Reported NSAID Allergy Increases Risk for OUD in Chronic Back Pain

woman with back pain
woman with back pain
Adults with chronic back pain who had adverse allergic reactions to NSAIDs are at higher risk for developing an opioid use disorder.

Adults with chronic back pain who reported adverse reactions from non-steroidal anti-inflammatory drugs (NSAIDs) may be at higher risk for developing opioid use disorder. These results, from a retrospective cohort study, were published in the Journal of Allergy and Clinical Immunology.

Researchers from Brigham and Women’s Hospital in Boston, Massachusetts, collected data from electronic health records within the Partners HealthCare System. Adult patients (N=47,114) with at least 2 diagnoses for back pain and at least 1 outpatient visit every 2 years between 2013 and 2018 were included. Patients who reported an adverse reaction to an NSAID that fell within the allergy module of their clinical record were defined as having an NSAID allergy. Patients with 2 or more codes in their clinical record for opioid abuse or dependence were defined as having opioid use disorder.

Among the included patients, 7.7% reported an adverse reaction to an NSAID. Patients with and without an adverse reaction differed by age (52 vs 50; P <.0001), gender (women: 75.9% vs 64.2%; P <.0001), ethnicity (P =.03), consultation with an allergist (35.8% vs 25.8%; P <.0001), number of inpatient or outpatient visits (P <.0001), insurance type (P <.0001), and rate of all non-malignant comorbidities.

Due to significant cohort differences, the investigators preformed a 1:4 propensity score matching procedure keeping data from 18,100 patients. These patients were well balanced for baseline characteristics with a mean age of 52 years; 75.9% were women, and 70.3% were White.

Allergy reactions were reported for aspirin (28.7%), undefined NSAIDs (21.5%), ibuprofen (16.7%), and naproxen (11%). Reported symptoms were gastrointestinal (45%), rash or bronchospasm (39%), and unknown (16%).

Patients with an NSAID allergy were more likely to be prescribed pregabalin (odds ratio [OR], 1.48; 95% CI, 1.27-1.71), amitriptyline (OR, 1.28; 95% CI, 1.13-1.46), opioids (OR, 1.22; 95% CI, 1.11-1.34), and gabapentin (OR, 1.20; 95% CI, 1.11-1.30).

Patients with an NSAID allergy had an increased risk for having documented opioid use disorder (adjusted odds ratio [aOR], 1.37; 95% CI, 1.12-1.69; P =.003) compared with patients with no NSAID allergy (aOR, 1.34; 95% CI, 1.07-1.67; P =.01).

In addition to NSAID allergy, strong predictors for opioid use disorder were gender (men vs women: aOR, 2.81; 95% CI, 2.28-3.46; P <.0001), depression (aOR, 2.22; 95% CI, 1.76-2.81; P <.0001), and anxiety (aOR, 1.61; 95% CI, 1.28-2.03; P <.0001).

One limitation of this study was the observational design. The investigators were unable to interrogate causation for opioid use disorder based on information from their clinical records.

The study authors concluded that allergy to NSAID may be a risk factor for developing opioid use disorders. They recommended for the development of clinical algorithms to assist clinicians in managing or referring patients with reported allergies and chronic musculoskeletal pain to avoid opioid use disorders among their patients.


Li L, Chang Y, Song S, Losina E, Costenbader KH, Laidlaw TM. Impact of reported NSAID “allergies” on opioid use disorder in back pain. Published online September 8, 2020. J Allergy Clin Immunol. doi:10.1016/j.jaci.2020.08.025