Factors influencing pain medication and opioid use in patients with musculoskeletal injuries: a retrospective insurance claims database study.

Opioid use is only recommended in selected cases of musculoskeletal (MSK) injuries. We assessed factors associated with increased opioid use in MSK injuries. In a retrospective analysis of over four million workers with MSK injuries using the Swiss National Accident Insurance Fund (Suva) database, we analyzed risk factors by multivariate logistic regression. Injury severity was associated with pain medication, opioid, and strong opioid use. Whereas fractures, contusions, and ruptures had higher odds for any pain medication use, increased odds for strong opioids were observed in fractures, superficial injuries, and other injuries. Injuries of the shoulders, elbow, chest, back/spine, thorax, and pelvis/hips showed high odds for opioid use (odds ratio (OR) > 2.0). Injuries of the shoulders had higher odds for strong opioid use (OR 1.136; 95% CI 1.040-1.241). The odds for using strong opioids increased from 2008 OR 0.843 (95% confidence interval (CI) 0.798-0.891) to 2018 OR 1.503 (95% CI 1.431-1.578), compared to 2013. Injury severity, type of injury, and injured body parts influenced the use of pain medication and overall opioid use in musculoskeletal injuries. Strong opioids were more often used in fractures but also in superficial and other minor injuries, which indicates that other factors play a role when prescribing strong opioids.

Increased Use and Large Variation in Strong Opioids and Metamizole (Dipyrone) for Minor and Major Musculoskeletal Injuries Between 2008 and 2018: An Analysis of a Representative Sample of Swiss Workers.

PURPOSE: Musculoskeletal (MSK) injuries are a major contributing factor for chronic pain. To date, little is known how pain medication use in MSK injuries has changed over time. We assessed pain medication prescription for MSK injuries in a representative sample of Swiss workers between 2008 and 2018. METHODS: Retrospective analysis of the Swiss Accident Insurance Fund (Suva) data. We calculated annual pain medication use, treatment days, and costs associated with pain medication use in minor and major MSK injuries. RESULTS: In total, 1,921,382 cases with MSK injuries with ≥ 1 pain medication were analyzed. Whereas MSK injuries with ≥ 1 pain medication increased by 9.4%, we observed a larger increase in metamizole (+ 254%), strong opioids (+ 88.4%), coxibs (+ 85.8%), and paracetamol (+ 28.1%). Strong opioids were increasingly used in minor (+ 91.4%) and major (+ 88.3%) injuries. The increase in metamizole (+ 390.6%) and coxibs (+ 115.5%) was larger in minor injuries compared to major injuries (+ 238.7% and + 80.6%, respectively). Medical expenses decreased in all medications except for strong opioids where a substantial increase was observed (+ 192.4% in minor; + 34% in major injuries). CONCLUSIONS: We observed a disproportionate increase in metamizole, strong opioids, coxibs, and paracetamol prescriptions even in minor MSK injuries between 2008 and 2018. Whereas treatment costs decreased for all pain medications, there was a substantial increase in strong opioids. A more liberal prescription practice of opioids conflict with current evidence-based practice recommendations and need to be addressed by physicians and policy makers.

Management of acute non-specific low back pain in the emergency department: do emergency physicians follow the guidelines? Results of a cross-sectional survey.

OBJECTIVES: Clinical guidelines for acute non-specific low back pain (LBP) recommend avoiding imaging studies or invasive treatments and to advise patients to stay active. The aim of this study was to evaluate the management of acute non-specific LBP in the emergency departments (ED). SETTING: We invited all department chiefs of Swiss EDs and their physician staff to participate in a web-based survey using two clinical case vignettes of patients with acute non-specific LBP presenting to an ED. In both cases, no neurological deficits or red flags were present. Guideline adherence and low-value care was defined based on current guideline recommendations. RESULTS: In total, 263 ED physicians completed at least one vignette, while 212 completed both vignettes (43% residents, 32% senior/attending physicians and 24% chief physicians). MRI was considered in 31% in vignette 1 and 65% in vignette 2. For pain management, non-steroidal anti-inflammatory drugs, paracetamol and metamizole were mostly used. A substantial proportion of ED physicians considered treatments with questionable benefit and/or increased risk for adverse events such as oral steroids (vignette 1, 12% and vignette 2, 19%), muscle relaxants (33% and 38%), long-acting strong opioids (25% and 33%) and spinal injections (22% and 43%). Although guidelines recommend staying active, 72% and 67% of ED physicians recommended activity restrictions. CONCLUSION: Management of acute non-specific LBP in the ED was not in agreement with current guideline recommendations in a substantial proportion of ED physicians. Overuse of imaging studies, the use of long-acting opioids and muscle relaxants, as well as recommendations for activity and work restrictions were prevalent and may potentially be harmful.

Low Back Pain in the Emergency Department: Prevalence of Serious Spinal Pathologies and Diagnostic Accuracy of Red Flags.

BACKGROUND: Very little evidence is available on the prevalence of serious spinal pathologies and the diagnostic accuracy of red flags in patients presenting to the emergency department (ED). This systematic review aims to investigate the prevalence of serious spinal pathologies and the diagnostic accuracy of red flags in patients presenting with low back pain to the ED. METHODS: We systematically searched MEDLINE, PUBMED, EMBASE, Cochrane Library, and SCOPUS from inception to January 2019. Two reviewers independently reviewed the references and evaluated methodological quality. RESULTS: We analyzed 22 studies with a total of 41,320 patients. The prevalence of any requiring immediate/urgent treatment was 2.5%-5.1% in prospective and 0.7%-7.4% in retrospective studies (0.0%-7.2% for vertebral fractures, 0.0%-2.1% for spinal cancer, 0.0%-1.9% for infectious disorders, 0.1%-1.9% for pathologies with spinal cord/cauda equina compression, 0.0%-0.9% for vascular pathologies). Examples of red flags which increased the likelihood for a serious condition were suspicion or history of cancer (spinal cancer); intravenous drug use, indwelling vascular catheter, and other infection site (epidural abscess). CONCLUSION: We found a higher prevalence of serious spinal pathologies in the ED compared to the reported prevalence in primary care settings. As the diagnostic accuracy of most red flags was reported only by a single study, further validation in high-quality prospective studies is needed.

Measurement Properties of the Modified Spinal Function Sort (M-SFS): Is It Reliable and Valid in Workers with Chronic Musculoskeletal Pain?

Purpose To analyze the reliability and validity of a picture-based questionnaire, the Modified Spinal Function Sort (M-SFS). Methods Sixty-two injured workers with chronic musculoskeletal disorders (MSD) were recruited from two work rehabilitation centers. Internal consistency was assessed by Cronbach's alpha. Construct validity was tested based on four a priori hypotheses. Structural validity was measured with principal component analysis (PCA). Test-retest reliability and agreement was evaluated using intraclass correlation coefficient (ICC) and measurement error with the limits of agreement (LoA). Results Total score of the M-SFS was 54.4 (SD 16.4) and 56.1 (16.4) for test and retest, respectively. Item distribution showed no ceiling effects. Cronbach's alpha was 0.94 and 0.95 for test and retest, respectively. PCA showed the presence of four components explaining a total of 74% of the variance. Item communalities were >0.6 in 17 out of 20 items. ICC was 0.90, LoA was ±12.6/16.2 points. The correlations between the M-SFS were 0.89 with the original SFS, 0.49 with the Pain Disability Index, -0.37 and -0.33 with the Numeric Rating Scale for actual pain, -0.52 for selfreported disability due to chronic low back pain, and 0.50, 0.56-0.59 with three distinct lifting tests. No a priori defined hypothesis for construct validity was rejected. Conclusions The M-SFS allows reliable and valid assessment of perceived self-efficacy for work-related tasks and can be recommended for use in patients with chronic MSD. Further research should investigate the proposed M-SFS score of <56 for its predictive validity for non-return to work.

Assessing Psycho-social Barriers to Rehabilitation in Injured Workers with Chronic Musculoskeletal Pain: Development and Item Properties of the Yellow Flag Questionnaire (YFQ).

Purpose To develop a multidimensional scale to asses psychosocial beliefs-the Yellow Flag Questionnaire (YFQ)-aimed at guiding interventions for workers with chronic musculoskeletal (MSK) pain. Methods Phase 1 consisted of item selection based on literature search, item development and expert consensus rounds. In phase 2, items were reduced with calculating a quality-score per item, using structure equation modeling and confirmatory factor analysis on data from 666 workers. In phase 3, Cronbach's α, and Pearson correlations coefficients were computed to compare YFQ with disability, anxiety, depression and self-efficacy and the YFQ score based on data from 253 injured workers. Regressions of YFQ total score on disability, anxiety, depression and self-efficacy were calculated. Results After phase 1, the YFQ included 116 items and 15 domains. Further reductions of items in phase 2 by applying the item quality criteria reduced the total to 48 items. Phase factor analysis with structural equation modeling confirmed 32 items in seven domains: activity, work, emotions, harm & blame, diagnosis beliefs, co-morbidity and control. Cronbach α was 0.91 for the total score, between 0.49 and 0.81 for the 7 distinct scores of each domain, respectively. Correlations between YFQ total score ranged with disability, anxiety, depression and self-efficacy was .58, .66, .73, -.51, respectively. After controlling for age and gender the YFQ total score explained between R2 27% and R2 53% variance of disability, anxiety, depression and self-efficacy. Conclusions The YFQ, a multidimensional screening scale is recommended for use to assess psychosocial beliefs of workers with chronic MSK pain. Further evaluation of the measurement properties such as the test-retest reliability, responsiveness and prognostic validity is warranted.