Study Design. A descriptive analysis of secondary data. Objective. The aim of this study was to estimate health care costs and opioid use for those with high-impact chronic spinal (back and neck) pain. Summary of Background Data. The US National Pain Strategy introduced a focus on high-impact chronic pain—that is, chronic pain associated with work, social, and self-care restrictions. Chronic neck and low-back pain are common, costly, and associated with long-term opioid use. Although chronic pain is not homogenous, most estimates of its costs are averages that ignore severity (impact). Methods. We used 2003 to 2015 Medical Expenditures Panel Survey (MEPS) data to identify individuals with chronic spinal pain, their health care expenditures, and use of opioids. We developed prediction models to identify those with high- versus moderate- and low-impact chronic spinal pain based on the variables available in MEPS. Results. We found that overall and spine-related health care costs, and the use and dosage of opioids increased significantly with chronic pain impact levels. Overall and spine-related annual per person health care costs for those with high-impact chronic pain ($14,661 SE: $814; and $5979 SE: $471, respectively) were more than double that of those with low-impact, but still clinically significant, chronic pain ($6371 SE: $557; and $2300 SE: $328). Those with high-impact chronic spinal pain also use spine-related opioids at a rate almost four times that of those with low-impact pain (48.4% vs. 12.4%), and on average use over five times the morphine equivalent daily dose (MEDD) in mg (15.3 SE: 1.4 vs. 2.7 SE: 0.6). Opioid use and dosing increased significantly across years, but the increase in inflation-adjusted health care costs was not statistically significant. Conclusion. Although most studies of chronic spinal pain do not differentiate participants by the impact of their chronic pain, these estimates highlight the importance of identifying chronic pain levels and focusing on those with high-impact chronic pain. Level of Evidence: 3

Limited Print and Electronic Distribution RightsThis document and trademark(s) contained herein are protected by law. This representation of RAND intellectual property is provided for noncommercial use only. Unauthorized posting of this publication online is prohibited. Permission is given to duplicate this document for personal use only, as long as it is unaltered and complete. Permission is required from RAND to reproduce, or reuse in another form, any of its research documents for commercial use. For information on reprint and linking permissions, please visit www.rand.org/pubs/permissions. The RAND Corporation is a research organization that develops solutions to public policy challenges to help make communities throughout the world safer and more secure, healthier and more prosperous. RAND is nonprofit, nonpartisan, and committed to the public interest. RAND's publications do not necessarily reflect the opinions of its research clients and sponsors.Support RAND Make a tax-deductible charitable contribution at www.rand.org/giving/contribute www.rand.org For more information on this publication, visit www.rand.org/t/RR2807Published by the RAND Corporation, Santa Monica, Calif.R® is a registered trademark.iii Preface This report is the second in a series of four RAND reports sponsored by the California Department of Industrial Relations as part of a regular effort to monitor the wage losses of injured workers in the California workers' compensation system between 2013 and 2017. This report focuses on earnings losses for workers injured in 2014-2015 and compares these worker outcomes to those for workers who were injured before, during, and after the Great Recession. In addition to quantifying wage loss for the 2014-2015 injury cohort and producing aggregated trends in wage loss over time, the report also analyzes trends for key subgroups of interest in the workers' compensation system, including analyses by receipt of indemnity benefits, industry, type of injury, and geographic region.This report builds on prior RAND research analyzing wage loss for injured workers in California. While that research has tended to focus on workers with permanent disabilities, this report presents trends for all injured workers in the system, as well as trends for all workers with indemnity benefits. Numerous recent changes in California, including the implementation of major reforms to the workers' compensation system and a long and sustained economic recovery following the Great Recession, motivate the need to gather an accurate and up-to-date estimate of wage loss for all injured workers in the state. RAND Institute for Civil JusticeThe RAND Institute for Civil Justice (ICJ) is dedicated to improving the civil justice system by supplying policymakers and the public with rigorous and nonpartisan research. Its studies identify trends in litigation and inform policy choices about liability, compensation, regulation, risk management, and insurance. The institute builds on a long tradition of RAND Corporation research characterized...

Workers' compensation is a state-level social insurance program that provides financial, medical, and rehabilitation benefits to workers who sustain job-related injuries or illnesses. Workers, employers, and other stakeholders involved in workers' compensation systems have long voiced concerns about the extent to which workers' compensation promotes occupational safety and health (OSH) and the well-being of injured workers; government reports and journalistic accounts in recent years have both highlighted perennial issues and documented emerging concerns. Key topic areas highlighted in these accounts include prevention of injury and disability; system coverage, benefit adequacy, and cost spillovers; claim management processes; and occupational health care. Despite the awareness of these issues across stakeholder groups, it is not clear how much consensus there is about which of these challenges to OSH in the workers' compensation system are most pressing, whether there is sufficient evidence to identify best practices, or what structural barriers have prevented policymakers from resolving these challenges.The National Institute for Occupational Safety and Health (NIOSH) requested that RAND explore the beliefs and priorities of key workers' compensation stakeholder groups about system challenges and research priorities that, if addressed, would be most useful for reforming workers' compensation systems to promote OSH and the well-being of workers. RAND conducted a literature scan to identify published criticisms of current workers' compensation systems, focusing on the implications of workers' compensation for worker safety, health, and economic well-being. After producing a compendium of such perspectives, RAND then convened a series of stakeholder conversations with selected representatives from five stakeholder groups. This report describes stakeholder views and attempts to synthesize these perspectives to offer suggestions for research and policy-analysis priorities likely to make workers' compensation policy more effective at promoting the health and well-being of workers.The research reported here was conducted in the RAND Justice Policy Program, which spans both criminal and civil justice system issues with such topics as public safety, effective policing, police-community relations, drug policy and enforcement, corrections policy, use of technology in law enforcement, tort reform, catastrophe and mass-injury compensation, court resourcing, and insurance regulation. Program research is supported by government agencies, foundations, and the private sector.RAND Justice, Infrastructure, and Environment (JIE) conducts research and analysis in civil and criminal justice, infrastructure development and financing, environmental policy, transportation planning and technology, immigration and border protection, public and occupational safety, energy policy, science and innovation policy, space, telecommunications, and trends and implications of artificial intelligence and other computational technologies. iv Questio...

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Study design. Markov model. Objective. Further validity test of a previously published model. Summary of background data. The previous model was built using data from ten randomized trials and examined the 1-year effectiveness and cost-effectiveness of 17 nonpharmacologic interventions for chronic low back pain (CLBP), each compared to usual care alone. This update incorporated data from five additional trials. Methods. Based on transition probabilities that were estimated using patient-level trial data, a hypothetical cohort of CLBP patients transitioned over time among four defined health states: high-impact chronic pain with substantial activity limitations; higher (moderate-impact) and lower (low-impact) pain without activity limitations; and no pain. As patients transitioned among health states, they accumulated quality-adjusted life-years, as well as healthcare and productivity costs. Costs and effects were calculated incremental to each study's version of usual care. Results. From the societal perspective and assuming a typical patient mix (25% low-impact, 35% moderate-impact, and 40% high-impact chronic pain), most interventions—including those newly added—were cost-effective (<$50,000/QALY) and demonstrated cost savings. From the payer perspective, fewer were cost-saving, but the same number were cost-effective. Results for the new studies generally mirrored others using the same interventions—for example, cognitive behavioral therapy (CBT) and physical therapy. A new acupuncture study had similar effectiveness to other acupuncture studies, but higher usual care costs, resulting in higher cost savings. Two new yoga studies’ results were similar, but both differed from those of the original yoga study. Mindfulness-based stress reduction was similar to CBT for a typical patient mix but was twice as effective for those with high-impact chronic pain. Conclusion. Markov modeling facilitates comparisons across interventions not directly compared in trials, using consistent outcome measures after balancing the baseline mix of patients. Outcomes also differed by pain impact level, emphasizing the need to measure CLBP subgroups. Level of Evidence: N/A

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