Cost of opioid-treated chronic low back pain: Findings from a pilot randomized controlled trial of mindfulness meditation-based intervention

Aleksandra E. Zgierska, MD, PhD; James Ircink, BBA; Cindy A. Burzinski, MS; Marlon P. Mundt, PhD

doi:10.5055/jom.2017.0384

Authors

Aleksandra E. Zgierska, MD, PhD
James Ircink, BBA
Cindy A. Burzinski, MS
Marlon P. Mundt, PhD

DOI:

https://doi.org/10.5055/jom.2017.0384

Keywords:

mindfulness meditation, chronic low back pain, opioids, economic evaluation

Abstract

Objective: Opioid-treated chronic low back pain (CLBP) is debilitating, costly, and often refractory to existing treatments. This secondary analysis aims to pilot-test the hypothesis that mindfulness meditation (MM) can reduce economic burden related to opioid-treated CLBP.

Design: Twenty-six-week unblinded pilot randomized controlled trial, comparing MM, adjunctive to usual-care, to usual care alone.

Setting: Outpatient.

Participants: Thirty-five adults with opioid-treated CLBP ( ≥ 30 morphine-equivalent mg/day) for 3 + months enrolled; none withdrew.

Intervention: Eight weekly therapist-led MM sessions and at-home practice.

Outcome Measures: Costs related to self-reported healthcare utilization, medication use (direct costs), lost productivity (indirect costs), and total costs (direct + indirect costs) were calculated for 6-month pre-enrollment and postenrollment periods and compared within and between the groups.

Results: Participants (21 MM; 14 control) were 20 percent men, age 51.8 ± 9.7 years, with severe disability, opioid dose of 148.3 ± 129.2 morphine-equivalent mg/d, and individual annual income of $18,291 ± $19,345. At baseline, total costs were estimated at $15,497 ± 13,677 (direct: $10,635 ± 9,897; indirect: $4,862 ± 7,298) per participant. Although MM group participants, compared to controls, reduced their pain severity ratings and pain sensitivity to heat stimuli (p < 0.05), no statistically significant within-group changes or between-group differences in direct and indirect costs were noted.

Conclusions: Adults with opioid-treated CLBP experience a high burden of disability despite the high costs of treatment. Although this pilot study did not show a statistically significant impact of MM on costs related to opioid-treated CLBP, MM can improve clinical outcomes and should be assessed in a larger trial with long-term follow-up.

Author Biographies

Aleksandra E. Zgierska, MD, PhD

Assistant Professor, Department of Family Medicine and Community Health, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin

James Ircink, BBA

Medical Student, Department of Family Medicine and Community Health, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin

Cindy A. Burzinski, MS

Associate Researcher, Department of Family Medicine and Community Health, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin

Marlon P. Mundt, PhD

Assistant Professor Department of Family Medicine and Community Health, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin

References

Davis K, Stremikis C, Schoen C, et al.: Mirror, Mirror on the Wall, 2014 Update: How the U.S. Health Care System Compares Internationally. The Commonwealth Fund. June 2014. Available at http://www.commonwealthfund.org/publications/fundreports/2014/jun/mirror-mirror. Accessed May 9, 2017.

Squires D, Anderson C: U.S Health Care from a Global Perspective: Spending, Use of Services, Prices, and Health in 13 Countries. The Commonwealth Fund. October 2015. Available at http://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-from-a-global-perspective. Accessed May 9, 2017.

Gore M, Sadosky A, Stacey BR, et al.: The burden of chronic low back pain: Clinical comorbidities, treatment patterns, and health care costs in usual care settings. Spine (Phila Pa 1976). 2012; 37(11): E668-E677.

US Department of Health and Human Services: Healthy People 2020, 2020 Topics and Objectives: Arthritis, Osteoporosis, and Chronic Back Conditions. Updated 2016. Available at https://www.healthypeople.gov/2020/topics-objectives/topic/Arthritis-Osteoporosis-and-Chronic-Back-Conditions. Accessed May 9, 2017.

Dagenais S, Caro J, Haldeman S: A systematic review of low back pain cost of illness studies in the United States and internationally. Spine J. 2008; 8(1): 8-20.

Manek NJ, MacGregor AJ: Epidemiology of back disorders: prevalence, risk factors, and prognosis. Curr Opin Rheumatol. 2005; 17(2): 134-140.

Ricci JA, Stewart WF, Chee E, et al.: Back pain exacerbations and lost productive time costs in United States workers. Spine. 2006; 31(26): 3052-3060.

Dillie KS, Fleming MF, Mundt MP, et al.: Quality of life associated with daily opioid therapy in a primary care chronic pain sample. J Am Board Fam Med. 2008; 21(2): 108-117.

Dunn KM, Saunders KW, Rutter CM, et al.: Opioid prescriptions for chronic pain and overdose: A cohort study. Ann Intern Med. 2010; 152(2): 85-92.

Gomes T, Mamdani MM, Dhalla IA, et al.: Opioid dose and drug-related mortality in patients with nonmalignant pain. Arch Intern Med. 2011; 171(7): 686-691.

Kabat-Zinn J: An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: theoretical considerations and preliminary results. Gen Hosp Psychiatry. 1982; 4(1): 33-47.

Patil SG: Effectiveness of mindfulness meditation (Vipassana) in the management of chronic low back pain. Indian J Anaesth. 2009; 53(2): 158-163.

Cramer H, Haller H, Lauche R, et al.: Mindfulness-based stress reduction for low back pain. A systematic review. BMC Complement Altern Med. 2012; 12: 162.

Garland EL, Manusov EG, Froeliger B, et al.: Mindfulness-oriented recovery enhancement for chronic pain and prescription opioid misuse: Results from an early-stage randomized controlled trial. J Consult Clin Psychol. 2014; 82(3): 448-459.

Zgierska AE, Burzinski CA, Cox J, et al.: Mindfulness meditation and cognitive behavioral therapy intervention reduces pain severity and sensitivity in opioid-treated chronic low back pain: Pilot findings from a randomized controlled trial. Pain Med. 2016; 17(10); 1865-1881.

Zgierska AE, Burzinski CA, Cox J, et al.: Mindfulness meditation-based intervention is feasible, acceptable, and safe for chronic low back pain requiring long-term daily opioid therapy. J Altern Complement Med. 2016; 22(8): 610-620.

Zgierska A, Wallace ML, Burzinski CA, et al.: Pharmacological and toxicological profile of opioid-treated, chronic low back pain patients entering a mindfulness intervention randomized controlled trial. J Opioid Manag. 2014; 10(5): 323-335.

Fairbank JC, Couper J, Davies JB, et al.: The Oswestry low back pain disability questionnaire. Physiotherapy. 1980; 66(8): 271-273.

Podichetty VK, Varley ES, Secic M: Role of patient-based health status outcome measurements in opioid management for low back pain. J Opioid Manag. 2008; 4(3): 153-162.

Walsh TL, Hanscom B, Lurie JD, et al.: Is a condition-specific instrument for patients with low back pain/leg symptoms really necessary? The responsiveness of the Oswestry Disability Index, MODEMS, and the SF-36. Spine (Phila Pa 1976). 2003; 28(6): 607-615.

Von Korff M, Jensen MP, Karoly P: Assessing global pain severity by self-report in clinical and health services research. Spine (Phila Pa 1976). 2000; 25(24): 3140-3151.

Manchikanti L, Abdi S, Atluri S, et al.: American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: Part I—Evidence assessment. Pain Physician. 2012; 15(3 suppl): S1-S65.

Kabat-Zinn J: Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness. New York: Delta, 1990.

Segal ZV, Williams JM, Teasdale JD: Mindfulness-Based Cognitive Therapy for Depression. 2nd ed. New York: Guilford Press, 2013.

Bowen S, Chawla N, Marlatt A: Mindfulness-Based Relapse Prevention for Addictive Behaviors: A Clinician's Guide. New York: Guilford Press, 2010.

Mattke S, Balakrishnan A, Bergamo G, et al.: A review of methods to measure health-related productivity loss. Am J Manag Care. 2007; 13(4): 211-217.

Sobell LC, Sobell MB: Timeline followback: A technique for assessing self-reported alcohol consumption. In Litten RZ, Allen J (eds.): Measuring Alcohol Consumption: Psychosocial and Biological Methods. Clifton, NJ: Humana Press, 1992.

Fals-Stewart W, O'Farrell TJ, Freitas TT, et al.: The timeline follow back reports of psychoactive substance use by drug-abusing patients: psychometric properties. J Consult Clin Psychol. 2000; 68(1): 134-144.

Wisconsin Hospital Association Information Center: Wisconsin PricePoint System. Available at http://www.wipricepoint.org. Accessed May 9, 2017.

Wisconsin Hospital Association Information Center: Hospital Inpatient Charges for Other Back/Neck Disorders/Fractures, Injuries, No Surgery. Wisconsin Hospitals, 2013.

Wisconsin Hospital Association Information Center: Emergency Department Charges for Neck/Back Sprains & Strains and Spinal Disorders. Wisconsin Hospitals, 2013.

Wisconsin Hospital Association Information Center: Hospital-Based Urgent Care Charges for Neck/Back Sprains & Strains and Spinal Disorders. Wisconsin Hospitals, 2013.

New Benefits, Ltd.: Drug Price Search. Available at www.rxpricequotes.com. Accessed May 9, 2017.

Drugs.com.: Drug Price Guide. Available at http://www.drugs.com/price-guide. Accessed May 9, 2017.

Walgreens Co.: Available at http://www.walgreens.com/. Accessed May 9, 2017.

United States Department of Labor, Bureau of Labor Statistics: Occupational Employment Statistics. May 2013 State Occupational Employment and Wage Estimates, Wisconsin. Available at http://www.bls.gov/oes/current/oes_wi.htm. Accessed May 9, 2017.

United States Department of Labor: Wages, Minimum Wage. Available at http://www.dol.gov/dol/topic/wages/minimumwage.htm. Accessed May 9, 2017.

Cohen J: A power primer. Psychol Bull. 1992; 112(1): 155-159.

Miller JJ, Fletcher K, Kabat-Zinn J: Three-year follow-up and clinical implications of a mindfulness meditation-based stress reduction intervention in the treatment of anxiety disorders. Gen Hosp Psychiatry. 1995; 17(3): 192-200.

Herron RE: Changes in physician costs among high-cost transcendental meditation practitioners compared with high-cost nonpractitioners over 5 years. Am J Health Promot. 2011; 26(1): 56-60.