Initial healthcare provider and opioid use in LBP?

Stimulated by Kazis et al 2019.[1]

Photo by Aiony Haust on Unsplash.
This photo was chosen to represent opioids being used on back pain because the first naturally occurring opioids were discovered in a flower. Yes, it is a shame (for my purposes here) that this artistic photographer did not use poppies :-). I am sure some will interpret this photo in other ways, but my focus was the flowers and the gestalt aesthetic.

This paper popped up on my PubMed searches yesterday morning, and I had a quick look at the abstract whilst walking from Paddington to the NCVO for one of our big London courses. It seemed interesting and topical but the abstract did not mention acupuncture at all, so I wasn’t sure it would be suitable to highlight here. But I was wrong!

This is another huge retrospective observational study using health insurance data, rather like those I have previously highlighted on this blog from Taiwan and Korea under the ‘big data‘ category. This one is from the US and involves 216 504 opioid-naïve patients with new-onset low back pain (LBP) diagnosed between 2008 and 2013. The study looked at the association between the initial healthcare provider (IHP) and opioid use (short-term and long-term).

The authors introduce the problem of opioid use in the USA by quoting some shocking figures: 12 million Americans with long-term opioid use or misuse in 2015; 42 000 prescription opioid-related deaths in 2016; a total estimated cost of prescription opioid use reaching $78.5 billion. They go on to say that LBP is one of the most common conditions for which opioids are prescribed.

Their results show that short-term use of opioids in their sample was 22%. But the big news was that patients who received their initial treatment from chiropractors or physical therapists had substantially reduced odds of short-term and long-term opioid use compared with those who received initial treatment from primary care physicians – an order of magnitude difference!

But what about the acupuncture I hear you cry! Well you have to look at the full table of results to see the IHP acupuncture figures. They were not highlighted in the abstract because the numbers were relatively low – only 0.8% of the sample (just under 2000 patients) saw an acupuncturist as their initial healthcare provider. Here are the results expressed as odds ratios compared with the rates when the IHP was a primary care physician:

Section of Table 2 from Kazis et al 2019.[1]

Whilst the number of patients seen initially for acupuncture is relatively small, the odds ratio for long-term opioid use is one third of that for the chiropractors, which are the next best group in this outcome. Of course in the world of the BMAS we train all of these IHPs to use acupuncture techniques, so whatever you call yourself you can have an alternative to letting your patient start on opioids for their back pain.

The bottom line:

Going for acupuncture as a first step when you get back pain may be associated with the lowest risk of ending up on opioid medication.


1         Kazis LE, Ameli O, Rothendler J, et al. Observational retrospective study of the association of initial healthcare provider for new-onset low back pain with early and long-term opioid use. BMJ Open 2019;9:e028633. doi:10.1136/bmjopen-2018-028633

Declaration of interests MC