Research Article| Volume 21, ISSUE 1-2, P135-145, January 2020

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Predicting Opioid Use, Increased Health Care Utilization and High Costs for Musculoskeletal Pain: What Factors Mediate Pain Intensity and Disability?

  • Trevor A. Lentz
    Address reprint requests to Trevor A. Lentz, PT, PhD, MPH, Duke Clinical Research Institute, Duke University, 200 Morris Street, Durham, NC 27701.
    Department of Orthopaedic Surgery Duke University, Duke Clinical Research Institute, Duke University, Durham, North Carolina
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  • Daniel I. Rhon
    Department of Orthopaedic Surgery Duke University, Duke Clinical Research Institute, Duke University, Durham, North Carolina

    Brooke Army Medical Center, San Antonio, Texas

    Physical Performance Service Line, G3/5/7, Army Office of the Surgeon General, Falls Church, Virginia
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  • Steven Z. George
    Department of Orthopaedic Surgery Duke University, Duke Clinical Research Institute, Duke University, Durham, North Carolina

    Department of Orthopeadic Surgery, Duke University, Durham, North Carolina
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      • Pain intensity and disability predict 12-month pain-related utilization and costs.
      • Mediation effects are outcome-specific, and more consistent for cost outcomes.
      • Baseline pain intensity may drive volume of health care, including opioid use.
      • Elevated catastrophizing and symptom distribution may drive higher cost service use.


      This study determined the predictive capabilities of pain intensity and disability on health care utilization (number of condition-specific health care visits, incident, and chronic opioid use) and costs (total condition-specific and overall medical costs) in the year following an initial evaluation for musculoskeletal pain. We explored pain catastrophizing and spatial distribution of symptoms (ie, body diagram symptom score) as mediators of these relationships. Two hundred eighty-three military service members receiving initial care for a musculoskeletal injury completed a region-specific disability measure, numeric pain rating scale, Pain Catastrophizing Scale, and body pain diagram. Pain intensity predicted all outcomes, while disability predicted incident opioid use only. No mediation effects were observed for either opioid use outcome, while pain catastrophizing partially mediated the relationship between pain intensity and number of health care visits. Pain catastrophizing and spatial distribution of symptoms fully mediated the relationship between pain intensity and both cost outcomes. The mediation effects of pain catastrophizing and spatial distribution of symptoms are outcome specific, and more consistently observed for cost outcomes. Higher pain intensity may drive more condition-specific health care utilization and use of opioids, while higher catastrophizing and larger spatial distribution of symptoms may drive higher costs for services received.


      This article examines underlying characteristics that help explain relationships between pain intensity and disability, and the outcomes of health care utilization and costs. Health care systems can use these findings to refine value-based prediction models by considering factors that differentially influence outcomes for health care use and cost of services.

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