Family Medicine Physician, Lebanon, PA

Dr. Orner reports no financial relationships relevant to this field of study.

SYNOPSIS: When compared to an initial visit with a primary care physician, patients who initially received care for new-onset low back pain from a chiropractor, physical therapist, or acupuncturist had decreased odds of both early and long-term opioid use.

SOURCE: Kazis LE, Ameli O, Rothendler J, et al. Observational retrospective study of the association of initial healthcare provider for
new-onset low back pain with early and long-term opioid use. BMJ Open 2019;9:e028633. doi:10.1136/bmjopen-2018-028633

In this retrospective cohort study, Kazis et al examined the association between types of providers seen for an initial concern of new-onset low back pain (LBP) with subsequent early and long-term opioid use. They examined de-identified outpatient and inpatient claims data from OptumLabs Data Warehouse from 2008 though 2013. Claims included visits to primary care providers (PCPs), specialists, chiropractors, acupuncturists, and physical therapists. In this study, chiropractors, acupuncturists, and physical therapists were considered conservative therapists.^1,

Of the 8.8 million adults who visited with a provider for LBP during the study period, 216,504 met the criteria for inclusion. To be included, patients needed to be continuously enrolled in a health plan for at least 24 months before and following the initial outpatient visit for back pain. Both medical and pharmacy claims data were required for that period of time. Patients were excluded for: 1) prescription for opioids in the preceding 12 months; 2) diagnosis of neoplasia in the preceding 12 months or within three months after the initial claim date; and 3) LBP diagnosis that typically would not be amendable to conservative therapy. Early opioid use was determined by a filled opioid prescription for a qualifying diagnosis within 30 days of the initial visit. Long-term opioid use was defined as an opioid prescription within 60 days of the initial visit and either ≥ 120 days’ supply over 12 months or ≥ 90 days’ supply of opioids and ≥ 10 prescriptions over 12 months.¹

Fifty-three percent of patients initially were seen by a PCP, followed by 23.1% by a chiropractor, 1.6% by a physical therapist, and 0.8% by an acupuncturist. When compared with seeing a PCP, patients who initially saw a conservative therapist had decreased odds of both early and long-term opioid use. There were decreased odds of early opioid use in those initially seen by orthopedic surgeons, neurosurgeons, and rehab physicians compared to PCPs. There was a significant increase in odds of early opioid use in those seen by emergency physicians and long-term use in those seen by physical rehabilitation physicians. Long-term opioid use odds were not significantly different in orthopedic surgeons, neurosurgeons, or emergency physicians compared to PCPs.

Researchers discussed a few possible reasons for the differences seen in opioid use based on initial provider. Conservative therapists are unable to prescribe opioids; therefore, patients seeking conservative therapy for their initial claim of new-onset LBP would be unable to obtain opioids at that visit. Also, it is possible that early participation with conservative therapists provides an opportunity to incorporate evidence-based nonpharmacological interventions and decreases the need for pharmacologic intervention. The authors noted that causation cannot be inferred because this is a claims-based study.

There are several limitations to this study. A claims-based study would miss cases treated outside of the insurance system. Insurance coverage for modalities such as chiropractic care and acupuncture vary. Also, the availability of physical therapy without a referral varies between insurance plans and states.¹ Based on the results, PCPs may want to think about their prescribing habits and nonpharmacologic modalities, such as physical therapy, acupuncture, and/or chiropractic care, early in the treatment of low back pain. There is additional evidence to suggest that early physical therapy participation is associated with decreased opioid prescriptions.²

REFERENCES

1. Kazis LE, Ameli O, Rothendler J, et al. Observational retrospective study of the association of initial healthcare provider for new-onset low back pain with early and long-term opioid use. BMJ Open 2019;9:e028633. Erratum: Observational retrospective study of the association of initial healthcare provider for new-onset low back pain with early and long-term opioid use BMJ Open 2020;10:e028633corr1.
2. Thackeray A, Hess R, Dorius J, et al. Relationship of opioid prescriptions to physical therapy referral and participation for medicaid patients with new-onset low back pain. J Am Board Fam Med 2017;30:784-794. doi:10.3122/jabfm.2017.06.170064