: Primary Care Prescribing Patterns and Use of Services
Richard A. Deyo, David H. M. Smith, Eric S. Johnson, Marilee Donovan, Carrie J. Tillotson, Xiuhai Yang, Amanda F. Petrik, Steven K. Dobscha
The Journal of the American Board of Family Medicine Nov 2011, 24 (6) 717-727; DOI: 10.3122/jabfm.2011.06.100232

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Opioids for Back Pain Patients: Primary Care Prescribing Patterns and Use of Services
Richard A. Deyo, David H. M. Smith, Eric S. Johnson, Marilee Donovan, Carrie J. Tillotson, Xiuhai Yang, Amanda F. Petrik, Steven K. Dobscha
The Journal of the American Board of Family Medicine Nov 2011, 24 (6) 717-727; DOI: 10.3122/jabfm.2011.06.100232
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