Smokers Are At High Risk for Low Back Pain, Hospitalization and Opioid Use

Smokers are at high risk for low back pain, and also have higher rates of healthcare utilization and opioid use, and physicians should ask these patients about other comorbidities that may make their pain treatment more difficult, according to a new study presented this week at the Association of Academic Physiatrists Annual Meeting in Puerto Rico.

Low back pain (LBP) and habitual tobacco use, especially smoking, are both highly prevalent conditions around the world. Recent research has shown a strong correlation between tobacco use and LBP, as well as an increase in the prevalence and severity of symptoms. To learn more about these high-risk patients, researchers at the University of Pittsburgh Medical Center conducted a retrospective, observational study comparing healthcare utilization and outcomes in smokers and non-smokers with LBP.

Low back pain is related to very high rates of disability and functional impairment,” said Rohit Navlani, DO, the study’s co-author. “This problem accounts for billions of dollars of health care spending annually, and we know that there are ties between smoking and low back pain. Smoking continues to be the leading cause of preventable disease in the United States. I wanted to closely examine the relationship between these two by analyzing the outcomes of patients with back pain who smoke versus those who do not smoke.”

The researchers extracted data from electronic medical records dating from January 2010 to March 2018 using ICD codes for spondylosis, disc disease, stenosis, sprains or radiculopathy involving the lumbosacral spine. They analyzed data on 462,315 patients with low back pain.

They identified 101,921 smokers and 360,394 non-smokers for the study. Illicit drug use was notably higher in the smoker population, they found. Smokers also were more likely to undergo surgery, but less likely to receive an epidural steroid injection for their pain. Smokers also had higher rates of depression and anxiety than the non-smokers.

Tobacco use was also linked to higher rates of opioid use prior to their diagnosis, post-diagnosis or at any point in the course of their time in the clinic. The researchers also found that patients with a history of smoking had higher rates of emergency department (ED) utilization. Patients who had a smoking history averaged 5 ED visits compared to 3 visits in the non-smoker population. Although they noticed higher ED utilization in this group, they also found less frequent clinic follow-up, or 11.9 follow-ups on average, per patient compared to 14.2 follow-ups in the non-smokers.

The study’s findings, recently updated to reflect new data, show that smokers are a high-risk subgroup of patients with LBP, and they have higher rates of healthcare utilization and opioid use. Healthcare professionals should ask these patients about other comorbidities that may make their LBP treatment more difficult. They should also adopt a multidisciplinary approach to treatment of LBP in smokers to address the complex nature of these patients’ care, the researchers concluded.

“Our research highlights that smokers with low back pain are a very high-risk population. Smoking has been correlated with increased incidence of illicit drug use, increased rates of comorbid psychiatric disease and higher opioid utilization,” said Dr. Navlani. “Unfortunately, this is a retrospective, observational study reviewing data, and it only allowed us to draw associations and not determine any true cause-effect relationships. We can say that these high-risk patients require that the physician not only address the somatic low back pain complaints, but the psychological and social components as well in an effort to break the feedback loop. Ideally, we would like to have seen that patients received an interdisciplinary care approach that addressed not only their back pain, but their anxiety and/or depression, and that their lifestyle risk factors, such as smoking, diet and exercise, had better outcomes.”

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