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      Association of Early Physical Therapy With Long-term Opioid Use Among Opioid-Naive Patients With Musculoskeletal Pain

      research-article
      , MD, PhD 1 , 2 , , , MA, MSc 3 , 4 , , MD, PhD 2 , , PT, PhD 5 , , DPT, PhD 5 , , PT, PhD 5
      JAMA Network Open
      American Medical Association

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          Key Points

          Question

          Is early physical therapy associated with long-term opioid use by patients with musculoskeletal pain?

          Findings

          In this cross-sectional analysis of 88 985 patients with shoulder, neck, knee, or low back pain, early physical therapy was associated with an approximately 10% statistically significant reduction in subsequent opioid use.

          Meaning

          By serving as an alternative or adjunct to short-term opioid use for patients with musculoskeletal pain, early physical therapy may play a role in reducing the risk of long-term opioid use.

          Abstract

          Importance

          Nonpharmacologic methods of reducing the risk of new chronic opioid use among patients with musculoskeletal pain are important given the burden of the opioid epidemic in the United States.

          Objective

          To determine the association between early physical therapy and subsequent opioid use in patients with new musculoskeletal pain diagnosis.

          Design, Setting, and Participants

          This cross-sectional analysis of health care insurance claims data between January 1, 2007, and December 31, 2015, included privately insured patients who presented with musculoskeletal pain to an outpatient physician office or an emergency department at various US facilities from January 1, 2008, to December 31, 2014. The sample comprised 88 985 opioid-naive patients aged 18 to 64 years with a new diagnosis of musculoskeletal shoulder, neck, knee, or low back pain. The data set (obtained from the IBM MarketScan Commercial database) included person-level International Classification of Diseases, Ninth Revision or Tenth Revision diagnosis codes, Current Procedural Terminology codes, and date of service as well as pharmaceutical information (National Drug Code, generic name, dose, and number of days supplied). Early physical therapy was defined as at least 1 session received within 90 days of the index date, the earliest date a relevant diagnosis was provided. Data analysis was conducted from March 1, 2018, to May 18, 2018.

          Main Outcomes and Measures

          Opioid use between 91 and 365 days after the index date.

          Results

          Of the 88 985 patients included, 51 351 (57.7%) were male and 37 634 (42.3%) were female with a mean (SD) age of 46 (11.0) years. Among these patients, 26 096 (29.3%) received early physical therapy. After adjusting for potential confounders, early physical therapy was associated with a statistically significant reduction in the incidence of any opioid use between 91 and 365 days after the index date for patients with shoulder pain (odds ratio [OR], 0.85; 95% CI, 0.77-0.95; P = .003), neck pain (OR, 0.92; 95% CI, 0.85-0.99; P = .03), knee pain (OR, 0.84; 95% CI, 0.77-0.91; P < .001), and low back pain (OR, 0.93; 95% CI, 0.88-0.98; P = .004). For patients who did use opioids, early physical therapy was associated with an approximately 10% statistically significant reduction in the amount of opioid use, measured in oral morphine milligram equivalents, for shoulder pain (−9.7%; 95% CI, −18.5% to −0.8%; P = .03), knee pain (−10.3%; 95% CI, −17.8% to −2.7%; P = .007), and low back pain (−5.1%; 95% CI, −10.2% to 0.0%; P = .046), but not for neck pain (−3.8%; 95% CI, −10.8% to 3.3%; P = .30).

          Conclusions and Relevance

          Early physical therapy appears to be associated with subsequent reductions in longer-term opioid use and lower-intensity opioid use for all of the musculoskeletal pain regions examined.

          Abstract

          This cross-sectional study examines the association between early physical therapy and subsequent opioid use among opioid-naive adults with a new diagnosis of musculoskeletal shoulder, neck, knee, or low back pain.

          Related collections

          Most cited references17

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          Implications of early and guideline adherent physical therapy for low back pain on utilization and costs

          Background Initial management decisions following a new episode of low back pain (LBP) are thought to have profound implications for health care utilization and costs. The purpose of this study was to evaluate the impact of early and guideline adherent physical therapy for low back pain on utilization and costs within the Military Health System (MHS). Methods Patients presenting to a primary care setting with a new complaint of LBP from January 1, 2007 to December 31, 2009 were identified from the MHS Management Analysis and Reporting Tool. Descriptive statistics, utilization, and costs were examined on the basis of timing of referral to physical therapy and adherence to practice guidelines over a 2-year period. Utilization outcomes (advanced imaging, lumbar injections or surgery, and opioid use) were compared using adjusted odds ratios with 99% confidence intervals. Total LBP-related health care costs over the 2-year follow-up were compared using linear regression models. Results 753,450 eligible patients with a primary care visit for LBP between 18–60 years of age were considered. Physical therapy was utilized by 16.3% (n = 122,723) of patients, with 24.0% (n = 17,175) of those receiving early physical therapy that was adherent to recommendations for active treatment. Early referral to guideline adherent physical therapy was associated with significantly lower utilization for all outcomes and 60% lower total LBP-related costs. Conclusions The potential for cost savings in the MHS from early guideline adherent physical therapy may be substantial. These results also extend the findings from similar studies in civilian settings by demonstrating an association between early guideline adherent care and utilization and costs in a single payer health system. Future research is necessary to examine which patients with LBP benefit early physical therapy and determine strategies for providing early guideline adherent care. Electronic supplementary material The online version of this article (doi:10.1186/s12913-015-0830-3) contains supplementary material, which is available to authorized users.
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            Does adherence to the guideline recommendation for active treatments improve the quality of care for patients with acute low back pain delivered by physical therapists?

            Numerous practice guidelines have been developed for patients with low back pain in an attempt to reduce inappropriate variations and improve the cost-effectiveness of care. Guideline implementation has received more research attention than the impact of adherence to guideline recommendations on outcomes and costs of care. Examine the association between adherence to the guideline recommendation to use active versus passive treatments with clinical outcomes and costs for patients with acute low back pain receiving physical therapy. Retrospective review of patients with acute low back pain receiving physical therapy in 2004-2005. Adherence to the recommendation for active treatment was determined from billing records. Clinical and financial outcomes were compared between patients receiving adherent or nonadherent care. A total of 1190 patients age 18-60 years old with low back pain of less than 90 days duration in 10 clinics in 1 geographic region. Clinical outcomes included the numeric pain rating and Oswestry disability questionnaire taken initially and at the completion of treatment. Financial outcomes included the number of sessions and charges for physical therapy care. Adherence rate was 40.4%. Adherence was greater for patients receiving workers' compensation (P < 0.05). Patients receiving adherent care had fewer visits and lower charges (P < 0.05), and showed more improvement in disability [adjusted mean difference for percentage improvement 25.8%, 95% confidence interval (CI): 21.3-30.4, P < 0.001] and pain (adjusted mean difference for percentage improvement 22.4%, 95% CI: 17.5-27.3, P < 0.001). Patients receiving adherent care were more likely to have a successful physical therapy outcome (64.7% vs. 36.5%, P < 0.001). Adherence to the guideline recommendation for active care was associated with better clinical outcomes and reduced cost.
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              Early Physical Therapy vs Usual Care in Patients With Recent-Onset Low Back Pain

              Low back pain (LBP) is common in primary care. Guidelines recommend delaying referrals for physical therapy.
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                Author and article information

                Journal
                JAMA Netw Open
                JAMA Netw Open
                JAMA Netw Open
                JAMA Network Open
                American Medical Association
                2574-3805
                14 December 2018
                December 2018
                14 December 2018
                : 1
                : 8
                : e185909
                Affiliations
                [1 ]Department of Health Research and Policy, Stanford University School of Medicine, Stanford University, Stanford, California
                [2 ]Department of Anesthesiology, Pain, and Perioperative Medicine, Stanford University School of Medicine, Stanford, California
                [3 ]Center for Health Policy, Stanford University School of Medicine, Stanford, California
                [4 ]Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, California
                [5 ]Duke Clinical Research Institute, Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina
                Author notes
                Article Information
                Accepted for Publication: October 23, 2018.
                Published: December 14, 2018. doi:10.1001/jamanetworkopen.2018.5909
                Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2018 Sun E et al. JAMA Network Open.
                Corresponding Author: Eric Sun, MD, PhD, Department of Anesthesiology, Pain, and Perioperative Medicine, Stanford University School of Medicine, 300 Pasteur Dr, Ste H3580, Stanford, CA 94305 ( esun1@ 123456stanford.edu ).
                Author Contributions: Dr Sun and Ms Moshfegh had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
                Concept and design: Sun, Cook, Goode, George.
                Acquisition, analysis, or interpretation of data: Sun, Moshfegh, Rishel, Goode, George.
                Drafting of the manuscript: Sun, Moshfegh, Goode, George.
                Critical revision of the manuscript for important intellectual content: Sun, Rishel, Cook, Goode, George.
                Statistical analysis: Sun, Moshfegh, Rishel.
                Obtained funding: Sun.
                Administrative, technical, or material support: Sun, Cook, Goode, George.
                Supervision: Sun.
                Conflict of Interest Disclosures: Dr Sun reported receiving grants from the National Institute on Drug Abuse during the conduct of the study as well as receiving consulting fees unrelated to this work from Egalet, Inc and the Mission Lisa Foundation. Dr George reported receiving grants from the National Center for Complementary and Integrative Health during the conduct of the study, personal fees from Rehab Essentials, and personal fees from the National Institutes of Health (NIH) outside the submitted work. No other disclosures were reported.
                Funding/Support: This study was supported in part by grant K08DA042314 from the National Institute on Drug Abuse (Dr Sun) and by grant UG3AT009790 from the National Center for Complementary and Integrative Health (Drs George, Cook, and Goode). The Stanford Center for Population Health Sciences Data Core is supported by award UL1 TR001085 from the NIH National Center for Advancing Translational Science and by internal Stanford funding.
                Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
                Disclaimer: The views expressed herein are those of the authors and do not reflect the official policy or position of the NIH.
                Article
                zoi180249
                10.1001/jamanetworkopen.2018.5909
                6324326
                30646297
                04afa79e-9f15-4d90-8a3d-a7f33ce840a9
                Copyright 2018 Sun E et al. JAMA Network Open.

                This is an open access article distributed under the terms of the CC-BY License.

                History
                : 13 August 2018
                : 22 October 2018
                : 23 October 2018
                Categories
                Research
                Original Investigation
                Online Only
                Anesthesiology

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