Research Review By Dr. Michael Haneline©


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Date Posted:

April 2022

Study Title:

Long-term Medicare costs associated with opioid analgesic therapy vs. spinal manipulative therapy for chronic low back pain in a cohort of older adults


Whedon J, Kizhakkeveettil A, Toler A, et al.

Author's Affiliations:

Health Services Research & Eastern Medicine Department, Southern California University of Health Sciences, Whittier, California; The Dartmouth Institute, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA

Publication Information:

Journal of Manipulative and Physiological Therapeutics 2021; 44(7): 519-526.

Background Information:

The most common condition for which opioid analgesics are prescribed in the United States, and one of the most common reasons for a physician visit in general, is low back pain (LBP).

Nonspecific back pain affects approximately 30% of older adults at any given time. This patient group (65 years of age and over) often experience recurrent episodes of LBP as well. The prevalence of chronic LBP (cLBP) increased between 2000 and 2007 by 64% in the United States and similar increases have been noted globally. Spinal pain is also one of the costliest medical conditions, even though there was a decline in positive clinical outcomes between 1997 and 2006 despite rising costs (1). We (as taxpayers and/or private consumers of healthcare) are paying way more, for no real benefit or improvement!

A recent study found that 31% of patients with LBP received prescriptions for opioid analgesics within the first 6 months of initial diagnosis, rising to 42% within 3 years (2). Nevertheless, the long-term effectiveness of opioid therapy for chronic LBP is unknown (3), whereas the risks of opioid analgesics are widely known and simply devastating on many levels. It has been reported that opioid analgesic therapy (OAT) results in 3.8% of patients developing opioid use disorder (4) and up to 26% of patients developing opioid dependence (5). Furthermore, almost 70% of US drug overdose deaths in 2018 involved an opioid, resulting in 46,802 deaths from opioid-related overdoses. It is troubling that many patients who end up with negative clinical consequences from opioid medications were first prescribed these drugs for low back pain!

Further, among patients with chronic, disabling musculoskeletal disorders, higher dosing of opioids is correlated with greater pain severity and higher levels of disability and depression (6).

In contrast, nonpharmacological therapies for spinal pain have been shown to be associated with a decreased use of opioids (7). One such nonpharmacological therapy, spinal manipulative therapy (SMT), has been shown to be an effective treatment for cLBP and current clinical guidelines recommend SMT as a first-line approach to the management of LBP (8).

Chiropractic management of LBP typically involves SMT, and several studies have evaluated the costs of such care as compared with usual care. However, the results of this research have been mixed. No studies have rigorously compared the long-term costs associated with OAT and SMT. Therefore, the purpose of this study was to compare Medicare expenditures for cLBP among patients aged 65-84 who were recipients of OAT versus SMT, hypothesizing that initiation of treatment with OAT would be associated with higher costs than with SMT.

Pertinent Results:

There were 28 160 older adult participants (aged 65-84) in the study, with 21 731 (77%) of them initially receiving OAT and 6429 (23%) SMT for cLBP.

Participants who received opioid analgesic therapy (OAT):
  • were more likely to be in a lower socioeconomic status;
  • had higher comorbidity scores than those who received SMT; and
  • were more likely to be diagnosed with radiculopathy, spondylolisthesis, spinal stenosis, a depressive disorder, and osteoarthritis of the hip or knee.
Among patients who received spinal manipulative therapy (SMT):
  • the frequency of cases of herniated disc was very low, and
  • fibromyalgia was diagnosed more frequently.
Cost Comparison:
Costs under Medicare for patients who received long-term care via OAT for a primary diagnosis of LBP were 58% lower (average annual per-patient cost was $1,173 lower) than those who received long-term SMT for the cLBP itself. Overall healthcare costs (over the 4 years), however, were higher for those who received OAT, with total adjusted Medicare payments being 1.87 times higher than for patients who initiated care with SMT ($15717 higher for part A, $20 928 for part B payments, and $7877 for part D payments).

Clinical Application & Conclusions:

The hypothesis of this study was that for Medicare beneficiaries who received long-term care for cLBP, OAT treatment would be associated with higher costs than with SMT. However, costs incurred specifically for the clinical care of cLBP were higher for those who received SMT, whereas overall costs were higher for those who received OAT.

These findings differ from a previous study which reported that treatment of Medicare patients with SMT for cLBP resulted in lower per-episode costs as well as overall costs as compared with medical care (9).

The authors pointed out that the higher costs of SMT alone for cLBP appeared to be offset by lower long-term costs for SMT in other areas which resulted in lower costs to Medicare overall. They speculated that the cost offset may have been due to savings resulting from complications associated with opioid use in the OAT group. However, more research is necessary to identify the sources of cost savings associated with use of SMT.

The long-term savings suggested in this study, combined with the fact that only 23% of this cohort received SMT initially, represents a huge potential savings for Medicare associated with the use of SMT! Remember, looking at the cost of care is only one aspect, we have to remain cognizant of the impact treatment decisions can have on the general health of patients over time and their risk exposure, which in this case would favor SMT dramatically over opioid therapy.

Study Methods:

This was retrospective analysis of outcomes in representative samples of Medicare claims data. A cohort design was used to evaluate the comparative costs of OAT versus SMT in the management of cLBP in older adults.

The study population included fee-for-service Medicare beneficiaries aged 65 to 84 years who resided in the US and were continuously enrolled under Medicare Parts A, B, and D from 2012 through 2016.

Participants must have had an episode of cLBP, defined as occurring with the recording of 2 paid claims with a primary diagnosis of LBP at least 90 days but less than 180 days apart. Claims were included if they involved outpatient office visits from clinicians that specialized in general practice, family practice, internal medicine, osteopathic manipulative medicine, physical medicine and rehabilitation, chiropractic, physical therapist in private practice, or pain management. Participants diagnosed with cancer or in hospice care were excluded, as well as those over the age of 84.

The 2 cohorts were comprised of patients who initiated long-term management of cLBP with either SMT or OAT. Long-term management via SMT for LBP was defined as ≥ 12 office visits in any 12-month period involving at least 1 visit per month. Long-term management via OAT was defined as 6 or more standard 30-day supply prescription fills in a 12-month period.

Study Strengths / Weaknesses:

This was a well-done observational study that retrospectively analyzed health claims data. As mentioned by the authors, however, this type of research has several limitations, including:
  • Inconsistencies in billing practices
  • Inconsistencies in coding of procedures and diagnoses
  • Lack of diagnoses in prescription drug claims
  • Lack of specific clinical findings (specifically pain severity, see below)
There were more severe and comorbid conditions in the OAT cohort (ex. spondylolisthesis, radiculopathy, spinal stenosis, hip or knee OA, depression) and no indicator of pain severity was available for either cohort. Several of the comorbid conditions (osteoarthritis of the knee and hip, as well as fibromyalgia and depressive disorder) were controlled for, though radiculopathy, spondylolisthesis and spinal stenosis were not. Participants with a diagnosis of cancer or use of hospice care were excluded.

Additional References:

  1. Martin BI, Turner JA, Mirza SK et al. Trends in health care expenditures, utilization, and health status among US adults with spine problems, 1997-2006. Spine 2009; 34(19): 2077-2084.
  2. Ong KL, Stoner KE, Yun BM, Lau E, Edidin AA. Baseline and postfusion opioid burden for patients with low back pain. Am J Manag Care 2018; 24(8): e234-e240.
  3. Abdel Shaheed C, Maher CG, Williams KA, Day R, McLachlan AJ. Efficacy, tolerability, and dose-dependent effects of opioid analgesics for low back pain: a systematic review and meta-analysis. JAMA Intern Med 2016; 176(7): 958-968.
  4. Fleming MF, Balousek SL, Klessig CL, Mundt MP, Brown DD. Substance use disorders in a primary care sample receiving daily opioid therapy. J Pain 2007; 8(7): 573-582.
  5. Boscarino JA, Rukstalis M, Hoffman SN, et al. Risk factors for drug dependence among out-patients on opioid therapy in a large US health-care system. Addiction 2010; 105(10): 1776-82.
  6. Kidner CL, Mayer TG, Gatchel RJ. Higher opioid doses predict poorer functional outcome in patients with chronic disabling occupational musculoskeletal disorders. J Bone Joint Surg Am 2009; 91(4): 919-927.
  7. Whedon J, Goehl J, Toler A, Kazal L. Association between utilization of chiropractic services for treatment of low back pain and risk of adverse drug events. J Manipulative Physiol Ther 2018; 41(5): 383-8.
  8. Qaseem A, Wilt TJ, McLean RM, Forciea MA. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2017; 166(7): 514-530.
  9. Weeks WB, Leininger B, Whedon JM, et al. The association between use of chiropractic care and costs of care among older Medicare patients with chronic low back pain and multiple comorbidities. J Manipulative Physiol Ther 2016; 39(2): 63-75.

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