Papers of the Week

Neuropathy, headache, and low back pain (LBP) are common conditions requiring pain management. Yet little is known regarding whether access to specialists impacts opioid prescribing. We aimed to identify factors associated with opioid initiation among opioid-naïve older adults and evaluate how access to particular specialists impacts prescribing. This retrospective cohort study used a 20% Medicare sample from 2010-2017. Opioid initiation was defined by a first opioid prescription filled within 12 months after a diagnosis encounter. Disease-related opioid initiation was defined by a first opioid prescription filled within 7 days following a disease-specific claim. Logistic regression using generalized estimating equations was used to determine the association of patient demographics, provider types, and regional physician specialty density with disease-related opioid initiation, accounting for within-region correlation. We found opioid initiation steadily declined from 2010-2017 (neuropathy:26% to 19%, headache:31% to 20%, LBP:45% to 32%) as did disease-related opioid initiation (4% to 3%, 12% to 7%, 29% to 19%) and 5-10% of initial disease-related prescriptions resulted in chronic opioid use within 12 months of initiation. Certain specialist visits were associated with lower likelihood of disease-related opioid initiation compared with primary care. Residence in high neurologist density regions had lower likelihood of disease-related opioid initiation (headache OR 0.76[95%CI:0.63-0.92]) and LBP (OR 0.7[95%CI:0.61-0.81]), and high podiatrist density regions for neuropathy (OR 0.56[95%CI:0.41-0.78]). We found that specialist visits and greater access to specialists were associated with lower likelihood of disease-related opioid initiation. These data could inform strategies to perpetuate reductions in opioid use for these common pain conditions. PERSPECTIVE: This article presents how opioid initiation for opioid-naïve patients with newly diagnosed neuropathy, headache, and low back pain varies across providers. Greater access to certain specialists decreased the likelihood of opioid initiation. Future work may consider interventions to support alternative treatments and better access to specialists in low density regions.