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FOTO Rehab Outcomes Blog

Can Physical Therapists Play a Role in Decreasing Opioid Use?

Did you see the buzz last Friday investigating early physical therapy intervention and reduction in opioid use? JAMA Network Open published the results after analyzing claims data.

opioids-physical-therapyI truly appreciated this particular investigation. From my perspective it was great to see leading physical therapist researchers teamed up with investigators outside of the physical therapist profession. The other aspect that I liked was the use of real data from real medical claims.  This study was also a bit different because it used IBM Watson Health - in particular MarketScan. Although it was clear that the patients included in the study were 18-64 years of age, what was not clear was what claims were included in the database other than commercial claims. I do not know if the data within the database represented the nation. The plans included for analysis were the preferred provider organizations or traditional indemnity plans with prescription drug coverage. 

This investigation eliminated anyone who had been prescribed a narcotic within the previous 12 months. The patients analyzed had a recent onset of a musculoskeletal condition. It appeared to me that a thoughtful filtering occurred so that the data focused on people who probably had an acute musculoskeletal condition. The one weakness that I can see is that onset data should have been included in the analysis. We know when the patient went to the emergency room or saw a physician for the musculoskeletal condition - what we do not know is when the patient first had symptoms. A patient could have potentially been someone who actually had a chronic condition but was finally sick and tired of hurting and decided to see a physician or went to the emergency room. The main reason that I mention this is because of the conversations I have with patients and listening to their perspective. Many of my patients wait anywhere from 30-90 days or more before seeking services because they try a do-it-alone or a wait and see approach believing they will improve with time.

One change you will notice was how the investigators defined "early physical therapy." Early physical therapy was defined as the patient receiving at least 1 physical therapy session within 90 days of a claim being generated for an acute musculoskeletal condition.  From other previous studies, I believe that maybe 7-12% of patients are typically referred for physical therapy services. 

If I understood the publication correctly, about 75% of patients who had an acute musculoskeletal condition did not use opioids. I suppose I look on the bright side because I was happy to see that the majority did not use opioids for their condition. For some reason, I was expecting more than 25% of the patients being prescribed an opioid. 

From other previous studies, I believe that maybe 7-12% of patients were typically referred for physical therapy services. An exciting trend noted in the study was the number of patients receiving early physical therapy. The trend changed from 27% in 2008 to 31% in 2014. 

As you will see in the abstract, early physical therapy did result in a reduction in prescribe opioids.

With the growing research demonstrating the value of seeing a physical therapist sooner versus later, it seems that alignment of this value needs to help create the changes needed so that patients do not have to jump through hoops to receive services - meaning real direct access. I wonder what it would be like if the patient financial responsibility was substantially reduced or even free for physical therapy services? Insurance benefit plans need to be adapted to incentivize beneficiary behaviors to seek services from physical therapists. Insurance companies also need to spend time and money promoting physical therapy services. Future studies will need to evolve to include the first touchpoint starting with a physical therapist evaluation.

You'll find the abstract to the recent study below.

Association of Early Physical Therapy With Long-term Opioid Use Among Opioid-Naive Patients With Musculoskeletal Pain



Importance  Nonpharmacologic methods of reducing the risk of new chronic opioid use among patients with musculoskeletal pain are important given the burden of the opioid epidemic in the United States.

Objective  To determine the association between early physical therapy and subsequent opioid use in patients with new musculoskeletal pain diagnosis.

Design, Setting, and Participants  This cross-sectional analysis of health care insurance claims data between January 1, 2007, and December 31, 2015, included privately insured patients who presented with musculoskeletal pain to an outpatient physician office or an emergency department at various US facilities from January 1, 2008, to December 31, 2014. The sample comprised 88 985 opioid-naive patients aged 18 to 64 years with a new diagnosis of musculoskeletal shoulder, neck, knee, or low back pain. The data set (obtained from the IBM MarketScan Commercial database) included person-level International Classification of Diseases, Ninth Revision or Tenth Revision diagnosis codes, Current Procedural Terminology codes, and date of service as well as pharmaceutical information (National Drug Code, generic name, dose, and number of days supplied). Early physical therapy was defined as at least 1 session received within 90 days of the index date, the earliest date a relevant diagnosis was provided. Data analysis was conducted from March 1, 2018, to May 18, 2018.

Main Outcomes and Measures  Opioid use between 91 and 365 days after the index date.

Results  Of the 88 985 patients included, 51 351 (57.7%) were male and 37 634 (42.3%) were female with a mean (SD) age of 46 (11.0) years. Among these patients, 26 096 (29.3%) received early physical therapy. After adjusting for potential confounders, early physical therapy was associated with a statistically significant reduction in the incidence of any opioid use between 91 and 365 days after the index date for patients with shoulder pain (odds ratio [OR], 0.85; 95% CI, 0.77-0.95; P = .003), neck pain (OR, 0.92; 95% CI, 0.85-0.99; P = .03), knee pain (OR, 0.84; 95% CI, 0.77-0.91; P < .001), and low back pain (OR, 0.93; 95% CI, 0.88-0.98; P = .004). For patients who did use opioids, early physical therapy was associated with an approximately 10% statistically significant reduction in the amount of opioid use, measured in oral morphine milligram equivalents, for shoulder pain (−9.7%; 95% CI, −18.5% to −0.8%; P = .03), knee pain (−10.3%; 95% CI, −17.8% to −2.7%; P = .007), and low back pain (−5.1%; 95% CI, −10.2% to 0.0%; P = .046), but not for neck pain (−3.8%; 95% CI, −10.8% to 3.3%; P = .30).

Conclusions and Relevance  Early physical therapy appears to be associated with subsequent reductions in longer-term opioid use and lower-intensity opioid use for all of the musculoskeletal pain regions examined.

Published: December 14, 2018. doi:10.1001/jamanetworkopen.2018.5909

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