Long-Term Medicare Costs Associated with Opioid
Analgesic Therapy vs Spinal Manipulative Therapy
for Chronic Low Back Pain in a Cohort of Older Adults

This section is compiled by Frank M. Painter, D.C.
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FROM:   J Manipulative Physiol Ther 2021 (Sep); 44 (7): 519-526 ~ FULL TEXT

James M. Whedon, DC, MSm Anupama Kizhakkeveettil, PhD, Andrew Toler, MS,
Todd A. MacKenzie, PhD, Jon D. Lurie, MD, MS, Serena Bezdjian, PhD,
Scott Haldeman, DC, MD, PhD, Eric Hurwitz, DC, PhD, Ian Coulter, PhD

Health Services Research,
Southern California University of Health Sciences,
Whittier, California.

FROM:   The Facts on Medicare Spending (2019)

Objectives:   The purpose of this study was to compare Medicare healthcare expenditures for patients who received long-term treatment of chronic low back pain (cLBP) with either opioid analgesic therapy (OAT) or spinal manipulative therapy (SMT).

Methods:   We conducted a retrospective observational study using a cohort design for analysis of Medicare claims data. The study population included Medicare beneficiaries enrolled under Medicare Parts A, B, and D from 2012 through 2016. We assembled cohorts of patients who received long-term management of cLBP with OAT or SMT (such as delivered by chiropractic or osteopathic practitioners) and evaluated the comparative effect of OAT vs SMT upon expenditures, using multivariable regression to control for beneficiary characteristics and measures of health status, and propensity score weighting and binning to account for selection bias.

Results:   The study sample totaled 28,160 participants, of whom 77% initiated long-term care of cLBP with OAT, and 23% initiated care with SMT. For care of low back pain specifically, average long-term costs for patients who initiated care with OAT were 58% lower than those who initiated care with SMT. However, overall long-term healthcare expenditures under Medicare were 1.87 times higher for patients who initiated care via OAT compared with those initiated care with SMT (95% CI 1.65-2.11; P < .0001).

Conclusions:   Adults aged 65 to 84 who initiated long-term treatment for chronic low back pain (cLBP) via opioid analgesic therapy (OAT) incurred lower long-term costs for low back pain but higher long-term total healthcare costs under Medicare compared with patients who initiated long-term treatment with spinal manipulative therapy (SMT).

Keywords:   Aged; Analgesics, Opioid; Costs and Cost Analysis; Low Back Pain; Manipulation, Spinal; Medicare.

From the FULL TEXT Article:


      Burden of Low Back Pain Among Older Adults

The crisis of opioid prescribing in the Unites States reflects in part a failure in the management of low back pain (LBP). Low back pain is highly prevalent in the United States and is the most common condition for which opioid analgesics are prescribed. [1] Low back pain is also one of the most common reasons for a physician visit in general, [2] and for older US adults in particular. [3] The point prevalence of nonspecific back pain among older adults is approximately 30%. [4] Older adults often have recurrent episodes of LBP. [5] Between 2000 and 2007, the total number of US adults with chronic low back pain (cLBP) increased by 64%. [6] Spinal pain is the most costly of all medical conditions. [7] A systematic review of LBP cost of illness studies that included 27 studies published between 1997 and 2007 found that direct costs ranged from $12 to $90 billion annually, and indirect costs ranged from $7 to $28 billion annually. [8] Because spine care in the Unites States has shown a decline in positive outcomes despite these rising costs, [9] it is important to assess the comparative value of treatments for cLBP.

      Opioid Analgesic Therapy for LBP

Evidence-based management of LBP for older adults often includes prescription analgesics, including opioids. [10] A recent examination of health claims data found that 31% of patients with LBP received prescriptions for opioid analgesics within the first 6 months of initial diagnosis; within 3 years the percentage increased to 42%. [11] However, although opioid prescribing for LBP is often prolonged, [12] 3 systematic reviews concluded that the long-term effectiveness of opioid therapy for cLBP is unknown. [13–15] The hazards of opioid analgesics are well known, however: the use and misuse of opioid analgesic therapy (OAT) has led to 3.8% of patients developing opioid use disorder, [16] and up to 26% of prescribed patients reporting opioid dependence. [17] In 2018, nearly 70% of US drug overdose deaths involved an opioid, and 46,802 people (128 per day on average) died from opioid-related overdoses. [18] In 2013, the cost of prescription opioid misuse totaled more than $78 billion, and among 6,917 Medicare patients, the additional annual per patient cost associated with diagnosis of opioid abuse or dependence was over $17,000. [19] Furthermore, among patients with a chronic disabling musculoskeletal disorder, higher dosing of opioids correlates with higher pain severity, greater disability, and higher levels of depression. [20] Recent studies suggest that OAT should be used sparingly and with caution for patients with cLBP owing to the risk of adverse effects. [11, 21]

      Spinal Manipulative Therapy for LBP

Nonpharmacological management of spinal pain is associated with decreased use of opioids, [22–25] and the National Academy of Medicine and the Joint Commission on Accreditation of Healthcare Organizations have recommended the use of nonpharmacological therapies as effective alternatives to pharmacotherapy for management of pain. [26, 27] Recent systematic reviews have found spinal manipulative therapy (SMT) to be an effective treatment for cLBP, [28–30] and current clinical guidelines recommend nonpharmacological therapies, including SMT, as a first-line approach to management of LBP. [31]

Chiropractic management of LBP, which often involves treatment with SMT, may offer a safer alternative to analgesic medication: an observational study of adults with LBP found that the likelihood of adverse drug events was significantly lower for recipients of chiropractic care compared with nonrecipients. [20] Among older Medicare beneficiaries with an office visit risk for a neuromusculoskeletal problem, the adjusted risk of injury to the head, neck, or trunk among recipients of SMT was 76% lower compared with recipients of primary care. [32] More recently, a systematic review on the benefits and harms of SMT for treatment of cLBP found limited evidence regarding adverse events. [33]

Thus, there is little cause for concern about the safety of SMT for LBP, but for long-term treatment of cLBP, the overall value of SMT remains uncertain. A series of US government reports based upon medical record reviews found that chiropractors (who provide more than 97% of all SMT services under Medicare [34]) frequently provide excessive and unnecessary SMT, particularly as “maintenance care,” which is provided on an ongoing long-term basis, ostensibly to prevent spinal problems from recurring or worsening. [35–37]

However, the government reports did not follow standardized review methods and failed to consider the value of chiropractic services. [38] It is also uncertain whether SMT offers a cost advantage for management of cLBP. A rigorously designed study that modelled the 1–year cost-effectiveness of adding nonpharmacologic interventions for cLBP to usual care analyzed data from randomized trials of nonpharmacologic therapies, and found that 15 of 17 therapies were cost-effective from the payer perspective, but the results for chiropractic care were less favorable for patients with high-impact chronic pain than for a typical mix of patients. [39]

A study of Medicare claims data found that patients with multiple comorbidities who only used SMT for cLBP had significantly lower costs, [40] and in a quasi-experimental study of over 84,000 older Medicare beneficiaries, Davis et al. found that increased access to chiropractic spinal manipulation was correlated with reduced spine-related costs. [41] However, the comparative value of SMT for older adults with cLBP remains uncertain.

      Cost of Care for cLBP Under Medicare

Owing to the high-cost burden imposed upon the Medicare system by care of patients with cLBP, it is critically important to identify high-value approaches to the treatment of cLBP. Until now, the long-term costs associated with OAT and SMT have not been rigorously compared. Therefore, the purpose of this study was to compare Medicare expenditures for cLBP among recipients of OAT versus SMT. We hypothesized that among older Medicare beneficiaries receiving long-term care for cLBP, initiation of treatment via OAT would be associated with higher costs compared with SMT.


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