@article{10.22454/PRiMER.2026.419119,
author = {Turner, Jamie K. and Grubb, Christopher T. and Britz, Jacqueline B. and Harden, Samantha M. and Hanlon, Alexandra L. and Epling, John W. and Rockwell, Michelle S.},
title = {A Difference-in-Differences Analysis of Low-Value Opioid Utilization for Acute Low Back Pain, 2019-2021},
journal = {PRiMER},
volume = {10},
year = {2026},
month = {9},
doi = {10.22454/PRiMER.2026.419119},
abstract = {Introduction: The use of opioids for acute low-back pain (LBP) is considered low-value in most clinical scenarios. Understanding trends in low-value opioid utilization can inform interventions to support guideline-concordant care. This study evaluated the utilization of low-value opioids for acute LBP, and variation by rurality, payer, and sex, before and during the COVID-19 pandemic.
Methods: In this retrospective cohort study, we examined opioid claims from Virginia’s All-Payer Claims Database among adults with commercial, Medicare Advantage (MA), or Medicaid insurance during 2019–2021. We identified low-value opioid claims for acute LBP and quantified utilization rates per 1,000 patients. Heterogeneous difference-in-differences models generated incidence rate ratios (IRRs) stratified by rurality, payer, and sex to estimate differences between the observed (during-pandemic) and expected (prepandemic) rates.
Results: Among our cohort (n = 853,775), 73.9% of opioids utilized for acute LBP were low-value. Utilization rates declined from 155.0 prescriptions/1,000 patients in 2019 to 107.5 prescriptions/1000 patients in 2021 and were 20.0% lower during the pandemic than expected rates (marginal IRR: 0.80, P = 0.002). Utilization was higher in rural than nonrural areas (marginal IRR: 1.74, P<0.001) without pandemic effect interaction (IRR: 1.02, P = 0.604). The rural effect was smaller for MA beneficiaries (IRR: 0.75, P = 0.046), and larger among males (IRR: 1.25, P<0.001).
Conclusions: The decline in low-value opioid utilization for acute LBP was accelerated during 2020–2021. Utilization was consistently higher in rural than nonrural areas. Findings highlight the need for targeted interventions and policy to reduce low-value opioid utilization, especially in rural areas to ensure equitable, high-value care for acute pain.},
URL = {https://journals.stfm.org//primer/2026/turner-0061/},
eprint = {https://journals.stfm.org//media/m14esteb/primer-2026-0061.pdf},
}