Study Explores Clinical Management of New Cases of Musculoskeletal Pain

An analysis of data from 360,000 health care visits over a 9-year period indicated that contrary to practice guidelines for managing musculoskeletal pain, many patients are initially prescribed opioids for a new chronic musculoskeletal problem. The analysis showed that opioid prescription was double that of physical therapy and that physicians who employ electronic medical records (EMRs) were more likely to prescribe opioids than physicians who use paper records. The study, conducted by the National Center for Complementary and Integrative Health (part of the National Institutes of Health), the Université de Montréal, and McMaster University was recently published in the Journal of Pain.

The scientists who conducted the study analyzed data from the National Ambulatory Medical Care Survey (2007-2015), identifying health care provider visits by people diagnosed with a new diagnosis for a chronic musculoskeletal pain condition using predetermined ICD-9 codes. The analysis looked at prescribed treatments at the first visit for likely chronic musculoskeletal pain.

The authors point out that using the EMR may decrease prescribing errors and the need for communication between the physician and pharmacist. They say whether the EMR is associated with more appropriate prescribing needs to be verified in future research.

Drug treatments were the most often prescribed therapies, and opioids were prescribed at 21.5 percent of initial visits for chronic musculoskeletal pain. (Other medications were prescribed at 40.2 percent of visits, with NSAIDs prescribed at 31.1 percent of visits.) Counseling was the most frequently prescribed (15.2 percent of visits) nonpharmacologic treatment. (Counseling included the areas of mental health, exercise, diet/nutrition, and weight reduction and was often done by the clinicians themselves.) Other nondrug treatments prescribed were injury prevention (4.9 percent of visits), casts/splints/wraps (3 percent), psychotherapy (0.14 percent), and stress management (0.9 percent). Providers also prescribed complementary and alternative medicine (6 percent of visits) and physical therapy (10 percent of visits).

The only race/ethnicity components occurred with opioid prescribing practices and counseling. Non-Hispanic whites were more likely to be prescribed opioids, while counseling was prescribed more for non-Hispanic blacks. Smoking status also affected prescribing practices—current tobacco users were more likely to get opioid prescriptions while nonsmokers were more likely to get prescritpions for non-opioid medications.

The scientists also noted: prescriptions for non-opioid medications tended to increase with patient age; opioid prescriptions peaked for patients between the ages of 25 and 64; and prescriptions for physical therapy decreased with increasing patient age. In addition, orthopedists were less likely than family practice physicians to prescribe drugs for these pain conditions, and they were more likely to prescribe physical therapy. The authors also point out that, per evidence-based quidelines, opioids should not be the first line of treatment, irrespective of preferences, and that opioids should not be recommended for routine management of chronic pain.