Physical Therapy Access May Reduce Opioid Prescriptions.

Low back pain is one of the most common conditions Americans seek care for—and one of the more common reasons for an opioid prescription. In the face of the opioid use disorder crisis, the American College of Physicians and the Centers for Disease Control and Prevention now recommend first trying non-pharmacological treatments for low back pain.

Now, a new School of Public Health study finds that patients who first saw a primary care physician (PCP) for low back pain were 79 percent more likely to use prescription opioids than patients who first went to a chiropractor, and 71 percent more likely than those who first went to a physical therapist.

The study was published in BMJ Open.

“To reduce the risks of short- and long-term opioid use, insurers should incentivize patients to see physical therapists or chiropractors first or early on following a bout of low back pain, before seeing PCPs,” says study lead author Lewis Kazis, professor of health law, policy & management.

Kazis and his colleagues looked at commercial insurance and Medicare Advantage claims data from the OptumLabs database for 216,504 adults across the country who were diagnosed with new-onset low back pain between 2008 and 2013 and had not been prescribed opioids before the diagnosis.

Previous research has only compared short-term opioid prescribing for low back pain in a handful of states, and/or only considered PCPs versus physical therapists. In addition to PCPs, the new, nationwide study also looked at visits to orthopedic surgeons, emergency physicians, rehabilitation physicians, neurosurgeons, and other healthcare professionals with MD degrees.

The researchers found that 22 percent of the patients filled an opioid prescription within a month of their first visit for low back pain, and 1.2 percent filled multiple opioid prescriptions over the next year.

They found that patients who first saw a physician for low back pain were 90 percent more likely to use prescription opioids in the short and long term than patients who first went to a chiropractor or acupuncturist, and 85 percent more likely than those who first went to a physical therapist. However, the authors noted that many factors could cause someone to decide to access these non-pharmacological treatments, including the severity of their pain and other medical issues, and their ability to access such treatments.

The researchers then controlled for as many socio-demographic, geographical, and medical history factors as they could get from the insurance claims data. In this analysis, they found that patients who first went to a chiropractor were 79 percent less likely to use opioids in the long term than those who first went to a PCP, and those who first went to a physical therapist were 71 percent less likely.

The researchers also found that patients in states with provisional or unrestricted access to physical therapy were much more likely to see a physical therapist first than patients in states with limited physical therapy access, illustrating the impact that state-level policy regulations  may have on opioid prescribing.

The study was co-authored by doctoral student Omid Ameli; James Rothendler, assistant professor of health law, policy & management; Brigid Garrity (SPH’18), who was a master’s student while working on the study; Howard Cabral, professor of biostatistics; Kathleen Carey, professor of health law, policy & management; Michael Stein, professor of health law, policy & management; and Robert Saper, associate professor of epidemiology.

The other co-authors were Christine McDonough of the University of Pittsburgh; Darshak Sanghavi of OptumLabs; David Elton of OptumHealth; and Julie Fritz of the University of Utah.

—Michelle Samuels