The Need for National Guideline Development for Opioid Prescribing for the First

Encounter of Low Back Pain in the Primary Care Setting: Analysis of a Private Payer

Insurance Claims Database

Micheal Raad*, MD, Jina Pakpoor*, MD, Andrew Harris, Varun Puvaresanajah, MD, Joseph

Canner, Khaled Kebaish, MD, Amit Jain, MD

Methods

This study examines opioid prescribing practices among primary care physicians after initial

encounters for low back pain in privately insured patients. The Truven Health

MarketScan® Commercial Claims and Encounters Database, which contains health information

on private-payer insurance beneficiaries from approximately 350 payers was utilized for this

study1. International Classification of Diseases 9th and 10th (ICD-9 724.2 or ICD-10 M54.4)

edition codes were used to identify patients in the outpatient setting presenting for an initial

encounter for isolated low back pain after a 1 year look back period. Patients with other

diagnoses indicating any spinal pathology were excluded. Similarly excluded were patients who

had filled opioid prescriptions in the 90 days prior to their encounter, required opioid forms

indicating more chronic use or those who were seen by a specialist. The primary outcome was

whether an opioid prescription was filled in the 30 days after the visit date. The proportion of

patients with a daily morphine milligram equivalence (MME/day) known to be associated with a

higher risk of over dose was also analyzed2. All proportions were imputed with Truven Health

MarketScan® trends and sampling weights. The Cochran-Armitage trends test was used to

analyze trends over time. Variation between states was analyzed using chi-square test and

caterpillar plots showing 95% logit confidence intervals (CI). Institutional review board approval

was obtained for this study. Significance was set at 0.05.

Results

418,565 patients between January 1 2011 and November 30, 2016 were included in this study.

Age was 44.7 [95% CI: 44.6 – 44.7] and 52.7% [52.6 – 52.9] were women. 25.7% [25.6 – 25.9]

of patients had a filled opioid prescription. Nationally, the proportion of patients with filled

opioid prescriptions declined significantly between 2011 and 2016 (p< 0.01: 28.5% in 2011,
27.6% in 2012, 26.3% in 2013, 25.5% in 2014, 23.5% in 2015, 20.4% in 2016). This decline was

evident across the Northeast, Midwest, South and West. Figure 1. Of those with a filled opioid

prescription, the proportion with > 20MME/day did not significantly change over time (p=0.16).

This varied significantly between the four regions with a decline in the Northeast and South

(p<0.01), no significant change in the Midwest (p=.09) and a rise in the West (p<0.01). Figure 1.

The proportion of patients with a filled opioid prescription varied significantly between the

various states (p<0.01), ranging from 12.9% in Hawaii to 33.6% in Arkansas. Figure 2.
Figure 1. Regional Scatter Plots of the Annual Proportions of Patients with Any filled Opioid

Prescription as well as the Proportion of those with a Filled Prescription Receiving More than 20

MME/day and their associated 95% Logit Confidence Intervals.

A. Northeast
B. Midwest
C. South
D. West
Figure 2. A Caterpillar Plot of the Proportion of Patients with a Filled Opioid Prescription

and the Associated 95% Logit Confidence Interval by Sate.