This article is excerpted from The Spine Blog of SPINE medical journal, written by Adam Pearson MD, MS, on January 25, 2019 and the study discussed, published in SPINE on February 1, 2019.
The opioid epidemic has been widely studied, and many narcotic addicts had their first exposure to opioids via a prescription for pain medication. Low back pain patients are at especially high risk for opioid prescription and subsequent addiction due to prescribing patterns and the chronic nature of the problem. While patient characteristics associated with long-term narcotic use have been studied extensively, the role of the specialty of the initial provider encountered for low back pain in predicting long-term use has been less well-studied.
In order to evaluate the association between initial provider specialty and likelihood of early and long-term narcotic prescription, [study author] Azad and colleagues from Stanford University analyzed 478,981 initial low back pain encounters in the MarketScan Commercial Claims database from 2010. All patients had an index low back pain or radiculopathy diagnosis without a prior similar diagnosis or opioid prescription in the prior 6 months. They considered these patients as opioid-naïve and presenting with acute back pain.
Initial encounters with medical professionals broke down as follows:
- Almost 50% had their initial encounter with a primary care physician
- 18% with a specialist
- 18% in an acute care setting (i.e. urgent care or the emergency department)
- 17% with a non-physician provider (i.e. acupuncturist, chiropractor, physical therapist, or physician’s assistant)
Results of the opioid prescription rate by provider and risk for long-term use is as follow:
- Overall, 40.4% received an opiate prescription within 1 year and 4.0% met criteria for long-term use (long-term use here means they received at least 6 prescriptions in that time frame).
- The most common initial provider type was family practice, associated with a 24.4% risk of early opiate prescription and a 2.0% risk of long-term opiate use .
- Risk of receiving an early opiate prescription was higher among patients initially diagnosed by emergency medicine at 43.1% or at an urgent care facility at 40.8%.
- Risk of long-term opiate use was highest for patients initially diagnosed by pain management/anesthesia at 6.7% or physical medicine and rehabilitation providers at 3.4%.
- Patients initially seen by an acupuncturist, chiropractor, or physical therapist were the least likely to receive an opioid prescription at any point or be a long-term user.
The authors have asked an interesting question about the role of the initial low back pain provider in setting the stage for opioid use. This question differs subtly from the likelihood of prescription by provider type as it attempts to look at the role of the first contact the patient has with the healthcare system. While acute care providers are frequently criticized for overprescribing opioids for back pain, it seems as though opioids prescribed in this setting were not associated with long-term use. It is also striking that simply having an initial encounter with a non-prescribing provider (i.e. acupuncturist, chiropractor, physical therapist) seems protective against receiving an opioid prescription even though many of these patients likely encountered physicians later in their course.
Like all large database studies, the ability to draw strong conclusions about causation is very limited. Many provider and patient characteristics that likely drove the decision to prescribe opioids were not captured in the database and could be strong confounders. For example, patients who were not interested in opioids or traditional medical care were probably more likely to see a non-prescribing provider initially, and this could have been the main driver of their lower risk of opioid prescription than those who sought care from a pain management provider. Additionally, the look back period was only 6 months, so some of these patients may have had a significant history of chronic back pain and/or narcotic use in the more distant past, and these patients may have been more likely to seek out different types of providers. Given the publicity about the opioid epidemic and publication of guidelines recommending against prescribing narcotics for low back pain, it would be interesting to see how patterns have changed recently compared to 2010. Avoiding the prescription of narcotics and considering alternative pain management strategies (i.e. physical therapy, chiropractic care, acupuncture) seems to be a reasonable approach to the management of acute low back pain.
Stop Taking Pain Medications!
The Bonati Spine Institute surgeons and staff do not believe in the use of opioids for pain relief, especially long-term use. These medications only mask the pain being caused by the condition. They do nothing to solve the pain. This is where the Bonati Spine Procedures can help. Developed by Dr. Bonati with patented tools to target the source of the pain, without damaging surrounding tissue, muscles and other sensitive structures, our procedures can provide immediate relief to those experiencing low back pain and eliminate the need for opioids or other pain medications. Allow our staff to review your case and verify if the Bonati Spine Procedures can help you. Click here to discuss your condition with one of our patient advocates or call us at 855-267-0482.
To read the full SPINE blog, click here: https://journals.lww.com/spinejournal/blog/SpineBlog/pages/post.aspx?PostID=574
To read the full published study, click here: https://journals.lww.com/spinejournal/Abstract/2019/02010/Initial_Provider_Specialty_Is_Associated_With.16.aspx