Prescription medication use among community-based US adults with chronic low back pain: a cross-sectional population based study

Abstract

Many classes of medications have been evaluated in chronic low back pain (cLBP), however their utilization in the community remains unclear. We examine patterns of prescription medication use among Americans with cLBP in a nationally representative, community-based sample. The Back Pain Survey was administered to a representative sample of US adults aged 20–69 (N = 5103) during the 2009–2010 cycle of the National Health and Nutrition Examination Survey (NHANES). cLBP was defined as self-reported pain in the area between the lower posterior margin of the ribcage and the horizontal gluteal fold on most days for at least 3 months (N = 700). Home-based interviews with pill bottle verification were used to capture commonly prescribed medications for chronic pain. Among the sample of US adults with cLBP aged 20–69, 36.9% took at least one prescription pain medication in the past 30 days. 18.8% used opioids, 9.7% NSAIDs, 8.5% muscle relaxants, 6.9% gabapentin or pregabalin. Non-pain antidepressants and hypnotics were used by 17.8% and 4.7%, respectively. Opioids were used long-term in 76.9% of cases (median 2 years) and were frequently co-administered with antidepressants, benzodiazepines, or hypnotics. 94% of prescription opioids in the cLBP population were used by subjects with less than a college education. Opioids were the most widely used prescription analgesic class in community-based US adults with cLBP and were often co-administered with other CNS-active medications. Opioid use was highly prevalent among less educated Americans with cLBP.

Introduction

Various medications, including opioids, are widely prescribed for chronic low back pain in the US despite limited supporting evidence, high costs, and often serious health risks [28, 49]. Treatment guidelines for cLBP have been difficult to establish due to heterogeneity of clinical trials and lack of high-quality evidence on long-term medication use [8, 4]. The 2017 American College of Physicians guidelines on pharmacologic management of cLBP highlight small effect sizes from most studied medications and only short-term utility [35]. The 2016 CDC guideline for prescribing opioids for chronic pain stresses the harms of opioids, and recommends pursuing alternative options for managing chronic pain [12].

Previous studies have suggested excessive opioid analgesic prescribing for cLBP in the US. A large claims-based study reported 19% long-term opioid use among patients with low back pain in the Pacific Northwest [9]. A prior National population-based survey from the 1990s reported 12% opioid use among US adults with low back pain, with the highest prevalence of opioid use in the South region [27]. Information on the use of non-opioid pain medications among US adults with cLBP is scarce, and largely comes from convenience-sample surveys. The Gallup-Palmer Annual Report, for example, indicates wide-spread use of NSAIDs and acetaminophen, as well as benzodiazepines [45]. Little is known about National patterns of non-opioid pain medication use among adults with cLBP in the US. Our study aimed to evaluate the use of different classes of prescription medications commonly used in the management of cLBP among Americans with cLBP. Additionally, we described the demographic characteristics of prescription opioid use in the cLBP population, as an aid in directing efforts for opioid use reduction [7].

Materials and Methods

Our primary objective was to identify the patterns of use for medications commonly prescribed for chronic pain among community-based US adults with cLBP, compared to those without cLBP. We analyzed data from The National Health and Nutrition Examination Survey (NHANES), 2009–2010 cycle, in which a comprehensive back pain questionnaire was administered to all adult participants ages 20 to 69 (N=5103) [52]. We identified the cLBP sample from participants who reported current pain in the area between the lower posterior margin of the ribcage and the horizontal gluteal fold at the time of survey with a history of pain lasting almost every day for at least 3 months (N=700) [41]. Prescription medication use information was collected by a trained NHANES interviewer in the participants’ home. The interviewer asked what prescription medications the patient used within the past 30 days, and recorded the medication name into the LexiconPlus® electronic database (a proprietary database of Cerner Multum, Inc.). Medications were matched with generic medication codes and classified according to therapeutic category. The interviewer also asked to see a prescription bottle when available, and recorded duration of use. We used Lexicon Plus® to identify common prescription medications used for cLBP, including analgesics: acetaminophen, NSAIDs, COX2 inhibitors, salicylates (other than aspirin, which was classified as an NSAID), opioid analgesics (including all schedule II and III opioids, combination opioid analgesics, tramadol and all preparations of codeine other than cold and cough medications), gabapentinoids (gabapentin, pregabalin), topical lidocaine, skeletal muscle relaxants, CNS-active medications used for pain: duloxetine, tricyclic antidepressants, benzodiazepines. Additionally, we analyzed the use of CNS-active medications that are not typically used for pain, including selective serotonin reuptake inhibitors (SSRIs), and non-benzodiazepine hypnotics (barbiturates, buspirone, doxepin, zolpidem, 1^st generation antihistamines).

We compared pain medication and non-pain CNS-active medication use by category between survey participants with cLBP and without. In the cLBP group (N = 700), we evaluated the median reported duration of use for each therapeutic category, the frequency of drug combinations, and the distribution of common prescription medication use in the population by demographic characteristics. Chi-square tests were used for unadjusted categorical comparisons. Logistic regression was used to produce adjusted odds ratios for binary outcomes, with adjustment for age, race, gender, comorbidities, and education level. In accordance with NHANES methodology, each survey participant represents a specific proportion of the population. Primary sample unit (“sdmvpsu”) and stratum (“sdmvstra”) variables, as well as 2-year interview weights (“wtint2yr”) were used to obtain national estimates for questionnaire variables, and 2-year mobile examination center (MEC) weights (“wtmec2yr”) – for MEC variables. All results were expressed in percentages of the US population. Detailed back pain survey methodology and cLBP sample characteristics have been published elsewhere [52, 41]. A 95% confidence level was set for all tests of significance. All statistical analyses were performed in SAS 9.4 (SAS Institute, Inc., Cary, NC). All research data was obtained from NHANES directly in deidentified form and did not require additional IRB approval. Funding sources: NIH Award Number 5T32DK007784-15. NIH Award Number UL1TR000114.

Role of the funding source: National Institutes of Health Award Number 5T32DK007784-15 supported Dr. Shmagel’s training and salary to complete this research. National Institutes of Health Award Number UL1TR000114 provided funding for statistical support of this study.

Results

Demographic characteristics by chronic low back pain status are presented in Table 1. US adults with cLBP compared to those without cLBP were older, more likely to be white, female, and to have a lower socio-economic status. Medical comorbidities and depression were more prevalent among subjects with cLBP. 36.9% of US adults with cLBP aged 20–69 used at least one prescribed pain medication in the past month, 17.8% used non-pain antidepressants, and 4.7% used hypnotics.

Table 1.

Demographic and behavioral characteristics of US adults, ages 20–69, with and without chronic low back pain (N = 5103).

	% with cLBP (SE%)	% w/o cLBP (SE%)	Chi-Sq P-value	Adjusted OR (95% CI)	AOR P-value
	N=700	N=4403
Age
20–29	15.1 (1.4)	22.7 (0.9)	<0.0001	1 (Ref.)	<0.001
30–39	18.3 (2.2)	20.7 (0.8)		1.39 (0.97–1.98)
40–49	19.3 (2.3)	23.1 (0.8)		1.27 (0.86–1.86)
50–59	27.4 (2.5)	19.9 (0.9)		2.03 (1.48–2.78)
60–69	20.0 (1.5)	13.6 (0.5)		2.07 (1.59–2.71)
Female gender	55.8 (2.6)	50.1 (0.7)	0.036	1.28 (1.03–1.58)	0.027
Race
African American	10.1 (1.4)	12.1 (0.9)	<0.0001	1 (Ref.)	0.001
Caucasian	74.9 (3.7)	64.9 (3.5)		1.52 (1.14–2.04)
Hispanic	11.9 (3.1)	14.9 (3.0)		0.98 (0.73–1.32)
Other	3.1 (0.8)	8.1 (1.3)		0.58 (0.34–0.97)
Education
College and higher	18.6 (2.6)	30.2 (1.5)	0.0001	1 (Ref.)	0.002
GED/AA degree	60.9 (2.1)	52.5 (1.4)		1.99 (1.33–2.98)
Less than High school	20.6 (1.2)	17.3 (0.9)		2.27 (1.53–3.38)
Annual HH income $
>100 000	17.4 (1.8)	24.7 (1.3)	0.0001	1 (Ref.)	0.006
65–99 000	16.8 (2.0)	18.8 (1.3)		1.18 (0.75–1.86)
45–64 000	16.2 (2.0)	15.8 (1.3)		1.36 (0.93–1.99)
20–44 000	29.0 (1.6)	28.0 (1.1)		1.42 (1.05–1.93)
<20 000	20.6 (2.9)	12.6 (1.0)		2.29 (1.46–3.58)
PHQ9 score (depression)
1–4 (none)	56.8 (2.9)	78.3 (1.2)	<0.0001	1 (Ref.)	<0.001
5–9 (mild)	21.3 (2.1)	15.7 (1.1)		1.86 (1.38–2.52)
10–14 (moderate)	10.0 (1.3)	4.2 (0.3)		3.30 (2.46–4.44)
15–19 (moderate-severe)	8.7 (1.7)	1.5 (0.2)		8.29 (5.19–13.24)
20–27 (severe)	3.1 (0.8)	0.4 (0.1)		10.62 (5.42–20.80)
Medical comorbidities
0–1	57.9 (2.3)	83.0 (0.7)	<0.0001	1 (Ref.)	<0.001
2–3	27.4 (1.4)	13.9 (0.6)		2.49 (2.10–2.95)
>3	14.8 (2.2)	3.1 (0.3)		6.09 (4.12–9.00)

SE – standard error. cLBP – chronic low back pain. Chi-Sq – Chi-square. AOR – adjusted odds ratio, adjusted for age, race, gender, education. CI – confidence interval. GED – general educational development. AA – associate’s. HH – household. BMI – body mass index. PHQ9 – patient health questionnaire 9.

Reference category not displayed for binary variables. All estimates are weighted to represent the national population

The prevalence of prescription medication use among US adults with cLBP and those without cLBP is summarized in Table 2. Current use of virtually all examined prescription pain medications, antidepressants, and hypnotics was more prevalent in the cLBP group than the non-cLBP group (adjusted odds ratios (aOR) ranging from 1.95 (hypnotics) to 6.80 (gabapentinoids)). COX2 inhibitors and topical lidocaine were rarely used in either group. Among prescription pain medications in the cLBP group, opioid analgesics were the most commonly used class, taken within the past 30 days by 18.8% of working-age Americans with cLBP. Other commonly used prescription pain medications in the cLBP population were acetaminophen 9.9% (almost entirely in combination preparations with opioids), NSAIDs 9.7%, muscle relaxants 8.5%, gabapentinoids 6.8%, and benzodiazepines 5.0%. Corresponding values for non-pain CNS-active medications were 12.9% for SSRIs, 5.1% for all other non-pain antidepressants, and 4.7% for hypnotics.

Table 2.

Prescription medication use among US adult participants of the 2009–2010 NHANES back pain survey, ages 20–69 (N = 5103).

	% with cLBP (SE%)	% w/o cLBP (SE%)	Chi-sq P-value	AOR (95% CI)	AOR p-value
	N=700	N=4403
Pain-related medications
Opioids	18.8 (1.0)	4.3 (0.5)	<0.001	4.4 (3.44–5.62)	<0.001
Acetaminophen	9.9 (1.5)	2.4 (0.3)	<0.001	3.87 (2.79–5.36)	<0.001
NSAIDs	9.7 (1.2)	4.1 (0.4)	<0.001	2.84 (2.00–4.03)	<0.001
Muscle Relaxants	8.5 (1.1)	1.3 (0.2)	<0.001	5.95 (3.91–9.04)	<0.001
Gabapentinoids	6.8 (0.9)	0.7 (0.2)	<0.001	6.80 (3.11–14.86)	<0.001
Benzodiazepines	5.0 (0.9)	1.2 (0.3)	<0.001	3.88 (2.23–6.75)	<0.001
Salicylates	2.7 (0.5)	0.7 (0.2)	<0.001	3.13 (1.64–5.96)	<0.001
Duloxetine	2.5 (1.1)	0.7 (0.1)	0.008	2.65 (1.01–6.92)	0.047
Tricyclic antidepressants	2.2 (0.5)	0.8 (0.2)	<0.001	2.41 (1.33–4.36)	0.004
COX2 Inhibitors	0.5 (0.3)	0.3 (0.1)	0.237	1.71 (0.33–8.87)	0.521
Topical lidocaine	0.5 (0.4)	0.1 (0.1)	0.091	4.91 (0.92–26.08)	0.061
Non-pain Antidepressants
SSRI	12.9 (1.4)	5.6 (0.7)	<0.001	2.50 (1.71–3.65)	<0.001
Other non-pain antidepressants	5.1 (0.8)	1.5 (0.2)	<0.001	3.00 (1.85–4.88)	<0.001
Hypnotics	4.7 (1.1)	2.1 (0.3)	<0.001	1.95 (1.20–3.16)	0.007

cLBP – chronic low back pain. SE – standard error. Chi-Sq – Chi-square. AOR – adjusted odds ratio, adjusted for age, race, gender, education. CI – confidence interval. IQR – interquartile range. All estimates are weighted to represent the national population.

The median duration of use for opioid analgesics in the cLBP group was 702 days (interquartile range (IQR) 314–1770 days). 76.9% of current prescription opioid users with cLBP reported taking opioids for 1 year or longer. The median duration of use for NSAIDs was 522 days (IQR 155-1924), for muscle relaxants – 682 days (IQR 258-1688), for gabapentinoids – 534 days (IQR 224-1611), and for benzodiazepines – 947 days (IQR 165-2115). SSRIs were used for a median of 1008 days (IQR 365-1764), and hypnotics for – 820 days (IQR 157-1729). Opioids, acetaminophen, NSAIDs, and muscle relaxants were used significantly longer by subjects with cLBP compared to those without cLBP (Table 3).

Table 3.

Self-reported duration of prescription medication use among US adult participants of the 2009–2010 NHANES back pain survey, ages 20–69 (N = 5103).

	Median number of days (IQR) Subjects with cLBP	Median number of days (IQR) Subjects without cLBP	P-value
	N=700	N=4403
Pain-related medications
Opioids	702 (314–1770)	119 (13–959)	<0.001
Acetaminophen	690 (324–1756)	31 (7–352)	<0.001
NSAIDs	522 (155–1924)	91 (29–564)	<0.001
Muscle Relaxants	682 (258–1688)	142 (15–777)	0.007
Gabapentinoids	534 (224–1611)	495 (173–1046)	0.64
Benzodiazepines	947 (165–2115)	675 (266–2013)	0.74
Salicylates	769 (332–1622)	605 (209–1173)	0.05
Duloxetine	522 (221–1139)	569 (171–959)	0.76
Tricyclic antidepressants	1494 (408–2516)	848 (190–3477)	0.77
COX2 Inhibitors	61 (61–162)	526 (144–1000)	0.006
Topical lidocaine	46 (34–59)	1460 (1460–1460)	<0.001
Non-pain Antidepressants
SSRI	1008 (365–1764)	983 (345–2041)	0.67
Other non-pain antidepressants	996 (59–2777)	658 (276–1567)	0.92
Hypnotics	820 (157–1729)	457 (170–1465)	0.45

cLBP – chronic low back pain. IQR – interquartile range. P values obtained for log-transformed means. All estimates are weighted to represent the national population.

Figure 1 shows the frequency of drug combinations in the cLBP population. Use of more than one pain medication was common and opioid analgesics, in particular, were frequently co-administered with other classes of medications. 9.8% of Americans with cLBP used an opioid with acetaminophen, accounting for over half of the reported opioids and virtually all reported acetaminophen in this population. 5.7% used opioids concomitantly with a muscle relaxant, and 4.9% used an opioid with an NSAID. Other common drug combinations included opioids with SSRIs (3.6%), opioids with gabapentinoids (3.2%), opioids with benzodiazepines (2.6%), and opioids with hypnotics (2.1%).

Figure 1.

Co-administration of pain medications, non-pain antidepressants, and hypnotics in US Adults with cLBP, % (SE%).

cLBP – chronic low back pain. SE – standard error. NSAIDs – non-steroidal anti-inflammatory drugs. APAP – acetaminophen. M. relax muscle relaxants. GABA – gabapentinoids. Benzo benzodiazepines. SSRIs – selective serotonin reuptake inhibitors. Other antidepr. – other non-pain antidepressants. The Heat Map shows the most frequently co-administered medications in red, and the least frequently co-administered medications in green. All estimates are weighted to represent percent of the national population 20–69 years of age. Note that some subjects used more than two classes of medications at the same time.

When compared by demographic characteristics, prescription opiate use in the cLBP population was most common among Americans aged 40–49 (27% opioid use), African Americans and Caucasians (24% and 19% opioid use, respectively), and those with less than college education (21% use among subjects with less than high school education and 22% use among those with high school and associates’ degrees, vs 5% use among subjects with a college degree or above), p<0.05 (Figure 2). Although persons with a college education represent 18.6% of the cLBP population, they comprised only 6% of opioid users. 94% of all opioids in the cLBP population were taken by subjects with less than a college degree. Muscle relaxants were most often used by cLBP subjects with high school and associate degrees (12% use, vs 4% use among subjects with less than high school education, and 2% use among subjects with a college degree or above), p = 0.002. Women with cLBP used more NSAIDs and muscle relaxants than men (p = 0.01). In a multivariable model of opioid analgesic use in the cLBP population, which included age, race, gender, education, income, and number of comorbidities, low levels of education remained strongly associated with opioid use: aOR 3.07 (1.12–8.39) for less than high school, and aOR 4.17 (1.73 – 10.03) for high school or associates’ degree, compared with college education. Full models are shown in Table 4. Similar results were observed in an analysis limited to long-term prescription opioid users with cLBP (Appendix 1).

Figure 2.

Demographic distribution of pain medication use in US Adults with cLBP

cLBP – chronic low back pain. NSAIDs – non-steroidal anti-inflammatory drugs. *Chi-square p-value <0.05. The bar charts illustrate the distribution of pain medication use in the cLBP population by age, gender, race, and education level. All estimates are weighted to represent percent of the national population 20–69 years of age. Opioids were most often used by adults in their 40s and 50s. Among races, African Americans were the most likely to use prescription opioids, followed by whites. Americans with cLBP who achieved a college degree or higher, were significantly less likely to use opioid analgesics and muscle relaxants, than less educated Americans. Women with cLBP used more NSAIDs and muscle relaxants than men.

Table 4.

Demographic factors associated with pain medication use in US adults with cLBP (n = 700)

	Model 1 Opioids Adjusted OR (95% CI)	Model 2 NSAIDs Adjusted OR (95% CI)	Model 3 Muscle Relaxants Adjusted OR (95% CI)	Model 4 Gabapentinoids Adjusted OR (95% CI)
Age	1.00 (0.98–1.03)	1.01 (0.99–1.04)	0.97 (0.95 – 1.00)	1.04 (1.00–1.08)
Female gender	1.16 (0.62–2.19)	1.70 (0.91–3.17)	2.17 (1.05–4.46)*	1.56 (0.49–4.97)
Race
African American	1 (Ref.)	1 (Ref.)	1 (Ref.)	1 (Ref.)
Caucasian	0.89 (0.48–1.65)	1.05 (0.52–2.10)	1.91 (0.98–3.70)	1.87 (0.86–4.06)
Hispanic	0.76 (0.33–1.73)	1.92 (0.91–4.05)	1.93 (0.58–6.44)	1.21 (0.43–3.39)
Other	0.09 (0.01–0.70)*	2.15 (0.66–6.94)	1.96 (0.09–43.15)	1.14 (0.17–7.79)
Education
College and higher	1 (Ref.)	1 (Ref.)	1 (Ref.)	1 (Ref.)
GED/AA degree	4.17 (1.73–10.03)**	1.13 (0.36–3.57)	3.83 (1.14–12.91)*	4.48 (0.63–31.95)
Less than High school	3.07 (1.12–8.39)*	1.72 (0.35–8.39)	0.95 (0.23–3.93)	4.10 (0.55–30.44)
Annual HH Income $
>65 000	1 (Ref.)	1 (Ref.)	1 (Ref.)	1 (Ref.)
35–64 000	1.36 (0.83–2.24)	2.41 (0.87–6.71)	6.69 (1.06–42.35)*	0.70 (0.16–3.01)
<35 000	1.92 (1.19–3.11)**	1.92 (0.69–5.36)	8.03 (1.33–48.49)*	1.69 (0.57–4.95)
Medical comorbidities
0–1	1 (Ref.)	1 (Ref.)	1 (Ref.)	1 (Ref.)
2 or more	3.32 (1.74–6.35)**	2.06 (1.09–3.90)*	6.98 (3.09–15.73)**	1.61 (0.64–4.09)

cLBP – chronic low back pain. OR – odds ratio. CI – confidence interval. GED – general educational development. AA – associate’s. HH – household.

^*p<0.05,

^**p<0.001.

Income expressed in tertiles of the national population. All estimates are weighted to represent the national population.

In summary, American adults with cLBP used multiple classes of analgesics, and were also more likely to use antidepressants and anxiolytics than those without cLBP. All evaluated prescription analgesics were used long-term. Opioid analgesics were the most common prescription analgesics used by community-based Americans with cLBP, and were frequently co-administered with other analgesics, as well as with antidepressants and anxiolytics. Opioid use was disproportionately higher among 40–49 year olds, African Americans, and adults with lower levels of education. After multivariable adjustment, education remained strongly associated with opioid use in the cLBP population.

Discussion

Our study examined the use of various classes of prescription analgesics by community-dwelling US adults with chronic low back pain. We found that opioids were the most commonly used class of prescription pain medications in the cLBP population, and were used long-term. These findings are consistent with previous studies that showed excessive opioid analgesic prescribing for cLBP in the US during the past two decades [9, 27]. After several major professional society recommendations to limit opioid prescribing, the number of prescriptions has declined by 13.1%, but remains 3 times as high as it was in 1999 and 4 times as high as the current prescription rate in Europe [22]. For example, in comparison with a similar population study from Portugal, Americans with cLBP reported 12 times higher prevalence of opioid use than the Portuguese subjects with cLBP [20].

There is no evidence for the benefits of long-term opioids greater than 6 months in chronic non-cancer pain [33]. Even in short-term studies, oral opioids for non-cancer pain may only be marginally more effective than placebo, and not superior to NSAIDs [19, 24, 1, 16]. A systematic review of opioid therapy for chronic pain found good to fair evidence for an increased risk of serious harms, including overdose, opioid abuse, fractures, and myocardial infarction [5]. Moreover, patients may develop opioid-induced hyperalgesia and tolerance as quickly as one month after initiation of opioid therapy [6, 56].

We also found that opioids were frequently used in combination with other CNS-active medications, including non-pain antidepressants and anxiolytics. It can be difficult to separate the beneficial effects of these combinations from potential hazards. For example, in one large study of patients treated with opioids for chronic non-cancer pain, the odds of opioid overdose increased four to seven-fold among subjects with concomitant depression, but treatment of depression with antidepressants was associated with a 20% reduction in overdose risk [47]. In the same study, subjects who used antidepressants together with opioids, but did not have a diagnosis of depression, had an increased risk of opioid overdose. Multiple other studies showed that the use of opioids in patients with mental health conditions or concomitant use with psychiatric medications is associated with increased risk of prolonged opioid use, misuse, and dependence [15, 3, 2].

We also found that opioids were frequently co-administered with other analgesics, most notably acetaminophen. The use of opioid-acetaminophen combinations maybe beneficial in some scenarios, as acetaminophen extends the analgesic effect of opioids and was shown to reduce opioid requirements in short-term studies of post-procedural pain [36, 37]. However, opioid-acetaminophen combination products have become the leading cause of acetaminophen overdose and account for most analgesic-related emergency department visits nationally [55]. Thus, opioid reduction, rather than avoidance of specific drug combinations, may be the most pertinent area for practice improvement.

We estimated that Americans with cLBP who have lower levels of education are four times more likely to use prescription opioids than college graduates. This association may in part be explained by known higher incidence and severity of many chronic conditions among less educated adults [10]. However, another possible explanation is overreliance on opioids by prescribers due to lack of resources for safer pain management alternatives. Non-pharmacologic pain management approaches are frequently not covered by health insurance, leaving disadvantaged cLBP patients without access to some of the most widely recommended treatment options [51]. Additionally, patients may not be appropriately informed about low efficacy and high risk of side effects with opioid use [44, 29]. Low levels of education have also been linked to increased drug poisoning and opioid-related mortality [25, 38]. Interestingly, while opioid use was most prevalent among African Americans, race no longer independently predicted opioid use when age, gender, socioeconomic status and comorbidities were taken into account. This finding highlights the relative importance of education level and health status over race when estimating the likelihood of long-term opioid use in individuals with cLBP. When designing patient-centered interventions for prevention and mitigation of opioid misuse in the cLBP population, understanding patients’ race and education level, as well as socioeconomic status, may aid in selecting the most effective tactics. Patient education strategies that include assessment of patients’ health literacy and post-intervention knowledge have been effective in changing pain perception, ensuring correct pain medication dosing, and promoting safe storage and disposal of prescription opioids [40, 11, 30]. As African Americans are more likely to have a lower quality of life due to pain [39], and less likely to receive care for chronic pain [21], interventions aimed at improving coping strategies and healthcare access may specifically benefit African Americans. Community involvement and church-based self-management programs have been effective in improving health outcomes and wellbeing among African Americans [26, 50]. Several strategies have also been developed to target healthcare providers’ racial bias when caring for African Americans with pain, including perspective-taking [14], and shared decision-making [13, 46]. Expansion of Medicaid coverage to include care coordination and peer support for disadvantaged opioid users has also been proposed in some states [31, 53].

While opioids are overused, other pain medications are possibly underutilized by Americans with cLBP. Celecoxib, for example, which was rarely used in our study, was found superior to tramadol in two randomized controlled trials in cLBP [34]. Addressing cardiovascular safety concerns, a recent trial in the osteoarthritis population showed a low risk of cardiovascular events with long-term celecoxib and NSAID use [32]. While gastrointestinal and renal side effects remain a concern in elderly patients with comorbid conditions [17, 47], Celecoxib has been associated with fewer GI side effects compared with non-selective NSAIDs, in both short term and long term use [32, 18]. It should be noted, however, that due to its high cost celecoxib may not be available to low-income groups in the US. Duloxetine and tricyclic antidepressants may also be modestly effective in chronic low back pain, while simultaneously addressing depressive symptoms [23, 49, 42]. SSRIs, which were much more often used in the cLBP population, have not shown benefit for pain management [43]. Using antidepressants with pain-relieving properties instead of SSRIs maybe a potential area of practice improvement, and appears to be a cost-effective strategy [54].

Our study’s strengths include a large nationally-representative sample, and the use of participant-reported medication information, which allow to make community-level population estimates, relatively unbiased by healthcare-seeking behavior. However, this study has several limitations. NHANES is a cross-sectional survey, with many self-report variables that may be subject to measurement error and recall bias. Temporal relationships and causality cannot be established from this study design, and, as with any observational study, residual confounding is likely present. Data collection took place during 2009–2010, and was limited to non-institutionalized subjects between 20 and 69 years of age, thus results may not be extrapolated on other populations and other time periods. We were unable to evaluate dosage and frequency of use for prescription medications. It is also likely that the use of over the counter medications, such as NSAIDs, acetaminophen, and some hypnotics is underreported in this study. While our study does not directly infer that the studied medications were used to treat back pain, we saw markedly elevated odds of every analgesic class use in American adults with cLBP compared with the non-cLBP population.

In conclusion, the patterns of analgesic use among US adults with cLBP highlight long-term, and likely excessive use of opioids, possible underutilization of other classes of analgesics, and demographic disparities in the use of different classes of analgesics. As clinical guidelines continue to emphasize opioid-related harms and advocate for cautious prescribing, evidence-based education for patients and providers, and expanded access to non-opioid cLBP treatments are urgently needed.

Perspective.

As prescription opioid use is an issue of national concern, we examined pain-related prescription medication use in community-dwelling among US adults with cLBP. Opioids were the most common prescription pain medication, typically used long-term, in combination with other CNS-active agents, and disproportionately among subjects with less than a college education.

Highlights.

• Opioids were the most common prescription pain medications among US adults with cLBP.

• Opioids were typically used long-term, and combined with other CNS-active agents.

• Low level of education was strongly associated with opioid use in cLBP population.