Association of Opioid Use Disorder Diagnosis With Use of Physical Therapy and Chiropractic Care Among Chronic Low Back Pain Patients: A Group-Based Trajectory Analysis.

Nonpharmacologic approaches are recommended as first-line treatment for chronic pain, and their importance is heightened among individuals with co-occurring opioid use disorder (OUD), in whom opioid therapies may be particularly detrimental. Our objectives were to assess the receipt and trajectories of nonpharmacologic pain treatment and determine the association of OUD diagnosis with these trajectories. This retrospective cohort study used Medicare claims data from 2016 to 2018 and applied group-based trajectory models to identify distinct patterns of physical therapy (PT) or chiropractic care treatment over the 12 months following a new episode of chronic low back pain. We used logistic regression models to estimate the association of co-occurring OUD with group membership in PT and chiropractic trajectories. Our sample comprised 607,729 beneficiaries at least 18 years of age, of whom 11.4% had a diagnosis of OUD. The 12-month prevalence of PT and chiropractic treatment receipt was 24.7% and 27.1%, respectively, and lower among Medicare beneficiaries with co-occurring OUD (PT: 14.6%; chiropractic: 6.8%). The final models identified 3 distinct trajectories each for PT (no/little use [76.6% of sample], delayed and increasing use [8.2%], and early and declining use [15.2%]); and chiropractic (no/little use [75.0% of sample], early and declining use [17.3%], and early and sustained use [7.7%]). People with OUD were more likely to belong in trajectories with little/no PT or chiropractic care as compared to other trajectories. The findings indicate that people with co-occurring chronic pain and OUD often do not receive early or any nonpharmacologic pain therapies as recommended by practice guidelines. PERSPECTIVE: PT and chiropractic care use were low overall and even lower among Medicare beneficiaries with co-occurring OUD compared with those without OUD. As updated guidelines on pain management are promulgated, targeted interventions (eg, insurance policy, provider, and patient education) are needed to ensure equitable access to guideline-recommended pain therapies.

Treatment Patterns and Population Characteristics of Nonpharmacological Management of Chronic Pain in the United States' Medicare Population: A Scoping Review.

Background and Objectives: Clinical practice guidelines recommend noninvasive nonpharmacological pain therapies; however, reviews that assess the literature pertaining to nonpharmacological pain management among older adults and people with long-term disabilities who are disproportionately affected by pain are lacking. This scoping review aimed to systematically map and characterize the existing studies about the receipt of noninvasive, nonpharmacological pain therapies by Medicare beneficiaries. Research Design and Methods: We conducted a literature search in MEDLINE (PubMed), CINAHL (EBSCO), SocINDEX (EBSCO), Cochrane Library, Web of Science citation indices, and various sources of gray literature. The initial search was conducted on November 2, 2021, and updated on March 9, 2022. Two independent reviewers screened titles, abstracts, and full texts for inclusion and extracted the characteristics of the studies, studied populations, and nonpharmacological pain therapies. Data were summarized using tabular and narrative formats. Results: The final review included 33 studies. Of these, 24 were quantitative, 7 were qualitative, and 2 were mixed-methods studies. Of 32 studies that focused on Medicare beneficiaries, 10 did not specify the Medicare type, and all but one of the remaining studies were restricted to fee-for-service enrollees. Back and neck pain and arthritis were the most commonly studied pain types. Chiropractic care (n = 19) and physical therapy (n = 17) appeared frequently among included studies. The frequency and/or duration of nonpharmacological treatment were mentioned in 13 studies. Trends in the utilization of nonpharmacological pain therapies were assessed in 6 studies but none of these studies went beyond 2008. Discussion and Implications: This scoping review found that manipulative therapies, mainly chiropractic, have been the most widely studied approaches for nonpharmacological pain management in the Medicare population. The review also identified the need for future research that updates trend data and addresses contemporary issues such as rising Medicare Advantage enrollment and promulgation of practice guidelines for pain management.

Racial and Ethnic Differences in Receipt of Nonpharmacologic Care for Chronic Low Back Pain Among Medicare Beneficiaries With OUD.

Importance: Nonpharmacologic treatments are important for managing chronic pain among persons with opioid use disorder (OUD), for whom opioid and other pharmacologic therapies may be particularly harmful. Racial and ethnic minority individuals with chronic pain and OUD are vulnerable to suboptimal pain management due to systemic inequities and structural racism, highlighting the need to understand their receipt of guideline-recommended nonpharmacologic pain therapies, including physical therapy (PT) and chiropractic care. Objective: To assess differences across racial and ethnic groups in receipt of PT or chiropractic care for chronic low back pain (CLBP) among persons with comorbid OUD. Design, Setting, and Participants: This retrospective cohort study used a 20% random sample of national Medicare administrative data from January 1, 2016, to December 31, 2018, to identify fee-for-service community-dwelling beneficiaries with a new episode of CLBP and comorbid OUD. Data were analyzed from March 1, 2022, to July 30, 2023. Exposures: Race and ethnicity as a social construct, categorized as American Indian or Alaska Native, Asian or Pacific Islander, Black or African American, Hispanic, non-Hispanic White, and unknown or other. Main Outcomes and Measures: The main outcomes were receipt of PT or chiropractic care within 3 months of CLBP diagnosis. The time (in days) to receiving these treatments was also assessed. Results: Among 69 362 Medicare beneficiaries analyzed, the median age was 60.0 years (IQR, 51.5-68.7 years) and 42 042 (60.6%) were female. A total of 745 beneficiaries (1.1%) were American Indian or Alaska Native; 444 (0.6%), Asian or Pacific Islander; 9822 (14.2%), Black or African American; 4124 (5.9%), Hispanic; 53 377 (77.0%); non-Hispanic White; and 850 (1.2%), other or unknown race. Of all beneficiaries, 7104 (10.2%) received any PT or chiropractic care 3 months after a new CLBP episode. After adjustment, Black or African American (adjusted odds ratio, 0.46; 95% CI, 0.39-0.55) and Hispanic (adjusted odds ratio, 0.54; 95% CI, 0.43-0.67) persons had lower odds of receiving chiropractic care within 3 months of CLBP diagnosis compared with non-Hispanic White persons. Median time to chiropractic care was longest for American Indian or Alaska Native (median, 8.5 days [IQR, 0-44.0 days]) and Black or African American (median, 7.0 days [IQR, 0-42.0 days]) persons and shortest for Asian or Pacific Islander persons (median, 0 days [IQR, 0-6.0 days]). No significant racial and ethnic differences were observed for PT. Conclusions and Relevance: In this retrospective cohort study of Medicare beneficiaries with comorbid CLBP and OUD, receipt of PT and chiropractic care was low overall and lower across most racial and ethnic minority groups compared with non-Hispanic White persons. The findings underscore the need to address inequities in guideline-concordant pain management, particularly among Black or African American and Hispanic persons with OUD.

Prevalence of opioid and nonopioid pain management therapies among Medicare beneficiaries with musculoskeletal pain conditions from 2016 to 2019.

INTRODUCTION: Pain treatment guidelines prioritize nonopioid therapies over opioid medications to prevent opioid-related harms. We examined trends in receipt and intensity of nonpharmacologic, nonopioid medication, and opioid therapies among Medicare beneficiaries. METHODS: Using a 20% national random sample of Medicare data from 2016 to 2019, we identified fee-for-service beneficiaries with ≥2 diagnoses of back, neck, fibromyalgia, or osteoarthritis/joint pain annually. We excluded beneficiaries with cancer. We calculated annual proportions of beneficiaries who received physical therapy (PT), chiropractic care, gabapentin, and opioids, overall and in demographic, geographic, and clinical subgroups. We estimated the intensity of therapies using the annual number of visitsor prescription fills, prescription days' supply, and opioid dose. RESULTS: During 2016-2019, PT receipt increased (22.8% to 25.5%) and the mean number of visits among recipients of PT went from 12 to 13. Chiropractic receipt (~18%) and mean annual visits (~10) remained unchanged. The prevalence of gabapentin receipt was stable at ~22% and the mean annual number of fills was unchanged though gabapentin days increased slightly. Opioid prescribing decreased (56.7% to 46.5%) and reductions in opioid dose and duration were observed. Opioid receipt was high among beneficiaries who were under 65 years, American Indian/Alaska Native, Black/African American, or had opioid use disorder (OUD), in whom nonpharmacologic therapies were also received the least. CONCLUSION: Utilization of nonopioid therapies lagged opioids among Medicare beneficiaries with musculoskeletal pain, with limited changes from 2016 to 2019. As opioid prescribing declines and alternative pain therapy receipt remains low, there are potential increasing risks of pain going untreated or undertreated and individuals seeking illicit opioids to alleviate their pain.

Exploring Factors Associated With Long-Term Opioid Therapy in Cancer Survivors: An Integrative Review.

CONTEXT: The prevalence of chronic pain in cancer survivors is double that of the general U.S. POPULATION: Opioids have been the foundation of cancer pain management for decades; however, there is a paucity of literature on long-term opioid therapy (LTOT) in cancer survivors. An understanding of factors related to LTOT use in cancer survivors is needed to address chronic pain and balance opioid harms in the expanding population of cancer survivors. OBJECTIVES: To analyze the research of LTOT utilization and factors associated with persistent opioid use in cancer survivors. METHODS: A five-stage integrative review process was adapted from Whittemore and Knafl. Data sources searched included Web of Science, PubMed, Embase, Cochrane, and Google Scholar. Quantitative research studies from 2010 to present related to cancer survivors managed on LTOT were included. Editorials, reviews, or abstracts were excluded. RESULTS: After reviewing 315 articles, 21 articles were included. We found that there were several definitions of LTOT in the reviewed studies, but the duration of opioid use (i.e., more than three months after completion of curative treatment) was the most common. The reviewed literature describes a relationship between LTOT and important biopsychosocial factors (cancer type, socioeconomic factors, and comorbidities). CONCLUSION: The studies in this review shed light on the factors associated with LTOT in cancer survivors. LTOT was common in certain populations of cancer survivors and those with a collection of patient-specific characteristics. This review suggests that there is a critical need for specialized research on chronic cancer pain and opioid safety in cancer survivors.

Disagreement and Uncertainty Among Experts About how to Respond to Marijuana Use in Patients on Long-term Opioids for Chronic Pain: Results of a Delphi Study.

BACKGROUND: Marijuana use is common among patients on long-term opioid therapy (LTOT) for chronic pain, but there is a lack of evidence to guide clinicians' response. OBJECTIVE: To generate expert consensus about responding to marijuana use among patients on LTOT. DESIGN: Analysis from an online Delphi study. SETTING/SUBJECTS: Clinician experts in pain and opioid management across the United States. METHODS: Participants generated management strategies in response to marijuana use without distinction between medical and nonmedical use, then rated the importance of each management strategy from 1 (not at all important) to 9 (extremely important). A priori rules for consensus were established, and disagreement was explored using cases. Thematic analysis of free-text responses examined factors that influenced participants' decision-making. RESULTS: Of 42 participants, 64% were internal medicine physicians. There was consensus that it is not important to taper opioids as an initial response to marijuana use. There was disagreement about the importance of tapering opioids if there is a pattern of repeated marijuana use without clinical suspicion for a cannabis use disorder (CUD) and consensus that tapering is of uncertain importance if there is suspicion for CUD. Three themes influenced experts' perceptions of the importance of tapering: 1) benefits and harms of marijuana for the individual patient, 2) a spectrum of belief about the overall riskiness of marijuana use, and 3) variable state laws or practice policies. CONCLUSIONS: Experts disagree and are uncertain about the importance of opioid tapering for patients with marijuana use. Experts were influenced by patient factors, provider beliefs, and marijuana policy, highlighting the need for further research.

Marijuana Use and Its Associations With Pain, Opioid Dose, and HIV Viral Suppression Among Persons Living With HIV on Chronic Opioid Therapy.

BACKGROUND: Medical marijuana is legal in 29 US states and the District of Columbia: both HIV and chronic pain are "approved conditions" for receipt. Chronic pain is common among people living with HIV (PLWH). We anticipate PLWH will question their providers about medical marijuana for chronic pain. We examined marijuana use and its associations with pain, opioid dose, and HIV viral suppression among PLWH receiving chronic opioid therapy. METHODS: PLWH prescribed chronic opioid therapy were recruited into the Targeting Effective Analgesia in Clinics for HIV cohort. The main exposure variable was any past 12-month marijuana use. The primary outcomes were (1) opioid misuse (≥9 on the Current Opioid Misuse Measure) and (2) opioid dose (morphine equivalent daily dose). HIV viral load (VL) suppression (<200 copies/µL) and pain severity and interference using the Brief Pain Inventory were exploratory outcomes. RESULTS: Participants (n = 166) were men (65%), Black (72%), and had an undetectable VL (89%). We found no significant association between current marijuana use and opioid misuse, opioid dose, or pain. Current marijuana use was associated with 3.03 times the odds of having a detectable VL (95% odds ratio: 1.11-8.31, P = 0.03) while controlling for depressive symptoms and other substance use. DISCUSSION: We did not detect an association between marijuana use and opioid misuse behaviors, opioid dose, or pain. In an exploratory analysis, current marijuana use was associated with 3× greater odds of having a detectable VL. This study provides insights into potential consequences of marijuana use among PLWH with chronic pain.

Marijuana Use Is Not Associated With Changes in Opioid Prescriptions or Pain Severity Among People Living With HIV and Chronic Pain.

BACKGROUND: People living with HIV (PLWH) commonly report marijuana use for chronic pain, although there is limited empirical evidence to support its use. There is hope that marijuana may reduce prescription opioid use. Our objective was to investigate whether marijuana use among PLWH who have chronic pain is associated with changes in pain severity and prescribed opioid use (prescribed opioid initiation and discontinuation). METHODS: Participants completed self-report measures of chronic pain and marijuana use at an index visit and were followed up for 1 year in the Center for AIDS Research Network of Integrated Clinical Systems (CNICS). Self-reported marijuana use was the exposure variable. Outcome variables were changes in pain and initiation or discontinuation of opioids during the study period. The relationship between exposure and outcomes was assessed using generalized linear models for pain and multivariable binary logistic regression models for opioid initiation/discontinuation. RESULTS: Of 433 PLWH and chronic pain, 28% reported marijuana use in the past 3 months. Median pain severity at the index visit was 6.3/10 (interquartile range 4.7-8.0). Neither increases nor decreases in marijuana use were associated with changes in pain severity, and marijuana use was not associated with either lower odds of opioid initiation or higher odds of opioid discontinuation. CONCLUSIONS: We did not find evidence that marijuana use in PLWH is associated with improved pain outcomes or reduced opioid prescribing. This suggests that caution is warranted when counseling PLWH about potential benefits of recreational or medical marijuana.

Managing Chronic Pain in Cancer Survivors Prescribed Long-Term Opioid Therapy: A National Survey of Ambulatory Palliative Care Providers.

CONTEXT: Chronic pain, or pain lasting more than three months, is common among cancer survivors, who are often prescribed long-term opioid therapy (LTOT). OBJECTIVE: Our objective was to explore palliative care providers' experiences with managing chronic pain in cancer survivors prescribed LTOT, specifically in ambulatory palliative care settings, and their strategies for overcoming challenges. METHODS: We recruited providers through leading national palliative care organizations who manage chronic pain in cancer survivors. Asked to consider only cancer survivors with chronic pain when responding, participants completed an online survey that included questions about use of opioid risk mitigation tools, confidence in addressing opioid misuse behaviors and discussing/recommending management approaches, and access to addiction treatment. RESULTS: Of 157 participants, most were physicians (83%) or nurse practitioners (15%). Most reported using opioid risk mitigation tools such as urine drug testing (71%), opioid treatment agreements (85%), and practitioner database monitoring programs (94%). Participants were confident (7-8/10) managing the most commonly encountered opioid misuse behaviors (missing appointments, marijuana use, and using more opioids than prescribed) and in their ability to recommend nonpharmacologic and nonopioid pharmacologic treatments for chronic pain (10/10). They were least confident prescribing naloxone or managing addiction (5/10); only 27% reported having training or systems in place to address addiction. Only 13% had a waiver to prescribe buprenorphine. CONCLUSION: Palliative care providers are comfortable with many aspects of managing chronic pain in cancer survivors on LTOT, although challenges persist, including the lack of systems-based approaches and training in addiction treatment.

Pharmacologic and non-pharmacologic treatments for chronic pain in individuals with HIV: a systematic review.

Chronic pain occurs in as many as 85% of individuals with HIV and is associated with substantial functional impairment. Little guidance is available for HIV providers seeking to address their patients' chronic pain. We conducted a systematic review to identify clinical trials and observational studies that examined the impact of pharmacologic or non-pharmacologic interventions on pain and/or functional outcomes among HIV-infected individuals with chronic pain in high-development countries. Eleven studies met inclusion criteria and were mostly low or very low quality. Seven examined pharmacologic interventions (gabapentin, pregabalin, capsaicin, analgesics including opioids) and four examined non-pharmacologic interventions (cognitive behavioral therapy, self-hypnosis, smoked cannabis). The only controlled studies with positive results were of capsaicin and cannabis, and had short-term follow-up (≤12 weeks). Among the seven studies of pharmacologic interventions, five had substantial pharmaceutical industry sponsorship. These findings highlight several important gaps in the HIV/chronic pain literature that require further research.