Restricted accessResearch articleFirst published online 2025-10
Trends and Disparities in the Use of Opioid,Gabapentinoid,and Nonpharmacologic Pain Therapies Among Medicare Beneficiaries With Acute Low Back Pain,2016–2019
Contemporary practice guidelines recommend nonpharmacologic therapies instead of prescription opioids as first-line treatment for many pain types, including acute low back pain (aLBP). This serial cross-sectional study describes trends in the annual prevalence of physical therapy (PT), chiropractic care, gabapentinoids, and prescription opioid receipt among Medicare beneficiaries diagnosed with aLBP from 2016 to 2019, overall and within key demographic, clinical, and geographic subgroups. Overall, changes in PT (5.5%–6.7%), chiropractic care (11.0%–11.7%), and gabapentinoid (9.6%–8.9%) receipt were limited, whereas prescription opioid use substantially decreased (26.2%–17.8%). Prescription opioid receipt was higher among individuals under age 65, American Indian/Alaskan Native, non-Hispanic Black/African American, and Hispanic individuals, individuals with opioid use disorder, and in Southern states, while the use of nonpharmacologic pain therapies remained low among these subgroups. It is essential to promote equitable access to multimodal and guideline-recommended approaches for aLBP management including nonpharmacologic therapies.
Allen-WattsK.SimsA. M.BuchananT. L.DeJesusD. J.QuinnT. L.BufordT. W.. . .RumbleD. D. (2022). Sociodemographic differences in pain medication usage and healthcare provider utilization among adults with chronic low back pain. Frontiers in Pain Research, 2, Article 806310.
2.
BeckerW. C.DorflingerL.EdmondS. N.IslamL.HeapyA. A.FraenkelL. (2017). Barriers and facilitators to use of non-pharmacological treatments in chronic pain. BMC Family Practice, 18, 1–8.
3.
BhondoekhanF.MarshallB. D.ShiremanT. I.TrivediA. N.MerlinJ. S.MoyoP. (2023). Racial and ethnic differences in receipt of nonpharmacologic care for chronic low back pain among Medicare beneficiaries with OUD. JAMA Network Open, 6(9), Article e2333251.
4.
CasazzaB. A. (2012). Diagnosis and treatment of acute low back pain. American Family Physician, 85(4), 343–350.
5.
ChengJ.RutherfordM.SinghV. M. (2020). The HHS pain management best practice inter-agency task force report calls for patient-centered and individualized care. Pain Medicine, 21(1), 1–3.
6.
ChengT.D’AmicoS.LuoM.LestoquoyA. S.Yinusa-NyahkoonL.LairdL. D.GardinerP. M. (2019). Health disparities in access to nonpharmacologic therapies in an urban community. The Journal of Alternative and Complementary Medicine, 25(1), 48–60.
7.
ChoeK.ZinnE.LuK.HoangD.YangL. H. (2023). Impact of COVID-19 pandemic on chronic pain and opioid use in marginalized populations: A scoping review. Frontiers in Public Health, 11, Article 1046683. https://doi.org/10.3389/fpubh.2023.1046683
8.
DowellD.RaganK. R.JonesC. M.BaldwinG. T.ChouR. (2022). CDC clinical practice guideline for prescribing opioids for pain—United States, 2022. MMWR. Recommendations and Reports, 71, 1–95.
9.
FrognerB. K.HarwoodK.AndrillaC. H. A.SchwartzM.PinesJ. M. (2018). Physical therapy as the first point of care to treat low back pain: An instrumental variables approach to estimate impact on opioid prescription, health care utilization, and costs. Health Services Research, 53(6), 4629–4646.
10.
GeorgeS. Z.FritzJ. M.SilfiesS. P.SchneiderM. J.BeneciukJ. M.LentzT. A.. . .NormanK. S. (2021). Interventions for the management of acute and chronic low back pain: Revision 2021. The Journal of Orthopaedic and Sports Physical Therapy, 51(11), CPG1–CPG60. https://doi.org/10.2519/jospt.2021.0304
11.
GiannitrapaniK. F.AhluwaliaS. C.McCaaM.PisciottaM.DobschaS.LorenzK. A. (2018). Barriers to using nonpharmacologic approaches and reducing opioid use in primary care. Pain Medicine, 19(7), 1357–1364.
12.
GoodmanC. W.BrettA. S. (2019). Gabapentinoids for pain: Potential unintended consequences. American Family Physician, 100(11), 672–675.
13.
IvanovaJ. I.BirnbaumH. G.SchillerM.KantorE.JohnstoneB. M.SwindleR. W. (2011). Real-world practice patterns, health-care utilization, and costs in patients with low back pain: The long road to guideline-concordant care. Spine Journal, 11(7), 622–632. https://doi.org/10.1016/j.spinee.2011.03.017
14.
JarrínO. F.NyandegeA. N.GrafovaI. B.DongX.LinH. (2020). Validity of race and ethnicity codes in Medicare administrative data compared with gold-standard self-reported race collected during routine home health care visits. Medical Care, 58(1), e1–e8.
KarosK.McParlandJ. L.BunzliS.DevanH.HirshA.KaposF.. . .Ashton-JamesC. E. (2020). The social threats of COVID-19 for people with chronic pain. Pain, 161(10), 2229–2235. https://doi.org/10.1097/j.pain.0000000000002004
17.
KazisL. E.AmeliO.RothendlerJ.GarrityB.CabralH.McDonoughC.. . .SaperR. (2019). 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, 9(9), Article e028633.
18.
LiouK. T.KorensteinD.MaoJ. J. (2021). Medicare coverage of acupuncture for chronic low back pain: Does it move the needle on the opioid crisis?Journal of General Internal Medicine, 36(2), 527–529. https://doi.org/10.1007/s11606-020-05871-6
19.
LyD. P. (2019). Racial and ethnic disparities in the evaluation and management of pain in the outpatient setting, 2006–2015. Pain Medicine, 20(2), 223–232.
20.
MikoszC. A.ZhangK.HaegerichT.XuL.LosbyJ. L.GreenspanA.. . .DowellD. (2020). Indication-specific opioid prescribing for US patients with Medicaid or private insurance, 2017. JAMA Network Open, 3(5), Article e204514.
21.
MordenN. E.ChynD.WoodA.MearaE. (2021). Racial inequality in prescription opioid receipt—Role of individual health systems. New England Journal of Medicine, 385(4), 342–351.
22.
MordenN. E.MunsonJ. C.CollaC. H.SkinnerJ. S.BynumJ. P.ZhouW.MearaE. (2014). Prescription opioid use among disabled Medicare beneficiaries: Intensity, trends, and regional variation. Medical Care, 52(9), 852–859.
23.
MoyoP.MerlinJ. S.GairolaR.GirardA.ShiremanT. I.TrivediA. N.MarshallB. D. (2024). Association of opioid use disorder diagnosis with management of acute low back pain: A Medicare retrospective cohort analysis. Journal of General Internal Medicine, 39, 2097–2105.
24.
MoyoP.VaillantJ.GirardA.GairolaR.ShiremanT. I.TrivediA. N.. . .MarshallB. D. (2023). Prevalence of opioid and nonopioid pain management therapies among Medicare beneficiaries with musculoskeletal pain conditions from 2016 to 2019. Drug and Alcohol Dependence, 248, 109930.
25.
PaulyN. J.DelcherC.SlavovaS.LindahlE.TalbertJ.FreemanP. R. (2020). Trends in gabapentin prescribing in a commercially insured U.S. adult population, 2009-2016. Journal of Managed Care & Specialty Pharmacy, 26(3), 246–252. https://doi.org/10.18553/jmcp.2020.26.3.246
26.
QaseemA.WiltT. J.McLeanR. M.ForcieaM. A., & Clinical Guidelines Committee of the American College of Physicians. (2017). Noninvasive treatments for acute, subacute, and chronic low back pain: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 166(7), 514–530.
27.
RadresaO.ChaunyJ. M.LavigneG.PietteE.PaquetJ.DaoustR. (2014). Current views on acute to chronic pain transition in post-traumatic patients: Risk factors and potential for pre-emptive treatments. Journal of Trauma and Acute Care Surgery, 76(4), 1142–1150.
28.
SandbrinkF.MurphyJ. L.JohanssonM.OlsonJ. L.EdensE.Clinton-LontJ., . . . VA/DoD Guideline Development Group. (2023). The use of opioids in the management of chronic pain: Synopsis of the 2022 updated U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline. Annals of Internal Medicine, 176(3), 388–397. https://doi.org/10.7326/M22-2917
29.
ShoffC.YangT. C.ShawB. A. (2021). Trends in opioid use disorder among older adults: Analyzing Medicare data, 2013–2018. American Journal of Preventive Medicine, 60(6), 850–855.
StevansJ. M.DelittoA.KhojaS. S.PattersonC. G.SmithC. N.SchneiderM. J.. . .SaperR. B. (2021). Risk factors associated with transition from acute to chronic low back pain in US patients seeking primary care. JAMA Network Open, 4(2), Article e2037371. https://doi.org/10.1001/jamanetworkopen.2020.37371
32.
ThackerayA.HessR.DoriusJ.BrodkeD.FritzJ. (2017). Relationship of opioid prescriptions to physical therapy referral and participation for Medicaid patients with new-onset low back pain. The Journal of the American Board of Family Medicine, 30(6), 784–794.
33.
TurnerH. N.OliverJ.ComptonP.MattelianoD.SowiczT. J.StrobbeS.. . .WilsonM. (2022). Pain management and risks associated with substance use: Practice recommendations. Pain Management Nursing: Official Journal of the American Society of Pain Management Nurses, 23(2), 91–108. https://doi.org/10.1016/j.pmn.2021.11.002
34.
VolkowN. D.McLellanA. T. (2016). Opioid abuse in chronic pain—Misconceptions and mitigation strategies. New England Journal of Medicine, 374(13), 1253–1263.
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