An Examination of Trends in the Rates of Low-Value Opioids Prescribed for Acute Low Back Pain in Rural vs. Non-Rural Virginia

Abstract

Background: The Centers for Disease Control and Prevention (CDC) recommends against the use of prescription opioids for most types of acute pain. Despite these recommendations, some evidence suggests that opioid prescribing for acute low back pain (LBP) - among the most common acute pain complaints - persists. This study evaluated trends in low-value opioid prescribing for acute LBP among patients residing in rural versus non-rural areas of Virginia during 2019-2021 and evaluated the influence of the COVID-19 pandemic timeframe on prescribing rates. Methods: In this retrospective cohort study, we examined insurance claims from the Virginia All-Payer Claims Database for adults continuously enrolled in Medicaid, Medicare Advantage, or commercial plans from 2019 to 2021. We used the Milliman MedInsight Health Waste Calculator to identify low-value claims and calculated annual and bi-monthly prescribing incidence rates per 1000 patients. Heterogeneous difference-in-differences models generated incidence rate ratios (IRRs) to express the difference in the rate of low-value opioids for acute LBP observed during the first two years of the COVID-19 pandemic (2020-2021) versus expected incidence based on the pre-pandemic timeframe (2019). IRRs were stratified by rurality. Results: Among our cohort (n=853,775), 1,338,371 claims for opioids for acute LBP were identified, 73.9% of which were low-value. The annual prescribing of low-value opioids for acute LBP declined by 30.6% from 2019 (155.0 claims per 1000 patients) to 2021 (107.5 claims per 1000 patients) compared with the expected decline (model-predicted) of 18.6% during this period. During 2020-2021, low-value opioid prescribing for acute LBP was 79.6% of expected incidence (IRR: 0.80, p<.001). Low-value opioid prescribing for acute LBP was 0.74 times higher in patients residing in rural versus non-rural areas throughout 2019-2021 (IRR: 1.74, p<.001), and the difference in low-value prescribing between rural and non-rural patients did not change significantly during 2020-2021 (IRR: 1.02, p=.060). Conclusions: Most opioids prescribed for acute LBP among this large, multi-payer Virginia cohort were low-value. The COVID-19 pandemic timeframe (2020-2021) was associated with an accelerated decline in low-value opioid prescribing for acute LBP. Persistent rural disparity in low-value opioid prescribing for acute LBP highlights the need to examine underlying drivers to reduce low-value prescribing and promote equitable, high-quality acute pain care.