Observational Retrospective Study of the Association of Initial Healthcare Provider for New-onset Low Back Pain with Early and Long-term Opioid Use

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SOURCE:   BMJ Open. 2019 (Sep 20); 9 (9): e028633

Lewis E Kazis, Omid Ameli, James Rothendler, Brigid Garrity, Howard Cabral, Christine McDonough, et. al.

Department of Health Law,
Policy and Management,
Boston University School of Public Health,
Boston, Massachusetts, USA

OBJECTIVE:   This study examined the association of initial provider treatment with early and long-term opioid use in a national sample of patients with new-onset low back pain (LBP).

DESIGN:   A retrospective cohort study of patients with new-onset LBP from 2008 to 2013.

SETTING:   The study evaluated outpatient and inpatient claims from patient visits, pharmacy claims and inpatient and outpatient procedures with initial providers seen for new-onset LBP.

PARTICIPANTS:   216,504 individuals aged 18 years or older across the USA who were diagnosed with new-onset LBP and were opioid-naïve were included. Participants had commercial or Medicare Advantage insurance.

EXPOSURES:   The primary independent variable is type of initial healthcare provider including physicians and conservative therapists (physical therapists, chiropractors, acupuncturists).

MAIN OUTCOME MEASURES:   Short-term opioid use (within 30 days of the index visit) following new LBP visit and long-term opioid use (starting within 60 days of the index date and either 120 or more days’ supply of opioids over 12 months, or 90 days or more supply of opioids and 10 or more opioid prescriptions over 12 months).

RESULTS:   Short-term use of opioids was 22%. Patients who received initial treatment from chiropractors or physical therapists had decreased odds of short-term and long-term opioid use compared with those who received initial treatment from primary care physicians (PCPs) (adjusted OR (AOR) (95% CI) 0.10 (0.09 to 0.10) and 0.15 (0.13 to 0.17), respectively). Compared with PCP visits, initial chiropractic and physical therapy also were associated with decreased odds of long-term opioid use in a propensity score matched sample (AOR (95% CI) 0.21 (0.16 to 0.27) and 0.29 (0.12 to 0.69), respectively).

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CONCLUSIONS:   Initial visits to chiropractors or physical therapists is associated with substantially decreased early and long-term use of opioids. Incentivising use of conservative therapists may be a strategy to reduce risks of early and long-term opioid use.

KEYWORDS:   Back pain; Opioid use; Pain management; opioid

From the FULL TEXT Article:


Over the past decade, there has been an increase in opioid use in the USA, with over 12 million Americans reporting long-term opioid use or misuse in 2015. [1–3] The National Survey on Drug Use and Health reported over 42,000 prescription opioid-related deaths in 2016, with total estimated costs of prescription opioid use reaching US $78.5 billion. [4, 5] One of the most common conditions for which opioids are prescribed is low back pain (LBP). [2–4] Several studies have reported that opioids are the most frequently prescribed medication for treatment of LBP, [4, 5] and more than half of opioid users report having a history of back pain. [6] This frequency of opioid prescribing is particularly concerning given that LBP is one of the three most common conditions for which Americans seek medical care. [2, 7]

Given the high prevalence of LBP, several guidelines have been issued for treatment, and specifically discourage opioids to treat pain. The American College of Physicians and the Centers for Disease Control recommend non-pharmacological treatments including exercise, physical therapy (PT), spinal manipulation, acupuncture and massage. [2, 8] These guidelines indicate that opioids should not be considered as a treatment option for LBP unless recommended treatments fail and if the benefits of their use outweigh the risk for the individual patient. [2, 8] Prior to the release of these recommendations, physician visits for new-onset LBP were much more common than non-pharmacological therapies like chiropractic care, PT and acupuncture. [8–11]

Several studies have attempted to elucidate the predictors of opioid use among patients with LBP. Comparisons of the treatment patterns of primary care physicians (PCPs) and conservative therapists (defined as chiropractors, physical therapists, acupuncturists) suggest that the use of conservative therapies for LBP may decrease the likelihood of opioid use. [9] Despite these findings, there has been little research comparing early and long-term opioid use among patients seeking initial care from various providers, including PCPs, chiropractors, physical therapists and acupuncturists as well as patients seeing orthopaedic surgeons, neurosurgeons and emergency physicians. [12–14] The purpose of this study is to examine the association of type of initial provider with subsequent early and long-term opioid use in a national sample of patients with new-onset LBP whose treatment could reasonably be managed by non-pharmacological therapy.

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