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The American Journal of Managed Care August 2018
Impact of a Medical Home Model on Costs and Utilization Among Comorbid HIV-Positive Medicaid Patients
Paul Crits-Christoph, PhD; Robert Gallop, PhD; Elizabeth Noll, PhD; Aileen Rothbard, ScD; Caroline K. Diehl, BS; Mary Beth Connolly Gibbons, PhD; Robert Gross, MD, MSCE; and Karin V. Rhodes, MD, MS
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Andrew M. Heekin, PhD; John Kontor, MD; Harry C. Sax, MD; Michelle S. Keller, MPH; Anne Wellington, BA; and Scott Weingarten, MD
Precision Medicine and Sharing Medical Data in Real Time: Opportunities and Barriers
Y. Tony Yang, ScD, and Brian Chen, PhD, JD
Levers to Reduce Use of Unnecessary Services: Creating Needed Headroom to Enhance Spending on Evidence-Based Care
Michael Budros, MPH, MPP, and A. Mark Fendrick, MD
Optimizing Number and Timing of Appointment Reminders: A Randomized Trial
John F. Steiner, MD, MPH; Michael R. Shainline, MS, MBA; Jennifer Z. Dahlgren, MS; Alan Kroll, MSPT, MBA; and Stan Xu, PhD
Impact of After-Hours Telemedicine on Hospitalizations in a Skilled Nursing Facility
David Chess, MD; John J. Whitman, MBA; Diane Croll, DNP; and Richard Stefanacci, DO
Currently Reading
Baseline and Postfusion Opioid Burden for Patients With Low Back Pain
Kevin L. Ong, PhD; Kirsten E. Stoner, PhD; B. Min Yun, PhD; Edmund Lau, MS; and Avram A. Edidin, PhD
Evaluating HCV Screening, Linkage to Care, and Treatment Across Insurers
Karen Mulligan, PhD; Jeffrey Sullivan, MS; Lara Yoon, MPH; Jacki Chou, MPP, MPL; and Karen Van Nuys, PhD
Reducing Coprescriptions of Benzodiazepines and Opioids in a Veteran Population
Ramona Shayegani, PharmD; Mary Jo Pugh, PhD; William Kazanis, MS; and G. Lucy Wilkening, PharmD
Medicare Advantage Enrollees’ Use of Nursing Homes: Trends and Nursing Home Characteristics
Hye-Young Jung, PhD; Qijuan Li, PhD; Momotazur Rahman, PhD; and Vincent Mor, PhD

Baseline and Postfusion Opioid Burden for Patients With Low Back Pain

Kevin L. Ong, PhD; Kirsten E. Stoner, PhD; B. Min Yun, PhD; Edmund Lau, MS; and Avram A. Edidin, PhD
Patients with low back pain have a high opioid burden, which increases following spinal fusion surgery; 27% of fusion patients filled opioid prescriptions at least 12 months post surgery.
ABSTRACT

Objectives: To evaluate opioid usage patterns for patients with low back pain (LBP) with and without spinal fusion surgery (fusion patients and nonfusion patients, respectively), including long-term prescriptions post fusion.

Study Design: Claims data of outpatient pharmaceutical prescriptions from privately insured patients.

Methods: The 3-year utilization, cost, and morphine milligram equivalents (MME) of opioid prescriptions were evaluated for patients with LBP with and without lumbar fusion. For fusion patients, opioid prescriptions before and after fusion, as well as prescription use 3, 6, and 12 months following fusion surgery, were analyzed.

Results: Thirty-one percent of patients with LBP had opioid prescriptions within the first 6 months of initial diagnosis, which increased to 42.1% within 3 years. More than twice as many fusion patients as nonfusion patients filled opioid prescriptions (87.2% vs 41.5%; P <.001). Fusion patients had 62% and 48% more days with opioid dosages of at least 50 and at least 90 MME/day, respectively, than nonfusion patients (≥50 MME/day, 84 days vs 52 days; ≥90 MME/day, 50 days vs 34 days; both P <.001). Opioid burden was greater for fusion patients following surgery. Fusion patients continued to have 2 months’ supply with at least 50 MME/day and 1 month’s supply with at least 90 MME/day at least 12 months following surgery.

Conclusions: The opioid burden in the LBP population is high and is further elevated in those who subsequently undergo fusion surgery. Long-term opioid prescriptions persisted in 27% of fusion patients 12 months post surgery. Efforts to identify efficacious alternative therapies to treat LBP may reduce the societal burden of chronic opioid use.

Am J Manag Care. 2018;24(8):e234-e240
Takeaway Points

Patients with low back pain (LBP) have a high opioid burden, which increases following fusion surgery; 27% of patients who underwent fusion surgery (fusion patients) filled opioid prescriptions at least 12 months post surgery.
  • Within 3 years after diagnosis, 42.1% of patients with LBP had opioid medications.
  • Patients who did not undergo fusion surgery had opioid dosages of at least 50 and at least 90 morphine milligram equivalents (MME) per day on a mean of 52 and 34 days per patient, respectively.
  • Fusion patients had opioid dosages of at least 50 and at least 90 MME/day on a mean of 84 and 50 days per patient, respectively.
  • Fusion patients continued to have 2 months’ supply with at least 50 MME/day and 1 month’s supply with at least 90 MME/day at least 12 months following surgery.
Low back pain (LBP) is among the most prevalent and costly musculoskeletal conditions and is the second most common reason for physician visits in the United States.1 The economic burden of LBP in the United States is between $84 billion and $625 billion, with significantly higher medical costs for patients with LBP than those without.1 Despite the prevalence of LBP, there are inconsistent recommendations for treating this ailment.2,3 Treatment options include nonsurgical and surgical approaches.2 Nonsurgical treatments commonly include physical therapy, exercise-based multidisciplinary rehabilitation programs, and analgesics, such as nonsteroidal anti-inflammatory drugs, antidepressants, anticonvulsants, and opioids.

Opioids are the most common class of analgesic medication prescribed for chronic LBP,4 and patients with chronic LBP have significantly greater opioid use than those without.1,5 Opioids have shown short-term analgesic efficacy for LBP, but their long-term efficacy is unclear.6-8 Some loss of long-term efficacy could stem from drug tolerance and emergence of hyperalgesia.7 Opioid use for LBP has also been associated with greater disability after 6 months.9

Opioid use is not only ubiquitous among hospitalized patients undergoing surgical procedures,10 but it is also common in many nonsurgical encounters.11 The elevated use of opioids appears to contribute to increased misuse.12 Moreover, opioid use has been linked to adverse events,10,11,13 which can lead to longer hospital stays, higher costs, readmissions, and mortality.10,13 Complications of opioid use for LBP include addiction and overdose-related mortality, which have risen along with prescription rates.7

As a reaction to the increased prescription rates in the United States, the CDC published guidelines in 2016 on prescribing opioids for chronic pain.14,15 The guidelines expressed that clinicians need to carefully reassess evidence of individual benefits and risks when increasing opioid dosage to at least 50 morphine milligram equivalents (MME) per day. They also recommend avoiding or carefully justifying a decision for dosing at least 90 MME/day. These recommendations were driven, in part, by the risk of overdose doubling at a dosage of between 50 and 99 MME/day, and increasing by up to 9 times at 100 MME/day or more, compared with the risk at less than 20 MME/day. Moreover, in a study of patients with chronic pain receiving opioids, patients who died of opioid overdose were prescribed higher opioid dosages than controls (average, 98 vs 48 MME/day).14

One surgical option for treating LBP is spinal fusion.2,16 However, many patients with LBP still continue to experience pain 1 to 8 years following the surgery.16 Lumbar fusion surgery is also associated with long-term analgesic medication use.17 Postoperative opioid usage may also be influenced by preoperative use; those who take opioids prior to surgery may have higher peri- or postoperative narcotic consumption.18-21 Moreover, greater healthcare costs are associated with patients with LBP who chronically use opioids after spinal fusion.19

With the prevalence of LBP, along with the growing societal burden of opioid use, this study aims to address the following hypotheses: (1) The majority of patients with LBP are prescribed opioids, (2) opioid prescriptions are higher for patients with LBP who undergo spinal fusion surgery (fusion surgery vs no fusion surgery; post fusion surgery vs pre–fusion surgery), and (3) a substantial proportion of spinal fusion surgery patients continue to be prescribed opioids 3, 6, and 12 months following the surgery.


 
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