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Observational retrospective study of the association of initial healthcare provider for new-onset low back pain with early and long-term opioid use
  1. Lewis E Kazis1,
  2. Omid Ameli1,2,
  3. James Rothendler1,
  4. Brigid Garrity1,
  5. Howard Cabral3,
  6. Christine McDonough4,
  7. Kathleen Carey1,
  8. Michael Stein1,
  9. Darshak Sanghavi2,
  10. David Elton5,
  11. Julie Fritz6,
  12. Robert Saper7
  1. 1 Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
  2. 2 OptumLabs, Cambridge, Massachusetts, USA
  3. 3 Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, USA
  4. 4 University of Pittsburgh School of Health and Rehabilitation Sciences, Pittsburgh, Pennsylvania, USA
  5. 5 OptumHealth, Eden Prairie, Minnesota, USA
  6. 6 Physical Therapy and Athletic Training, University of Utah, Salt Lake City, Utah, USA
  7. 7 Boston University Medical Campus, Boston, Massachusetts, USA
  1. Correspondence to Dr Lewis E Kazis; lek{at}


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 (physical therapists, chiropractors, acupuncturists).

Main outcome measures Short-term opioid use (within 30 days of the index visit) following new LBP visit and long-term opioid use (starting within 60 days of the index date 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 Short-term use of opioids was 22%. Patients who received initial treatment from chiropractors or physical therapists had decreased odds of short-term and long-term 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) and 0.15 (0.13 to 0.17), respectively). Compared with PCP visits, initial chiropractic and physical therapy also were associated with decreased odds of long-term opioid use in a propensity score matched sample (AOR (95% CI) 0.21 (0.16 to 0.27) and 0.29 (0.12 to 0.69), respectively).

Conclusions Initial visits to chiropractors or physical therapists is associated with substantially decreased early and long-term use of opioids. Incentivising use of conservative therapists may be a strategy to reduce risks of early and long-term opioid use.

  • Opioid use
  • Back pain
  • opioid

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  • Contributors LEK, JR, OA, HC, CMcD, KC and RS were responsible for project design and conceptualisation. OA and HC were responsible for data analysis. LEK, JR, OA, HC, CMcD, KC, RS, MS and BG were responsible for writing of the manuscript. DS, DE and JF provided critical feedback during the analysis and writing of the manuscript. All authors were involved in the editing and review of the manuscript.

  • Funding This project was funded by the American Physical Therapy Association, OptumLabs and UnitedHealthCare.

  • Disclaimer The American Physical Therapy Association, OptumLabs and UnitedHealthCare had no editorial control or influence for the final content of this paper.

  • Competing interests Drs OA, DS and DE work for OptumLabs but do not have any competing interests to report. This study was commissioned by OptumLabs and the American Physical Therapy Association (APTA). The funders provided comments on the production of the manuscript. The primary author, Dr LEK Professor at Boston University, had final editorial comment on the manuscript.

  • Patient consent for publication Not required.

  • Ethics approval This study was approved by Boston Medical Center (IRB approval number: H-36499).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Certain data from OptumLabs Data Warehouse may be available upon request.

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