Drug Use for Emergency Back Pain Shifts Over Time

NATIONAL HARBOR, Md. -- Emergency department (ED) use of tramadol for back pain doubled from 2007 to 2016 in the U.S. despite an overall decrease in opioid use in that period, an analysis of National Hospital Ambulatory Medical Care Survey (NHAMCS) data showed.

Tramadol -- either administered in the ED or prescribed -- was used in 8.4% of back pain visits in 2016, up from 4.1% in 2007 (P=0.001), reported Peter Mullins, MD, MA, MPH, of Brigham and Women's Hospital in Boston, and colleagues, at the annual meeting of the American Academy of Pain Medicine here.

Back pain is the most common pain complaint worldwide and accounted for about 9% of all U.S. ED visits in the study period, Mullins noted.

"Our research demonstrates that the use of opioid medications given and prescribed during these visits decreased by 7%, an important finding in light of the current opioid epidemic," he told MedPage Today.

EDs saw 10.5 million visits for back pain in 2016, an increase over the 8.1 million seen in 2007, Mullins added. Besides the increase in tramadol use, the study also showed that "diagnostic resources used in these visits continued to increase, in particular with the use of advanced imaging," he said.

Tramadol was originally approved by the FDA in 1995 as a non-controlled analgesic, and the DEA placed the drug into schedule IV of the Controlled Substances Act in 2014, noted Samer Narouze, MD, PhD, of Western Reserve Hospital in Cuyahoga Falls, Ohio, who wasn't involved with the research.

"During this study period – 2007 to 2016 – some states didn't have tramadol scheduled," Narouze said.

The increase in tramadol for back pain in the ED may reflect an overall trend toward cutting down on "other, stronger opioids and prescribing tramadol instead, as it would be perceived as safer as it is less scheduled compared to other stronger opioids," Narouze told MedPage Today.

Tramadol has several arguments against it, he noted: "It is a prodrug and the parent drug has no analgesic effects," he pointed out. It also has potent serotonin reuptake inhibition, but that can be a plus, Narouze said: "There's no need to co-prescribe another antidepressant." Like other opioids, tramadol has drug interactions, he added. "It is not my favorite or my first choice, but it is still a good choice for some patients," he said.

In their study, Mullins and co-authors analyzed data from NHAMCS, an annual survey conducted by the CDC's National Center for Health Statistics, assessing patients who presented with neck or back symptoms or back injury as a reason for their ED visit.

Over the study period, the number of ED visits for back pain increased by over two million, although the proportion did not increase significantly. Admission rates decreased, but laboratory testing and advanced imaging increased. Acetaminophen and muscle relaxant use increased.

Overall opioid use declined significantly, while tramadol use increased significantly. In 2007, overall opioid use was 53.5%; in 2016, it was 46.5% (P=0.001). The largest drop was in hydrocodone use.

Besides the nationwide focus on reducing opioid prescriptions, there's an effort to limit imaging for ED back pain visits, Mullins noted. "Given the significant variability in management observed in our study, further research into the optimal strategies for caring for these patients is needed," he said.

The findings in this analysis are limited by NHAMCS methodology. NHAMCS is based on a national sample of visits to EDs, outpatient departments, and ambulatory surgery locations of non-institutional general and short-stay hospitals.

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