Patterns of health care utilization for low back pain.

BACKGROUND: The purpose of this study was to determine if primary care patients with low back pain (LBP) cluster into definable care utilization subgroups that can be explained by patient and provider characteristics. MATERIALS AND METHODS: Adult primary care patients with an incident LBP encounter were identified from Geisinger Clinic electronic health records over 5 years. Two-thirds of the cohort had only one to two encounters. Principal component analysis was applied to the data from the remaining one-third on use of ambulatory, inpatient, emergency department, and surgery care and use of magnetic resonance imaging, injections, and opioids in 12 months following the incident encounter. Groups were compared on demographics, health behaviors, chronic and symptomatic disease burden, and a measure of physician efficiency. RESULTS: Six factors with eigenvalues >1.5 explained 71% of the utilization variance. Patient subgroups were defined as: 1-2 LBP encounters; 2+ surgeries; one surgery; specialty care without primary care; 3+ opioid prescriptions; laboratory dominant care; and others. The surgery and 3+ opioid subgroups, while accounting for only 10.4% of the cohort, had used disproportionately more magnetic resonance imaging, emergency department, inpatient, and injectable resources. The specialty care subgroup was characterized by heavy use of inpatient care and the lowest use of injectables. Anxiety disorder and depression were not more prevalent among the surgery patients than in the others. Surgery patients had features in common with specialty care patients, but were older, had higher prevalence of Fibromyalgia, and were associated primary care physicians with worse efficiency scores. CONCLUSION: LBP care utilization is highly variable and concentrated in small subgroups using disproportionate amounts of potentially avoidable care that reflect both patient and provider characteristics.

Long-term use of opioids for complex chronic pain.

Increased opioid prescribing for back pain and other chronic musculoskeletal pain conditions has been accompanied by dramatic increases in prescription-opioid addiction and fatal overdose. Opioid-related risks appear to increase with dose. Although short-term randomised trials of opioids for chronic pain have found modest analgesic benefits (a one-third reduction in pain intensity on average), the long-term safety and effectiveness of opioids for chronic musculoskeletal pain remains unknown. Given the lack of large, long-term randomised trials, recent epidemiologic data suggest the need for caution when considering long-term use of opioids to manage chronic musculoskeletal pain, particularly at higher dosage levels. Principles for achieving more selective and cautious use of opioids for chronic musculoskeletal pain are proposed.

Group Health's initiative to avert opioid misuse and overdose among patients with chronic noncancer pain.

Increased opioid prescribing for chronic pain that is not due to cancer has been accompanied by large increases in abuse and overdose of prescription opioids. This paper describes how Group Health, a Seattle-based nonprofit health care system, implemented a major initiative to make opioid prescribing safer. In the initiative's first nine months, clinicians developed documented care plans for almost 6,000 patients receiving long-term opioid therapy for chronic pain. Evaluation of the initiative's effects on care processes and trends in adverse events is under way.

Opioid pharmacotherapy for chronic non-cancer pain in the United States: a research guideline for developing an evidence-base.

UNLABELLED: This document reports the consensus of an interdisciplinary panel of research and clinical experts charged with reviewing the use of opioids for chronic noncancer pain (CNCP) and formulating guidelines for future research. Prescribing opioids for chronic noncancer pain has recently escalated in the United States. Contrasting with increasing opioid use are: 1) The lack of evidence supporting long-term effectiveness; 2) Escalating misuse of prescription opioids including abuse and diversion; and 3) Uncertainty about the incidence and clinical salience of multiple, poorly characterized adverse drug events (ADEs) including endocrine dysfunction, immunosuppression and infectious disease, opioid-induced hyperalgesia and xerostomia, overdose, falls and fractures, and psychosocial complications. Chief among the limitations of current evidence are: 1) Sparse evidence on long-term opioid effectiveness in chronic pain patients due to the short-term time frame of clinical trials; 2) Insufficiently comprehensive outcome assessment; and 3) Incomplete identification and quantification of ADEs. The panel called for a strategic interdisciplinary approach to the problem domain in which basic scientists and clinicians cooperate to resolve urgent issues and generate a comprehensive evidence base. It offered 4 recommendations in 3 areas: 1) A research strategy for studying the effectiveness of long-term opioid pharmacotherapy; 2) Improvements in evidence-generation methodology; and 3) Potential research topics for generating new evidence. PERSPECTIVE: Prescribing opioids for CNCP has outpaced the growth of scientific evidence bearing on the benefits and harms of these interventions. The need for a strong evidence base is urgent. This guideline offers a strategic approach to creating a comprehensive evidence base to guide safe and effective management of CNCP.