In the Journals

Early physical therapy linked to decreased opioid use for musculoskeletal pain

Eric Sun, MD, PhD
Eric Sun

Early physical therapy among patients with musculoskeletal pain — particularly those with shoulder, knee or lower back pain — is associated with reduced longer-term, and lower intensity, use of opioids, according to data published on the JAMA Open Network.

“Given the recent convergence in national priorities, a broader investigation of nonpharmacologic pain management for [low back pain] and other prevalent types of musculoskeletal pain, such as neck and knee pain, is warranted,” Eric Sun, MD, PhD, of the Stanford University School of Medicine, and colleagues wrote.

In an interview with Healio Rheumatology, Sun noted that this analysis is especially important “because musculoskeletal pain is a fairly common condition that affects many adults. A particularly salient concern is that patients with musculoskeletal pain may be at higher risk for longer-term opioid use.”

To evaluate the association between early physical therapy and later opioid use among patients with new musculoskeletal pain, Sun and colleagues conducted a cross-sectional study of health insurance claims data from the IBM MarketScan Commercial database, for dates between Jan. 1, 2007, and Dec. 31, 2015.

Data included information on privately insured patients across the United States who presented with musculoskeletal pain to an outpatient facility or ED from Jan. 1, 2008, to Dec. 31, 2014. The researchers analyzed data on 88,985 patients with musculoskeletal shoulder, neck, knee or lower-back pain aged 18 to 64 years, who had not yet taken any opioid medication.

The data also included person-level IDC-9 or -10 diagnosis codes, Current Procedural Terminology codes, the date of service and pharmaceutical information. The researchers defined early physical therapy as at least one session within 90 days of the index date. The primary outcome was opioid use between 91 and 365 days following the index date. Data analysis was performed from March 1 to May 18, 2018.

According to the researchers, 29.3% of the analyzed patients received early physical therapy. After adjusting for potential confounders, early physical therapy was associated with a statistically significant decrease in the incidence of opioid use between 91 and 365 days follow the index date among patients with shoulder pain (OR = 0.85; 95% CI, 0.77-0.95), neck pain (OR = 0.92; 95% CI, 0.85-0.99), knee pain (OR = 0.84; 95% CI, 0.77-0.91) and lower-back pain (OR = 0.93; 95% CI, 0.88-0.98).

Among patients who ultimately received opioids during that time, early physical therapy was associated with an approximately 10% reduction in the amount of opioid use — measured in oral morphine milligram equivalents — for shoulder pain (P = .03), knee pain (P = .007) and lower-back pain (P = .046), but not for neck pain (P = .3).

“The key takeaway is that early physical therapy is associated with decreased risk for long-term opioid use among patients with musculoskeletal pain [in the shoulder, knee and low back], suggesting that clinicians should encourage early physical therapy for these patients,” Sun told Healio Rheumatology.

However, Sun and colleagues noted that “the same protective association was not identified for the intensity of opioid use in patients, particularly in patients with neck pain.” The researchers indicated that further research would be needed to determine why early physical therapy did not alleviate long-term opioid use for neck pain, as well as what services could be used in its place. – by Jason Laday

Disclosure: Sun reports grants from the National Institute on Drug Abuse, as well as consulting fees from Egalet Inc. and the Mission Lisa Foundation. Please see the study for all other authors’ relevant financial disclosures.

Eric Sun, MD, PhD
Eric Sun

Early physical therapy among patients with musculoskeletal pain — particularly those with shoulder, knee or lower back pain — is associated with reduced longer-term, and lower intensity, use of opioids, according to data published on the JAMA Open Network.

“Given the recent convergence in national priorities, a broader investigation of nonpharmacologic pain management for [low back pain] and other prevalent types of musculoskeletal pain, such as neck and knee pain, is warranted,” Eric Sun, MD, PhD, of the Stanford University School of Medicine, and colleagues wrote.

In an interview with Healio Rheumatology, Sun noted that this analysis is especially important “because musculoskeletal pain is a fairly common condition that affects many adults. A particularly salient concern is that patients with musculoskeletal pain may be at higher risk for longer-term opioid use.”

To evaluate the association between early physical therapy and later opioid use among patients with new musculoskeletal pain, Sun and colleagues conducted a cross-sectional study of health insurance claims data from the IBM MarketScan Commercial database, for dates between Jan. 1, 2007, and Dec. 31, 2015.

Data included information on privately insured patients across the United States who presented with musculoskeletal pain to an outpatient facility or ED from Jan. 1, 2008, to Dec. 31, 2014. The researchers analyzed data on 88,985 patients with musculoskeletal shoulder, neck, knee or lower-back pain aged 18 to 64 years, who had not yet taken any opioid medication.

The data also included person-level IDC-9 or -10 diagnosis codes, Current Procedural Terminology codes, the date of service and pharmaceutical information. The researchers defined early physical therapy as at least one session within 90 days of the index date. The primary outcome was opioid use between 91 and 365 days following the index date. Data analysis was performed from March 1 to May 18, 2018.

According to the researchers, 29.3% of the analyzed patients received early physical therapy. After adjusting for potential confounders, early physical therapy was associated with a statistically significant decrease in the incidence of opioid use between 91 and 365 days follow the index date among patients with shoulder pain (OR = 0.85; 95% CI, 0.77-0.95), neck pain (OR = 0.92; 95% CI, 0.85-0.99), knee pain (OR = 0.84; 95% CI, 0.77-0.91) and lower-back pain (OR = 0.93; 95% CI, 0.88-0.98).

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Among patients who ultimately received opioids during that time, early physical therapy was associated with an approximately 10% reduction in the amount of opioid use — measured in oral morphine milligram equivalents — for shoulder pain (P = .03), knee pain (P = .007) and lower-back pain (P = .046), but not for neck pain (P = .3).

“The key takeaway is that early physical therapy is associated with decreased risk for long-term opioid use among patients with musculoskeletal pain [in the shoulder, knee and low back], suggesting that clinicians should encourage early physical therapy for these patients,” Sun told Healio Rheumatology.

However, Sun and colleagues noted that “the same protective association was not identified for the intensity of opioid use in patients, particularly in patients with neck pain.” The researchers indicated that further research would be needed to determine why early physical therapy did not alleviate long-term opioid use for neck pain, as well as what services could be used in its place. – by Jason Laday

Disclosure: Sun reports grants from the National Institute on Drug Abuse, as well as consulting fees from Egalet Inc. and the Mission Lisa Foundation. Please see the study for all other authors’ relevant financial disclosures.