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. 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. One of the most common conditions for which opioids are prescribed is low back pain (LBP). Several studies have reported that opioids are the most frequently prescribed medication for treatment of LBP, and more than half of opioid users report having a history of back pain. 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.
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 spinal manipulation, acupuncture and massage. Prior to the release of these recommendations, physician visits for new-onset LBP were much more common than non-pharmacological therapies like chiropractic care.
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. 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. 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.
This retrospective study of patients seen by a healthcare provider for new-onset LBP management and who were opioid-naïve at the time of the initial visit demonstrated that of a total of 8,797,787 patients had a visit with a provider for LBP during the study period. More than half the patients initially saw a PCP, and the most frequent initial conservative provider seen was chiropractor followed by physical therapist and acupuncturist. Most patients had commercial insurance. Of patients with an acupuncturist as the initial provider type, nearly all (99.3%) had commercial insurance. For all other initial provider types, 87%–89% of patients had commercial insurance. This is one of the first national studies to compare early and long-term opioid use among patients with LBP who receive care from conservative therapists, physician specialists and PCPs.
Approximately 18% of patients received an opioid fill within 3 days of the initial LBP visit, 22% received such a fill within the first 30 days and 1.2% met criteria for long-term use. Eighteen per cent of patients received short-acting opioids; 17.4% received prescriptions for non-steroidal anti-inflammatory drugs.
Compared with seeing a PCP as initial provider, patients who first saw conservative therapists (chiropractor, acupuncturists and physical therapists) all had significantly decreased odds of both early and long-term opioid use. For early opioid use, patients initially visiting chiropractors had 90% decreased odds, while those visiting an acupuncturists had 91% decreased odds and those visiting physical therapists had 85% decreased odds. Patients seeing emergency physicians initially had significantly increased odds of early opioid use. However, compared with PCP as first provider, odds for long-term opioid use were no longer significantly different for orthopaedic surgeons, neurosurgeons and emergency physicians, but were significantly increased for rehab physicians.