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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
29.2
35.8
Increased back pain
12.4
50
44.47
39.37
40
30
No symptoms
Symptoms
20
15.3
Irritable
10
0
5
10
15
20
25
30
35
40
P-values
Percentage
0
Early
12
10
NO Late Opioid
Withdrawals
8
Late Opioid
Withdrawals
6
##
4
2
P-Values
# 0.037
0
Average Pain
Figure 3
Unmedicated
Pain
Panic Among Withdrawal Patients
Percentage
● p = .027
60
50
40
30
20
10
0
Frequent
Depression
♦ p = .064
50
23.4
●
●
EARLY
47.5
25
♦
♦
No
Symptoms
Opioid Withdrawals
0.529
0.053
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.
DISCUSSION
Symptoms
LATE
Late
Opioid Withdrawal Symptoms
Pain and Depression Prevalent in Opioid
Withdrawal Patients
Figure 2
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.
52.73
Increased senstivity to pain
Spasms
64.76
60
11.7
Anxiety or worry
Current Opioid Dosage
70
Mean Values
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. 2 However,
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.
Prevalent Opioid Withdrawal Symptoms
Figure 1
Mean Values
BACKGROUND
Figure 4
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
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.
1.
2.
Trescot AM, Helm S, Hansen H, Benyamin R, Glaser SE, Adlaka R, et al. Opioids in the management of chronic noncancer 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.