Papers of the Week

Nonpharmacologic approaches are recommended as first-line treatment for chronic pain and their importance is heightened among individuals with cooccurring opioid use disorder (OUD), in whom opioid therapies may be particularly detrimental. Our objectives were to assess the receipt and trajectories of nonpharmacologic pain treatment and determine the association of OUD diagnosis with these trajectories. This retrospective cohort study used Medicare claims data from 2016-2018 and applied group-based trajectory models to identify distinct patterns of physical therapy (PT) or chiropractic care treatment over the 12 months following a new episode of chronic low back pain. We used logistic regression models to estimate the association of cooccurring OUD with group membership in PT and chiropractic trajectories. Our sample comprised 607,729 beneficiaries at least 18 years of age, of whom 11.4% had a diagnosis of OUD. The 12-month prevalence of PT and chiropractic treatment receipt was 24.7% and 27.1%; respectively, and lower among Medicare beneficiaries with cooccurring OUD (PT: 14.6%; chiropractic: 6.8%). The final models identified three distinct trajectories each for PT (no/little use [76.6% of sample], delayed and increasing use [8.2%], and early and declining use [15.2%]); and chiropractic (no/little use [75.0% of sample], early and declining use [17.3%], and early and sustained use [7.7%]). People with OUD were more likely to belong in trajectories with little/no PT or chiropractic care as compared to other trajectories. The findings indicate that people with cooccurring chronic pain and OUD often do not receive early or any nonpharmacologic pain therapies as recommended by practice guidelines. PERSPECTIVE: Physical therapy and chiropractic care use was low overall and even lower among Medicare beneficiaries with co-occurring OUD compared with those without OUD. As updated guidelines on pain management are promulgated, targeted interventions (e.g., insurance policy, provider and patient education) are needed to ensure equitable access to guideline-recommended pain therapies.