583: Prescribing Patterns Across Social Determinants in Low Back Pain

Topic: Education, Societal Impact, and Others
Subtopic: Epidemiology

Background and Aims: Nonspecific low back pain (NLBP) is among the leading causes of disability worldwide, yet treatment selection remains highly variable across patient populations. Social determinants of health (SDoH), including economic instability, housing insecurity, educational attainment, and psychosocial adversity, may contribute to disparities in clinical decision-making; however, their specific influence on NLBP treatment pathways remains poorly characterized. This retrospective cohort study examined the association between documented SDoH factors (ICD-10-CM Z55-Z65) and the selection of pharmacologic and rehabilitative treatments within 6 months of NLBP diagnosis, using real-world electronic health records (EHR).

Methods: Extracting data from the TriNetX research network, we divided NLBP patients into groups with documented SDoH and those without. For each group, we assessed the use of eight specific treatment categories within six months of diagnosis. We also examined the use of specific multi-treatment combinations. Analysis included both general and specific SDoH factors. We employed three statistical measures: adjusted prevalence ratios (PRs) from modified Poisson regression, adjusted odds ratios (ORs) from logistic regression, and average risk differences (ARDs) from inverse probability of treatment weighting, all controlling for demographic and clinical confounders. Results were adjusted using the Benjamini–Hochberg false discovery rate.

Results: The cohort included 81,742 adults with NLBP (2000–2019); 22,373 (27.4%) had documented SDoH. Among treated patients (~34K), opioids (48.9%) were the most prescribed medication, and any SDoH was associated with greater medication utilization. SDoH effects channeled primarily through opioids and non-opioid multi-drug regimens (PR=1.28–2.05), with reduced muscle relaxant–based combinations (PR=0.26–0.89). Occupational risk exposure was associated with rehabilitation-containing combinations, housing/economic problems with NSAID plus non-opioid analgesic combinations, and upbringing problems showed a strong inverse association with muscle relaxant plus NSAID combinations.

Conclusions: We conducted a retrospective study using real-world EHR data to assess differences in NLBP treatment approaches among patients with SDoH. SDoH was associated with increased pharmacological treatment intensity, higher opioid exposure, greater polypharmacy, and distinct treatment signatures across individual factors. Housing and economic problems (Z59) emerged as the strongest factor associated with increased medication usage, while education/literacy problems (Z55) and social environment factors (Z60) were associated with patterns more aligned with guideline-concordant care. Our findings suggest that SDoH factors do not uniformly increase treatment burden but rather channel patients into different treatment trajectories.

References: 1. Ferreira ML, Luca K de, Haile LM, et al. Global, regional, and national burden of low back pain, 1990–2020, its attributable risk factors, and projections to 2050: a systematic analysis of the Global Burden of Disease Study 2021. The Lancet Rheumatology. 2023;5(6):e316-e329. doi:10.1016/S2665-9913(23)00098-X

2. Koes BW, van Tulder MW, Thomas S. Diagnosis and treatment of low back pain. BMJ. 2006;332(7555):1430-1434. doi:10.1136/bmj.332.7555.1430

3. Maher C, Underwood M, Buchbinder R. Non-specific low back pain. The Lancet. 2017;389(10070):736-747. doi:10.1016/S0140-6736(16)30970-9

4. Oliveira CB, Maher CG, Pinto RZ, et al. Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview. Eur Spine J. 2018;27(11):2791-2803. doi:10.1007/s00586-018-5673-2

5. Zhou T, Salman D, McGregor AlisonH. Recent clinical practice guidelines for the management of low back pain: a global comparison. BMC Musculoskelet Disord. 2024;25:344. doi:10.1186/s12891-024-07468-0

6. Chiarotto A, Koes BW. Nonspecific Low Back Pain. New England Journal of Medicine. 2022;386(18):1732-1740. doi:10.1056/NEJMcp2032396

7. Pak SS, Jiang Y, Lituiev DS, De Marchis EH, Peterson TA. Evaluating associations between social risks and health care utilization in patients with chronic low back pain. PAIN Reports. 2024;9(6):e1191. doi:10.1097/PR9.0000000000001191

8. Karran EL, Grant AR, Moseley GL. Low back pain and the social determinants of health: a systematic review and narrative synthesis. PAIN. 2020;161(11):2476. doi:10.1097/j.pain.0000000000001944

9. Mathieu J, Roy K, Robert MÈ, Akeblersane M, Descarreaux M, Marchand AA. Sociodemographic determinants of health inequities in low back pain: a narrative review. Front Public Health. 2024;12. doi:10.3389/fpubh.2024.1392074

10. Social determinants of health. Accessed January 19, 2026. https://www.who.int/health-topics/social-determinants-of-health

11. Rethorn ZD, Cook C, Reneker JC. Social Determinants of Health: If You Aren’t Measuring Them, You Aren’t Seeing the Big Picture. Journal of Orthopaedic & Sports Physical Therapy. 2019;49(12):872-874. doi:10.2519/jospt.2019.0613

12. Pottkotter K, Hazlett M, Mansfield CJ, et al. Understanding social determinants of health and physical therapy outcomes in patients with low back pain: A scoping review. Musculoskeletal Care. 2024;22(2):e1888. doi:10.1002/msc.1888

13. Allen-Watts K, Sims AM, Buchanan TL, et al. Sociodemographic Differences in Pain Medication Usage and Healthcare Provider Utilization Among Adults With Chronic Low Back Pain. Front Pain Res (Lausanne). 2022;2:806310. doi:10.3389/fpain.2021.806310

14. Roseen EJ, Conyers FG, Atlas SJ, Mehta DH. Initial Management of Acute and Chronic Low Back Pain: Responses from Brief Interviews of Primary Care Providers. The Journal of Alternative and Complementary Medicine. 2021;27(S1):S-106. doi:10.1089/acm.2020.0391

15. Hendricks-Sturrup RM, Yankah SE, Lu CY. Social determinants of health Z-code documentation practices in mental health settings: a scoping review. Health Aff Sch. 2024;2(4):qxae046. doi:10.1093/haschl/qxae046

16. Hau C, Grubber JM, Ferguson RE, et al. Social Determinants of Health ICD-10 Code Use by a Large Integrated Healthcare System. Healthcare (Basel). 2025;13(21):2710. doi:10.3390/healthcare13212710

17. Lee JS, MacLeod KE, Kuklina EV, Tong X, Jackson SL. Social Determinants of Health–Related Z Codes and Health Care Among Patients With Hypertension. AJPM Focus. 2023;2(2):100089. doi:10.1016/j.focus.2023.100089

18. Karran EL, Fryer CE, Middleton JW, Moseley GL. Exploring the Social Determinants of Health Outcomes for Adults with Low Back Pain or Spinal Cord Injury and Persistent Pain: A Mixed Methods Study. The Journal of Pain. 2022;23(9):1461-1479. doi:10.1016/j.jpain.2022.04.001

19. Yap ZL, Summers SJ, Grant AR, Moseley GL, Karran EL. The role of the social determinants of health in outcomes of surgery for low back pain: a systematic review and narrative synthesis. The Spine Journal. 2022;22(5):793-809. doi:10.1016/j.spinee.2021.11.013

20. Gatchel RJ, Polatin PB, Noe C, Gardea M, Pulliam C, Thompson J. Treatment- and Cost-Effectiveness of Early Intervention for Acute Low-Back Pain Patients: A One-Year Prospective Study. J Occup Rehabil. 2003;13(1):1-9. doi:10.1023/A:1021823505774

21. Botnar K, Nguen JT, Farnsworth MG, Golovko G, Khanipov K. EHRchitect: An open-source software tool for medical event sequences data extraction from Electronic Health Records. J Clin Transl Sci. 9(1):e79. doi:10.1017/cts.2025.55

22. Health Equity and Access to Health Care as a Social Determinant of Health: The Role of the Primary Care Provider - ClinicalKey. Accessed January 20, 2026. https://www.clinicalkey.com/#!/content/playContent/1-s2.0-S0095454323000465?returnurl=https:%2F%2Flinkinghub.elsevier.com%2Fretrieve%2Fpii%2FS0095454323000465%3Fshowall%3Dtrue&referrer=https:%2F%2Fpubmed.ncbi.nlm.nih.gov%2F

23. Walker RJ, Strom Williams J, Egede LE. Influence of Race, Ethnicity and Social Determinants of Health on Diabetes Outcomes. Am J Med Sci. 2016;351(4):366-373. doi:10.1016/j.amjms.2016.01.008

24. Teshale AB, Htun HL, Owen A, et al. The Role of Social Determinants of Health in Cardiovascular Diseases: An Umbrella Review. J Am Heart Assoc. 2023;12(13):e029765. doi:10.1161/JAHA.123.029765

25. Korn AR, Walsh-Bailey C, Correa-Mendez M, et al. Social determinants of health and US cancer screening interventions: A systematic review. CA Cancer J Clin. 2023;73(5):461-479. doi:10.3322/caac.21801

26. Athanasakis K. “Inclusive” health systems increase healthy life expectancy. Rural Remote Health. 2022;22(2):7014. doi:10.22605/RRH7014

27. Arena R, Pronk NP, Woodard C. Predicting life expectancy in the United States: The importance of healthy living behaviors and residential geography. Prog Cardiovasc Dis. 2024;85:26-30. doi:10.1016/j.pcad.2024.01.021

28. Zhou T, Salman D, McGregor AH. Recent clinical practice guidelines for the management of low back pain: a global comparison. BMC Musculoskelet Disord. 2024;25(1):344. doi:10.1186/s12891-024-07468-0

29. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians | Annals of Internal Medicine. Accessed January 22, 2026. https://www.acpjournals.org/doi/10.7326/M16-2367

30. WHO guideline for non-surgical management of chronic primary low back pain in adults in primary and community care settings. Accessed January 22, 2026. https://www.who.int/publications/i/item/9789240081789

31. Margetis K, Singh C, Casiano VE, Varacallo MA. Back Pain. In: StatPearls. StatPearls Publishing; 2025. Accessed January 22, 2026. http://www.ncbi.nlm.nih.gov/books/NBK538173/

32. Giraldo JP, Williams GP, Lee JJ, Potts EA, Uribe JS. An evidence-based review of the current surgical treatments for chronic low-back pain: rationale, indications, and novel therapies. Published online February 7, 2025. doi:10.3171/2024.9.SPINE24580

33. Vrtikapa K, Hoque Urmy F, Hoque F. Social Determinants of Health: The Impact of This Overlooked Vital Sign. J Brown Hosp Med. 4(3):138072. doi:10.56305/001c.138072

34. Shraim M, Cifuentes M, Willetts JL, Marucci-Wellman HR, Pransky G. Length of Disability and Medical Costs in Low Back Pain: Do State Workers’ Compensation Policies Make a Difference? Journal of Occupational and Environmental Medicine. 2015;57(12):1275. doi:10.1097/JOM.0000000000000593

35. The Timing of Physical Therapy for Low Back Pain: Does It Matter in Workers’ Compensation? WCRI. Accessed January 20, 2026. https://www.wcrinet.org/reports/the-timing-of-physical-therapy-for-low-back-pain-does-it-matter-in-workers-compensation

36. Poulain C, Kernéis S, Rozenberg S, Fautrel B, Bourgeois P, Foltz V. Long-term return to work after a functional restoration program for chronic low-back pain patients: a prospective study. Eur Spine J. 2010;19(7):1153-1161. doi:10.1007/s00586-010-1361-6

37. Gallagher RM, Williams RA, Skelly J, et al. Workers’ Compensation and return-to-work in low back pain. Pain. 1995;61(2):299-307. doi:10.1016/0304-3959(94)00190-P

38. Gebauer S, Salas J, Scherrer JF. Neighborhood Socioeconomic Status and Receipt of Opioid Medication for New Back Pain Diagnosis. J Am Board Fam Med. 2017;30(6):775-783. doi:10.3122/jabfm.2017.06.170061

39. Hanney WJ, Munyon MD, Mangum LC, Rovito MJ, Kolber MJ, Wilson AT. Perceived barriers to accessing physical therapy services in Florida among individuals with low back pain. Front Health Serv. 2022;2:1032474. doi:10.3389/frhs.2022.1032474

40. Oosman S, Weber G, Ogunson M, Bath B. Enhancing Access to Physical Therapy Services for People Experiencing Poverty and Homelessness: The Lighthouse Pilot Project. Physiother Can. 2019;71(2):176-186. doi:10.3138/ptc.2017-85.pc

41. Huang J, Birkenmaier J, Kim Y. Job Loss and Unmet Health Care Needs in the Economic Recession: Different Associations by Family Income. Am J Public Health. 2014;104(11):e178-e183. doi:10.2105/AJPH.2014.301998

42. Cook CE, Garcia AN, Shaffrey C, Gottfried O. The Influence of Unemployment and Disability Status on Clinical Outcomes in Patients Receiving Surgery for Low Back-Related Disorders: An Observational Study. Spine Surg Relat Res. 2020;5(3):182-188. doi:10.22603/ssrr.2020-0156

43. Shraim M, Cifuentes M, Willetts JL, Marucci‐Wellman HR, Pransky G. Regional socioeconomic disparities in outcomes for workers with low back pain in the United States. Am J Ind Med. 2017;60(5):472-483. doi:10.1002/ajim.22712

44. Pak SS, Jiang Y, Lituiev DS, De Marchis EH, Peterson TA. Evaluating associations between social risks and health care utilization in patients with chronic low back pain. PAIN Reports. 2024;9(6):e1191. doi:10.1097/PR9.0000000000001191

45. Institute of Medicine (US) Committee on the Changing Market MC, Lewin ME, Altman S. The Core Safety Net and the Safety Net System. In: Americas’s Health Care Safety Net: Intact but Endangered. National Academies Press (US); 2000. Accessed January 22, 2026. https://www.ncbi.nlm.nih.gov/books/NBK224521/

46. Lewis VA, Spivack S, Murray GF, Rodriguez HP. FQHC Designation and Safety Net Patient Revenue Associated with Primary Care Practice Capabilities for Access and Quality. J Gen Intern Med. 2021;36(10):2922-2928. doi:10.1007/s11606-021-06746-0

47. Berkowitz SA, Parashuram S, Rowan K, et al. Association of a Care Coordination Model With Health Care Costs and Utilization: The Johns Hopkins Community Health Partnership (J-CHiP). JAMA Netw Open. 2018;1(7):e184273. doi:10.1001/jamanetworkopen.2018.4273

48. Sullivan MD, Edlund MJ, Zhang L, Unützer J, Wells KB. Association between mental health disorders, problem drug use, and regular prescription opioid use. Arch Intern Med. 2006;166(19):2087-2093. doi:10.1001/archinte.166.19.2087

49. Braden JB, Sullivan MD, Ray GT, et al. Trends in long-term opioid therapy for noncancer pain among persons with a history of depression. Gen Hosp Psychiatry. 2009;31(6):564-570. doi:10.1016/j.genhosppsych.2009.07.003

50. National Academies of Sciences E, Division H and M, Policy B on HS, et al. Pain Management and the Intersection of Pain and Opioid Use Disorder. In: Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use. National Academies Press (US); 2017. Accessed January 22, 2026. https://www.ncbi.nlm.nih.gov/books/NBK458655/

51. Sullivan MD, Howe CQ. Opioid therapy for chronic pain in the United States: promises and perils. Pain. 2013;154 Suppl 1(0 1):S94-S100. doi:10.1016/j.pain.2013.09.009

52. Silva MJ, Coffee Z, Yu CH, Martel MO. Anxiety and Fear Avoidance Beliefs and Behavior May Be Significant Risk Factors for Chronic Opioid Analgesic Therapy Reliance for Patients with Chronic Pain—Results from a Preliminary Study. Pain Med. 2021;22(9):2106-2116. doi:10.1093/pm/pnab069

53. Gatchel RJ, Neblett R, Kishino N, Ray CT. Fear-Avoidance Beliefs and Chronic Pain. Journal of Orthopaedic & Sports Physical Therapy. 2016;46(2):38-43. doi:10.2519/jospt.2016.0601

54. Jamison RN, Edwards RR, Liu X, et al. Relationship of Negative Affect and Outcome of an Opioid Therapy Trial Among Low Back Pain Patients. Pain Pract. 2013;13(3):10.1111/j.1533-2500.2012.00575.x. doi:10.1111/j.1533-2500.2012.00575.x

55. Reme SE, Lie SA, Eriksen HR. Are 2 Questions Enough to Screen for Depression and Anxiety in Patients With Chronic Low Back Pain? Spine (Phila Pa 1976). 2014;39(7):E455-E462. doi:10.1097/BRS.0000000000000214

56. Grande-Alonso M, Muñoz-García D, Cuenca-Martínez F, et al. Relationship between healthcare seeking and pain expansion in patients with nonspecific chronic low back pain. PeerJ. 2020;8:e8756. doi:10.7717/peerj.8756

Presenting Author: Ryan Pontiff
Submitting Author: Ryan Pontiff

Senior Author: Ryan Pontiff

IASP 2026 Global Year theme of Neuropathic Pain: No

• Ryan Pontiff: DPT, PhD - UTMB
• Kostiantyn Botnar: MS, PhD - UTMB
• Missy Morrow: MS, PhD - UTMB
• Carole A Tucker: MS, PhD - UTMB