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Thesis Defense: An Examination of Trends in the Rates of Low-Value Opioids Prescribed for Acute Low Back Pain in Rural vs. Non-Rural Virginia

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Jamie Turner

Thesis Defense: An Examination of Trends in the Rates of Low-Value Opioids Prescribed for Acute Low Back Pain in Rural vs. Non-Rural Virginia 

Jamie Turner

Graduate Student, Translational Biology, Medicine, and Health
Graduate Research Assistant, Rockwell & Epling Lab of Research in Family and Community Medicine
December 2, 2025, at 11 a.m.
1 Riverside Circle, Suite 102 Boardroom

 

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About this Thesis

Background: The Centers for Disease Control and Prevention (CDC) recommends against the use of prescription opioids for most types of acute pain. Despite these recommendations, some evidence suggests that opioid prescribing for acute low back pain (LBP) - among the most common acute pain complaints - persists. This study evaluated trends in low-value opioid prescribing for acute LBP among patients residing in rural versus non-rural areas of Virginia during 2019-2021. We also evaluated the impact of the COVID-19 pandemic on associated prescribing rates.


Methods: In this retrospective cohort study, we examined insurance claims from the Virginia All-Payer Claims Database for adults continuously enrolled in Medicaid, Medicare Advantage, or commercial plans from 2019 to 2021. We used the Milliman MedInsight Health Waste Calculator to identify low-value claims and calculated annual and bi-monthly prescribing rates per 1000 patients. Heterogeneous difference-in-differences models generated incidence rate ratios (IRRs) to express the difference in the rate of low-value opioids for acute LBP observed during the first two years of the COVID-19 pandemic (2020-2021) vs. expected rates based on the pre-pandemic timeframe (2019). IRRs were stratified by rurality.


Results: Among our cohort (n=853,775), 1,338,371 claims for opioids for acute LBP were identified, 74% of which were low-value. The annual prescribing of low-value opioids for acute LBP declined by 30.6% from 2019 (155.0 claims per 1000 patients) to 2021 (107.5 claims per 1000 patients) compared to the expected decline of 18.6% during this period. Throughout 2020-2021, the rate of low-value opioids for acute LBP was 80% of expected rates (IRR: 0.796, p<.001). Low-value opioid prescribing for acute LBP was 0.74 times higher in patients residing in rural versus non-rural areas throughout 2019-2021 (IRR: 1.738, p<.001). The pandemic’s impact was similar among patients living in rural and non-rural areas (IRR: 1.017, p=.060).


Conclusions: The majority of opioids prescribed for acute LBP among this large, multi-payer Virginia cohort were low-value. The COVID-19 pandemic accelerated the decline in low-value opioid prescribing for acute LBP during 2020-2021 over the expected annual decline. Persistent rural disparity in low-value opioid prescribing for acute LBP suggests an opportunity to explore its drivers to inform efforts to reduce rates of low-value opioids and ensure equitable high-quality treatment for acute pain.

More About the Candidate and Project

Education

Virginia Tech, Translational Biology, Medicine, and Health, M.S. Student

Virginia Tech, MPH, Public Health

Radford University, B.S. Psychology

Training

Graduate Research Assistant, Rockwell & Epling Lab

Mentor

  • Michelle Rockwell, Ph.D., RD, Director, Research in the Department of Family and Community Medicine at Carilion Clinic; Co-Director, VTCSOM Health Systems Science and Interprofessional Practice; Assistant Professor, Family and Community Medicine at VTCSOM and the Franlin Biomedical Research Institute

Committee Members

  • John W. Epling Jr., MD, Vice Chair, VTCSOM Research and Population Health; Professor, Department of Health Sciences; Professor, VTCSOM Family and Community Medicine; Research Fellow, Fralin Biomedical Research Institute
  • Samantha Harden, Ph.D., 500 RYT, Associate Professor, Department of Human Nutrition, Food, and Excerise
  • Alexandra L. Hanlon, Ph.D., Director, Center for Biostatistics and Health Data Science; Associate Professor, Department of Statistics

Publications

  • Rockwell, M., Turner, J. K., Singh, E., Epling, J., Vinson, M., Oyese, E., & Yim, I. (2023). A Scoping Review of Interventions to De-implement Potentially Harmful NSAIDs in Healthcare Settings. Annals of Family Medicine, 21(Suppl 3), 5280. https://doi.org/10.1370/afm.22.s1.5280


  • Yeh, Y., Freitas-Lemos, R., Craft, W., Tomlinson, D., Craft, C., Turner, J., & Bickel, W. (2023). A comparison of different data quality control methods through the magnitude effect in delay discounting: A practical guide for MTurk research. The Psychological Record. 73. https://doi.org/10.1007/s40732-023-00566-w


  • Rockwell, M. S., Chang, B., Zagarese, V., Turner, J. K., Southworth, A., Wu, Y., Yeaton, P., Li, L., Stein, J. S., Parker, S. H., & Epling, J. W. (2024). Patients' experiences with 'sludge' (administrative burden) in the cancer screening process and its relationship with screening completion, experience and health system distrust. Family medicine and community health, 12(Suppl 2), e002933. https://doi.org/10.1136/fmch-2024-002933


  • Rockwell, M. S., Oyese, E. G., Singh, E., Vinson, M., Yim, I., Turner, J. K., & Epling, J. W. (2024). Scoping review of interventions to de-implement potentially harmful non-steroidal anti-inflammatory drugs (NSAIDs) in healthcare settings. BMJ open, 14(4), e078808. https://doi.org/10.1136/bmjopen-2023-078808


  • Chang, B., Ahrens, M., Turner, J. K., Epling, J., Rockwell, M., & Zagarese, V. (2024). Interactions of multiple chronic conditions and sludge on treatment burden and delayed/skipped colorectal cancer screenings. Annals of Family Medicine, 22(Suppl 1), 7051. https://doi.org/10.1370/afm.22.s1.7051

  • Rockwell, M. S., Grubb, C., Turner, J. K., Vinson, M., Yim., I., Hanlon, A., and Epling, J. (2025). Disproportionate high-risk nonsteroidal anti-inflammatory drug (NSAID) prescribing in rural virginia. Preprint. medRxiv. 2025;2025.01.03.25319965v.1. Published 2025 Jan 7. https://doi.org/10.1101/2025.01.03.25319965


  • Epling, J. W., Turner, J. K., Peregrino, G., Rockwell, M. S., Sharp, H., Cox, E. R.,& Dulaney, K. A. (2025). Diaphragmatic breathing vs control to improve blood pressure rechecks. The Annals of Family Medicine Sep 2025, 23 (Supplement 1) 8259; DOI: 10.1370/afm.23.s1.8259

  • Epling, J., King, M., Hester, C., Rockwell, M., Callen, E., Clay, T., Oyese, E., Turner, J. K., & Stein, J. Discounting behavior in primary care clinicians and association with low-value care decision making. (In Submission)
  • Turner, J. K. (Poster) The Impact of COVID-19 on Low-Value Opioid Prescribing in Virginia, Translational Biology, Medicine, and Health Research Symposium, Roanoke, VA, 2022.
  • Turner, J. K. (Poster) The Impact of COVID-19 on Low-Value Opioid Prescribing in Virginia, Carilion Research Day, Roanoke, VA, 2023.
  • Turner, J. K. (Poster) The Impact of COVID-19 on Inappropriate Opioid Prescribing in Virginia, Virginia Rural Health Association’s Rural Voices Conference, Roanoke, VA, 2023.
  • Epling, J., King, M., Hester, C., Rockwell, M., Callen, E., Clay, T., Oyese, E., Turner, J. K., & Stein J. (Poster) Discounting Behavior in Primary Care Clinicians and Association with Low-Value Care Decision Making, North American Primary Care Research Group Conference, San Francisco, CA, 2023.
  • Rockwell, M. S., Oyese, E. G., Singh, E., Vinson, M., Yim, I., Turner, J. K., & Epling, J. (Poster) A Scoping Review of Interventions to De-implement Potentially Harmful Nonsteroidal Anti-inflammatory Drugs (NSAIDs) in Healthcare Settings, North American Primary Care Research Group Conference, San Francisco, 2023.
  • Turner, J. K. (Poster) Patient Experience of “Sludge” in the colorectal cancer screening process, Translational Biology, Medicine, and Health Research Symposium, Roanoke, VA ,2024
  • Turner, J. K. (Poster) The Impact of COVID-19 on Inappropriate Opioid Prescribing in Virginia, Appalachian Studies Association 47th Annual Conference, Cullowhee, NC, 2024
  • Chang, B., Epling, J., Rockwell, M., Turner, J., & Ahrens, M. (Poster) Evaluating the Interaction Between Sludge and Multiple Chronic Conditions on Treatment Burden in Colorectal Cancer Screening. Practice-Based Research Network Conference, Reston, VA, 2024
  • Turner, J. K., Epling, J., Harden, S. M., & Rockwell, M. (Poster) A Scoping Review of Interventions to Reduce Non-Guideline Concordant Opioid Prescribing for Acute Pain in Primary Care. Practice-Based Research Network Conference, Reston, VA, 2024
  • Turner, J. K. (Poster) Patient Experience of “Sludge” in the colorectal cancer screening process, Carilion Research Day, Roanoke, VA, 2024
  • Rockwell, M. S., Chang, B., Zagarese, V., Turner, J. K., Parker, S., & Epling., J. (Poster) An Evaluation of Patient Outcomes Associated with Sludge (Administrative Burdens) in Cancer Screening. North American Primary Care Research Group Conference, 52nd NAPCRG Annual Meeting, Quebec, CAN, 2024.
  • Rockwell, M. S., Krist, A., Dickerson, L., Carver, M., Turner, J. K., Harden, S. M., Cox, E., & Epling, J. (Poster) A Practice-Based Intervention to De-implement Potentially Harmful Nonsteroidal Anti-Inflammatory Drugs in Primary Care. North American Primary Care Research Group Conference, 52nd NAPCRG Annual Meeting, Quebec, CAN, 2024.
  • Chang, B., Ahrens, M., Turner, J. K., Rockwell, M. S., Zagarese, V., & Epling, J. (Poster) Interactions of Multiple Chronic Conditions and Sludge on Treatment Burden and Delayed/Skipped Colorectal Cancer Screenings. North American Primary Care Research Group Conference, 52nd NAPCRG Annual Meeting, Quebec, CAN, 2024
  • Turner, J. K. (Poster) Patient Experience of “Sludge” in the colorectal cancer screening process, Virginia Rural Health Association’s Rural Voices Conference, Abington, VA 2024.
  • Turner, J. K. (Poster) Variation in Maternal and infant Health Outcomes and Health Risk in Virginia’s Maternity Care Deserts. Carilion Research Day, Roanoke, VA 2025.
  • First Place Poster Award. Virginia Rural Health Association: Rural Voices Conference, VT  (2023)
  • 2022 – Present: Certified Health Education Specialist Certification (CHES) 
  • 2023-2024: Member, Roanoke Graduate Student Association, VT
  • 2023 – Present: Member of the Virginia Rural Health Association, VRHA
  • 2023 – 2025: Member of the Appalachian Studies Association, ASA
  • 2023 – 2025: Member, North American Primary Care Research Group, NAPCRG
  • 2024: Member, American Public Health Association, APHA
  • 2024 – 2025: Selected Student Representative for the Board of the Virginia Rural Health Association, VRHA
  • 2024 – Present: Student Editor, Psi Beta Journal of Student Research, Psi Beta Psychology National Honors Society for the Two-Year College