Back Pain Contribution to Opioid Crisis

Dan Miulli, DO, FACOS Neurosurgeon

Disclosure I have:

• No Commercial interest or support • No Financial relationships with outside individuals

or companies • No Conflict of interest

Objective

• Determine how pathophysiology of LBP can lead to opioid abuse

• Describe non-opioid treatment modalities for LBP

• Describe how appropriate surgery decreases opioid use

• Improving and Empowering Health through Human Touch

Cultural Barriers

• Language Barrier could led to delay – availability of translators crucial

• Personal Beliefs creating treatment issues – concern regarding PT, medications – necessitates detailed explanations

• Ethno cultural Beliefs that delay treatment – concern regarding procedures at certain ages

Summary

• Day 1 History & Physical to ID lesion

• Day 2 Multi-modality Treatment if able to improve without surgery OMM as effective Two weeks to see improvement

• Day 16 Imaging if no improvement or plateaus

• Day 18 Surgeon to rule out surgical lesion

Opioid Use

• Use & Abuse exponentially increasing • Death all drugs↑ 137% Opioid >200% (5Xs>2000)

SAFE

October 2017, the United States declared the opioid epidemic a

national public health emergency

Opioid Epidemic Cause • Pharmaceutical industries’ marketing strategies • Penalizing physicians & hospitals for not treating pain • Article

– NEJM 1980 5 sentence letter SAFE Not Addicting – Cited > 600 times over 25 yrs

• 1996 sustained release formulation of oxycodone was distributed and marketed as a “less addicting” medication

• Changing hospital reimbursement being linked to patient satisfaction surveys

– Hospitals ensure patients are content with the service they receive in the facility to receive proper funding

– and it often results in increased opioid usage

x x

x

Greater than 20 MME/day increased odds of

overdose 2 or more prescriptions in one year for problem led to overdose. Higher number of days on opioid led to overdose More than 3 prescribers or pharmacies led to death

Acute pain at highest dose associated with more overdoses

Frequent user greater risk for opioid overdose except

Higher Risk for Overdose

• Concurrent benzodiazepine or sedative hypnotic

• History of non-opioid abuse • History of opioid abuse • History mental illness • Respiratory conditions

HOW CAN THE PRACTICE OF MEDICINE REDUCE THE OPIOID NATIONAL PUBLIC HEALTH EMERGENCY?

Methods

• Four centers- 2 County 2 Managed Care • IRB approval • 18 y/o + • Elective lumber fusion degenerative disease back

& radicular pain • Consecutive cases last 118 pt charts • No: trauma, addiction, hip, knee pain • Pain before surgery, immediate after, on

discharge, & 15-30 days

Morphine Milligram Equivalent Drug Conversion Factor Dose Equiv. to 120mg

morphine per day

Butorphanol (nasal) [s] 7 17

Codeine 0.15 800

Fentanyl (patch) 7.2 50mcg/hr patch q 3D

Hydrocodone [v,n] 1 120

Hydromorphone (oral) [d] 3.75 32

Levorphanol 11 11

Meperidine (oral) [d] 0.1 1200

Methadone 4 30

Morphine (oral) 1 120

Morphine (parental) 3 40

Oxycodone [o] 1.5 80

Oxymorphone 3 40

Pentazocine 0.33 363

Tramadol 0.1 1200

Patient Demographics Patient Demographics

County A County B Managed

Care A Managed

Care B Total (n) 10 10 10 10 Age 34-79 26-75 37-91 35-88 Mean 66.2 65.6 67.1 69.4 Median 56 53 65 62 Sex Male 60% 70% 50% 40% Female 40% 30% 50% 60% Levels fused 2.4 2.1 1.3 1.2

County vs Managed Care Mean PreOP

Daily MME OP

Mean PostOp Daily MME IP

Mean PostOp Daily MME OP

Difference PreOP and PostOP MME

P Value

County A 48.23 60.26 23.20 25.03 0.0005 County B 43.00 48.62 30.50 12.50 0.0035 County Combined

45.62 54.44 26.85 18.77 0.0034

Managed Care A

40.00 64.89 25.50 14.50 0.0027

Managed Care B

88.00 142.97 81.00 7.00 0.2819

Managed Care Combined

64.00 103.93 53.25 10.75 0.1803

County vs Managed

0.1605

Preop vs Postop Details County A County B Managed A Managed B County Managed

Care Mean PreOP (different) opioid Rx

1.27 0.8 1 1.2 1.03 1.1

Mean PreOP Daily MME (Median)

48.23 (46)

43 (42)

40 (40)

88 (64)

45.62 64

Mean Levels fused

2.4 2.1 1.3 1.2 2.25 1.25

Total IP MME 327.17 248.90 237.70 605.60 288.03 421.65 Mean Inpatient Days

5 5 3.4 4.2 5 3.8

Mean PostOp IP MME per Day

60.26 48.62 64.89 142.97 54.44 103.93

Mean PostOp Follow Up Daily MME (Median)

23.20 (20)

30.50 (30)

25.50 (24)

81.00 (56)

26.85 53.25

Patient Pain Scale County Hospital Managed Care Combined

A B A B County Managed

Average Pre Op Pain

9.07 8.60 9.20 8.40 8.84 8.80

Average Post OP Pain

8.06 7.45 7.11 6.43 7.75 6.77

Discharge Pain

7.27 5.80 5.60 3.40 6.53 4.50

Difference 1.80 2.80 3.60 5.00 2.30 4.30

Comparison Pooled Cohort C v. MC Managed vs County

P Value PreOp MME vs PostOp MME 0.1605 Inpatient PostOp MME dosage levels Managed vs County

0.0427

Pain Scale average Inpatient Managed vs County

0.0088

Pain Scale average at Discharge Managed vs County

0.1455

Results

• Increased pre-operative opioid use for longer periods at managed care hospitals

Results • Decreased 8%-51.9% opioid use post-op • Decreased use of opioids in the postoperative follow-

up phase after lumbar fusion in both the county and managed care facilities 3 out of 4 hospitals (P< 0.01)

• Significance when the data from facilities were pooled • Significant decrease in opioid use during the post-

operative inpatient phase for county compared to managed care facilities (P=0.0427)

• Pain rating reported by patients during hospital stay was significantly higher at county facilities in comparison (P=0.0088)

• Difference at discharge was not significant (P=0.14)

Summary

• Day 1 History & Physical to ID lesion

• Day 2 Multi-modality Treatment if able to improve without surgery OMM as effective Two weeks to see improvement

• Day 16 Imaging if no improvement or plateaus

• Day 18 Surgeon to rule out surgical lesion

Conclusion

• Less opioid is used in patients post-operative compared to pre-operative

• No difference whether county hospital vs managed care hospital

• No difference in level of pain experienced post-op between hospitals and all better than pre-op

Conclusion

• More opioids are used pre-op in managed care facilities

• More opioids are used post-op in managed care facilities

Adjuvant-Non-Opioid • The institution with greatest reduction in opioid usage out

of the four hospitals reviewed in this study • Muscle relaxers and anti-inflammatory medications were

used in the postoperative phase – Surgeons cautious to use NSAID medications d/t anti-platelet

effects causing postoperative hematomas and possibility of inhibiting bony fusion from the anti-inflammatory effects

• All patients continuous infusion of ketorolac tromethamine drip 120 mg in 500 ml 0.9% saline to run continuously at 10 ml/hour for 50 hours in the immediate postoperative phase

• Icing, manipulation, and early mobilization have also been shown to be effective for treating low back pain

Why More Opioids • Increased preoperative opioid usage and dosage in our

MC patients may be related to prolonged time in the healthcare system treated with conservative management

• Many patients in a MC setting have easier access to healthcare & placed in protocol driven regimens

• Initial symptom improvement, often due to opiate use, may delay surgical referrals – total knee replacements: 54% of patients delayed surgical

intervention by 2 years secondary to opioid use. – Maintaining patients eventually identified for surgery on

non-surgical treatment for prolonged periods of time often lead to opioid tolerance and dependence

– Berend K, Zhao R, Carlson A, Stultz M. Patient Factors Affecting Surgeon Selection and the Decision to Delay Total Knee Arthroplasty. Reconstructive Review. Reconstructive Review 2017

Why More Opioids • Shift towards patient-centered satisfaction ratings • Hospital ratings based on patient satisfaction scores

– although subjective, affect reimbursement rates – trend being adopted by private insurers – Aim to make patients happier through treating

postoperative pain more aggressively with opioid medication rather than nonopioid alternatives.

– Added benefit of opioid-induced euphoria may serve as a secondary bonus for higher patient satisfactory scores.

• Shirley ED, Sanders JO. Patient satisfaction: Implications and predictors of success. J. Bone Joint Surg. Am. 2013;95(10):e69. • Zgierska A, Miller M, Rabago D. Patient satisfaction, prescription drug abuse, and potential unintended consequences. JAMA

2012;307(13):1377-1378. • Lyu H, Wick EC, Housman M, Freischlag JA, Makary MA. Patient satisfaction as a possible indicator of quality surgical care. JAMA Surg

2013;148(4):362-367. • Geiger NF. On tying Medicare reimbursement to patient satisfaction surveys. Am. J. Nurs. 2012;112(7):11

Case • 45 y/o RH Caucasian male c/o LBP with

post axial radiation into top of right foot, with paresthesia in similar distribution and subjective paresis of EHL, no change reflexes. Pain increased with coughing and sitting, relieved with lying down.

Epidemiology – Back Pain

• Second leading cause of disability and work- related injury

• Affects 50 million Americans annually • Most common health problem in 20-50 y/o • 13 million US doctor visits annually • Most lost productivity • 175.8 million restricted days • Annual prevalence 15-20% • 70-80% world experience LBP

Summary

• Day 1 History & Physical to ID lesion

• Day 2 Multi-modality Treatment if able to improve without surgery OMM as effective Two weeks to see improvement

• Day 16 Imaging if no improvement or plateaus

• Day 18 Surgeon to rule out surgical lesion

Pain

Heat Pressure Cold Chemical Complex

Phospholipids Lysosomes

Arachidonic acid Histamine Bradykinin Kinins

Lipoxygenase cyclooxygenase (COX 1-3) free rad SRSA Leukotriene B2 Prostaglandins Thromboxanes Slow Reacting Subs Anaphy

Inflammation erythema edema pain loss of function

Medication Non-sedating muscle relaxants

continuously for two weeks no longer Longer use makes the muscles dependant and weak leading

to further loss of tone and pain Anti-inflammatory

pain and muscle irritation. Physical therapy OMT

ice early on in the first two weeks later warm moist heat for 30 minutes at a time 4-5 times per

day. The use of heat for greater periods of time can promote muscle tissue swelling and of course worsen the problem

Summary

• Day 1 History & Physical to ID lesion

• Day 2 Multi-modality Treatment if able to improve without surgery OMM as effective Two weeks to see improvement

• Day 16 Imaging if no improvement or plateaus

• Day 18 Surgeon to rule out surgical lesion

Improving and Empowering Health through Human Touch

Physical Therapy

Manipulation, massage, ultrasound and muscle stimulation therapy help the spasms associated with muscle disease

OMT reduces need for adjunctive therapy. Works if normally respond to adjunctive therapy.

Scientific Data RCT: OMM effective

Cochrane data base: Cochrane.org/cochrane/revabstr/AB00424

9.htm National Guidelines Clearing House

Guidelines.gov/summary/summary.aspx?doc id=3803&nbr=3030&string=neck+and+”upper+back”

Scientific Data Literature Review: OMT significantly reduced low

back pain (effect size, -0.30; 95% confidence interval, -0.47 - -0.13; P = .001

Osteopathic manipulative treatment for low back pain: a systematic review and meta analysis of randomized controlled trials. Licciardone JC, et al. BMC Musculoskelet Disord. 2005 Aug 4;6:43. Osteopathic Research Center, University of North Texas Health Science Center, Fort Worth, TX 76107, USA

Osteopathic therapy is as good as allopathic therapy and uses less medicine and physical therapy for LBP.

A comparison of osteopathic manipulation with standard care for patients with low back pain by G Anderson Robert Kappler James Lipton NEJM November 4, 1999

OMT …for Chronic LBP: RCT

• 455 pts: OMT (n=230) v Sham OMT (n=230) – And US v sham US

• 6 Rx over 8 wks • Measure outcomes at 12 weeks • Conclusion: Pts receiving OMT were more

likely than pts receiving sham OMT to achieve moderate (P<.001) and substantial improvements (P=.002) in LBP at 12 weeks

» Ann. Fam Med 11:2 122-129 2013

OMT Ann. Fam Med 11:2 122-129 2013

• OMT pts more likely to be very satisfied with low back care throughout study (P<.001)

• OMT Pts used less prescription drugs during 12 weeks (P=.048)

Make the connection

OMT Associated With Reduced Analgesic Prescribing and Fewer Missed Work Days in Patients With Low Back Pain: An Observational Study February 2014, Vol. 114, 90-98

J. Prinsen, PhD; K. Hensel, DO, PhD; R. Snow, DO, MPH

• AOA CAP Program- 1013 records Characteristic No. (%)b

Age, y, mean (SD)c 44.7 (15.9)

BMI, mean (SD)d 29.6 (8.1)

Sex

Male 415 (41.0)

Female 598 (59.0)

Comorbid Disease

Neurologic disease 91 (9.0)

Spondylolisthesis 65 (6.4)

Connective tissue disease 50 (4.9)

Function No. (%)

Sensory/Proprioception (n=831)

No loss 729 (87.7)

Some loss 102 (12.3)

Motor (n=854)

No loss 636 (74.5)

Some loss 218 (25.5)

Deep Tendon Reflex

Ankle (n=814)

Normal 744 (91.4)

Reduced 70 (8.6)

Knee (n=829)

Normal 755 (89.0)

Reduced 93 (11.0)

Body Area

Patients, No. (%) Number of OMT Sessions, mean (SD) ⩾1 Session OMT No OMTa

Lumbar 576 (56.9) 437 (43.1) 2.89 (2.6)

Thoracic spine 411 (40.6) 602 (59.4) 2.3 (2.0)

Sacrum/pelvis 440 (43.4) 573 (56.6) 2.81 (1.9)

Rib 261 (25.8) 752 (74.2) 2.38 (1.4)

Lower extremity 256 (25.3) 757 (74.7) 2.86 (2.2)

Medication

Patients, No. (%)

P Value ⩾1 Session OMT (n=330)

No OMTa (n=209)

Nonopioid analgesia 208 (63.0) 152 (72.7) .0199

Muscle relaxant 192 (58.2) 112 (53.6) .2947

Opioid 53 (16.1) 68 (32.5) .0001

Oral steroids 17 (5.2) 20 (9.6) .0481

Injection 37 (11.2) 9 (4.3) .0052

Analgesic, opioid, and nonopioid

217 (65.8) 162 (77.5) .0036

Any medication 259 (78.5) 174 (83.3)

Measure

⩾1 Session OMT ⩾No OMT P Value

Mean (SD) No. (%) Mean

(SD) No. (%)

Visual analog scalea

2.87 (2.2) 235 2.76

(2.0) 93 .2638

Straight-leg raisingb

8.69 (6.8) 189 6.25

(3.5) 60 .0092

No. days off work

2.08 (10.6) 330 5.84

(7.1) 209 .0001

No. days worked, limited duties

2.26 (9.8) 330 3.76

(9.8) 209 .0001

(OMT/LBP) LBP Guidelines. • OMT reduces pain more than expected from placebo

effects alone • Results have the potential to last beyond the first year of

treatment • Clinically relevant effects of OMT were found for reducing

pain and improving functional status in patients with acute and chronic nonspecific LBP and for LBP in pregnant and postpartum women 3 months after treatment.

• AOA Task Force on the Low Back Pain Clinical Practice Guidelines American Osteopathic Association Guidelines for Osteopathic Manipulative Treatment (OMT) for Patients With Low Back Pain

• JAOA, 116 (8): 536-549 (2016)

LBP JAMA, 2017; 317 (14): 1451 • Spinal manipulation therapy caused modest

improvements in pain & function at up to 6 weeks – Paul Shekelle, M.D., Ph.D., of the West LA VA reviewed previous studies to

assess the effectiveness and harms associated with spinal manipulation compared with other nonmanipulative therapies for adults with acute (six weeks or less) low back pain.

– 26 RCTs, 15 RCTs (1,711 patients) moderate-quality evidence of SMT significant improvements in pain

– 12 RCTs (1,381 patients) moderate-quality evidence of SMT significant improvements in function

– No RCT reported any serious adverse event – Clinician performing SMT, type, study quality, SMT w/ or w/o package of

therapies unknown

SPORT: Surgical vs Non-Surgical Treatment

• Surgical & nonsurgical care of intervertebral disk herniation same improvement in symptoms of low back and leg pain

• Treatment effect of surgery for intervertebral disk herniation was less

• Surgery better versus nonsurgical treatment of degenerative spondylolisthesis and lumbar spinal stenosis

• Spine Patient Outcomes Research Trial (SPORT): J Am Acad Orthop Surg. 2012 Mar;20(3):160-6 NIH Funded Dartmouth

Treating LBP & RR

• BE: deeply caring, empathetic, compassionate, and patient centered, encourage the body's natural healing process through treating the whole person, focus on augmenting and restoring the body’s functions, prevent disease, improve lifestyles, caring touch, and maximize the special role of the psyche, family and community to improve patient outcomes and experience at the best cost

Medication Non-sedating muscle relaxants

continuously for two weeks no longer Longer use makes the muscles dependant and weak leading

to further loss of tone and pain Anti-inflammatory

pain and muscle irritation. Physical therapy

ice early on in the first two weeks later warm moist heat for 30 minutes at a time 4-5 times per

day. The use of heat for greater periods of time can promote muscle tissue swelling and of course worsen the problem

Summary

• Day 1 History & Physical to ID lesion

• Day 2 Multi-modality Treatment if able to improve without surgery OMM as effective Two weeks to see improvement

• Day 16 Imaging if no improvement or plateaus

• Day 18 Surgeon to rule out surgical lesion

Summary

• Day 1 History & Physical to ID lesion

• Day 2 Multi-modality Treatment if able to improve without surgery OMM as effective Two weeks to see improvement

• Day 16 Imaging if no improvement or plateaus

• Day 18 Surgeon to rule out surgical lesion

HNP Sx

All of the treatments for back disease Disk does not return to the healthy young non

diseased state Comparable to removing a splinter. Not only mass

removed, the inflammation is allowed to subside

Microdiscectomy Standard of Care Surgery is an art. The anatomy and

pathology is interpreted in the surgeons mind prior to the operation and must match what is actually seen

One level microdiscectomy incision is usually 2 cm. in length (longer in more robust individuals)

Disk continues to degenerate after nucleotomy

Need to RESTORE morphology and function

HOW CAN THE PRACTICE OF MEDICINE REDUCE THE OPIOID NATIONAL PUBLIC HEALTH EMERGENCY?

PRACTICE OSTEOPATHIC MEDICINE

CME Questions • In this study, the concluding result demonstrated that:

A. Opioid usage trending towards increase at the post-operative clinic visit.

B. Patients at county facilities used more opioids than patients in the managed care facility

C. Patients in county facilities are using less opioids postoperatively but managed care patients are used more opioids after lumbar fusion by the initial postoperative clinic visit

D. Patients in county facilities are using more opioids postoperatively but managed care patients are using less opioids after lumbar fusion by the initial postoperative clinic visit

E. Patients in both systems, county and managed care, are using less opioids after lumbar fusion by the initial postoperative clinic visit

CME Questions • In this study, the concluding result demonstrated that:

A. Opioid usage trending towards increase at the post-operative clinic visit. B. Patients at county facilities used more opioids than patients in the managed

care facility C. Patients in county facilities are using less opioids postoperatively but

managed care patients are used more opioids after lumbar fusion by the initial postoperative clinic visit

D. Patients in county facilities are using more opioids postoperatively but managed care patients are using less opioids after lumbar fusion by the initial postoperative clinic visit

E. Patients in both systems, county and managed care, are using less opioids after lumbar fusion by the initial postoperative clinic visit

The results of this study demonstrated that patients at both county facilities and managed care facilities used required a lessened opioid dosage (converted to morphine milligram equivalents) after having lumbar fusion performed compared to their preoperative dosage levels.

CME Question

• In October 2017, the United States declared the opioid epidemic to be: A. DEFCON 3 B. National Crisis C. National Public Health Emergency D. National Emergency

CME Question

• In October 2017, the United States declared the opioid epidemic to be: A. DEFCON 3 B. National Crisis C. National Public Health Emergency D. National Emergency

In October 2017, the president of the United States declared the opioid epidemic to be a National Public Health Emergency. This allocated additional funds under the Public Health Services Act.

CME Question

• Patients presenting with acute onset of back pain without neurological deficits should be managed conservatively without surgical intervention unless: A. Pain does not improve, with anti-inflammatory

medications and physical therapy over 4-6 weeks B. Progressive neurological deficits, such as

weakness of the affected myotome C. Saddle anesthesia and/or incontinence D. All the above

CME Question • Patients presenting with acute onset of back pain without neurological

deficits should be managed conservatively without surgical intervention unless:

A. Pain does not improve, with anti-inflammatory medications and physical therapy over 4-6 weeks

B. Progressive neurological deficits, such as weakness of the affected myotome

C. Saddle anesthesia and/or incontinence D. All the above

Nerve root impingement from herniated disc can become a surgical emergency in certain circumstances. However, initial conservative care is recommended if no profound neurological deficit is noted. Patients presenting with signs/symptoms of neurological dysfunction should be referred for emergent imaging and surgical consultation. If patients fail to respond to conservative care or symptoms continue to progress, imaging should be obtained, and surgical consultation should be sought if findings are concerning for compression of neural elements.

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