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

The following amendments in Abstract were considered to the original version of this article.

1. Acupuncturists have been included, along with chiropractors and physical therapists, as one of the 3 types of conservative therapists that were included in the analyses.

2. Referring to opioid use, the term ‘early’ rather than ‘short-term’ is now used throughout the abstract, consistent with the terminology in the full manuscript.

3. In the ‘Main outcomes measures’ section, the wording has been slightly modified to clarify the outcomes of interest.

4. In the ‘Results’ section, the odds ratios for opioid use have been clarified and expanded. In the original abstract, the odds ratios for early opioid use were provided for chiropractors and physical therapists based on the multivariate analyses (from Table 2 of the manuscript), but they were not clearly labelled. The odds ratios for long-term opioid use were provided for chiropractors and physical therapists based on the propensity analyses (Appendix Table 5). In the revised abstract, the odds ratios for both the early and long-term use of opioids are more clearly labelled, both are based on multivariate analyses, and the results for acupuncturists are now provided in addition to those for chiropractors and physical therapists.

5. In the ‘Conclusion’ section, the phrase ‘compared with PCPs’ was added to clarify that the comparison was to PCPs.

The text of the revised abstract follows:

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 (chiropractors, physical therapists and acupuncturists).

Main outcome measures Early opioid use (within 30 days of the index visit for new-onset LBP) and long-term opioid use (starting within 60 days of the index visit 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 Early use of opioids was 22%. Patients who received initial treatment from chiropractors, physical therapists and acupuncturists had decreased odds of early 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), 0.15 (0.13 to 0.17) and 0.09 (0.07 to 0.12), respectively). Compared with PCP visits, initial chiropractic, physical therapy and acupuncture also were associated with decreased odds of long-term opioid use (AOR (95% CI) 0.22 (0.18 to 0.26), 0.27 (0.15 to 0.48), and 0.07 (0.01 to 0.48), respectively).

Conclusions Initial visits to chiropractors, physical therapists or acupuncturists, compared with PCPs, are associated with substantially decreased early and long-term use of opioids. Incentivizing use of conservative therapists may be a strategy to reduce risks of early and long-term opioid use.