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Opioids becoming more common as treatment for noncancer pain

Tuesday September 17, 2013
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Prescribing of strong opioid medications for noncancer pain in the U.S. has nearly doubled during the past decade, according to a study.

At the same time, prescribing of nonopioid pain relievers has been stable or declined, researchers reported in the October issue of the journal Medical Care.

“There is an epidemic of prescription opioid addiction and abuse in the United States, and we felt it was important to examine whether or not this epidemic has coincided with improved identification and treatment of pain,” study author G. Caleb Alexander, MD, MS, of Johns Hopkins Bloomberg School of Public Health in Baltimore, said in a news release.

Using a nationally representative database of U.S. physician office visits, the researchers analyzed trends in visits for pain and medications prescribed for pain from 2000 to 2010. The study focused on trends in the use of strong opioid (morphine-related) pain medications for noncancer pain, and was performed with the Johns Hopkins Center for Drug Safety and Effectiveness, of which Alexander is co-director.

The results showed no significant change in the proportion of patients who visited physician offices with pain. Throughout the decade, pain consistently was reported by patients or diagnosed by physicians at about a fifth of visits.

The researchers found a significant increase in prescriptions for opioid medications, with the rate for pain visits increasing from 11.3% in 2000 to 19.6% in 2010. At the same time, prescribing of nonopioid pain-relieving drugs remained stable at between 26% and 29% throughout the decade.

Out of approximately 164 million pain visits in 2010, about half were treated with some kind of pain-relieving drug: 20% with an opioid and 27% with a nonopioid pain reliever.

Analysis of visits for new-onset musculokeletal pain found a similar increase in opioid prescribing but a significant decrease, from 38% to 29%, in prescribing of nonopioid analgesics. The percentage of patients receiving both opioid and nonopioid pain relievers also increased during the period studied.

After adjustment for other factors, the researchers found few patient, physician or practice characteristics related to higher or lower rates of opioid use for noncancer pain. Rather, “increases in opioid prescribing generally occurred nonselectively over time,” they wrote.

Alternatives

Chronic pain affects about 100 million U.S. adults and carries major costs in terms of healthcare and lost productivity. A growing awareness of the high prevalence and impact of pain has prompted efforts to improve its identification and management, such as by routinely assessing pain as the “fifth vital sign,” according to the report.

An unintended consequence of those efforts has been a well-documented increase in opioid use and abuse in the United States, with consistent increases in ED visits and deaths from prescription opioid abuse. “By 2008, the annual number of fatal drug poisonings surpassed those of motor vehicle deaths, and overdose deaths attributable to prescription drugs exceeded those of cocaine and heroin combined,” Alexander and colleagues wrote.

The study is described as one of the first to focus on trends in pain treatment in ambulatory care. The results highlight the importance of balancing the risks and benefits of analgesics prescribed in the primary care setting. “The majority of pain medications are prescribed by primary care physicians, who treat over half of the chronic pain patients in the United States,” Matthew Daubresse, MHS, lead author of the study, said in the news release. “Pain specialists only treat a fraction of these patients.”

“We found that not only have the rates of treated pain not improved, but in many cases, use of safer alternatives to opioids, such as medicines like ibuprofen and acetaminophen, have either stayed flat or declined,” Alexander said. “This suggests that efforts to improve the identification and treatment of pain may have backfired, due to an over-reliance on prescription opioids that have caused incredible morbidity and mortality among patients young and old alike.”

The researchers noted nonopioid prescribing decreased despite a lack of evidence showing opioids are more effective or safer for the treatment of noncancer pain.

“Policymakers, professional organizations and providers should re-evaluate prior efforts to improve the identification, treatment and management of nonmalignant pain and promote approaches that adequately reflect the importance of nonopioid and nonpharmacologic treatments,” they concluded.

Study abstract: http://bit.ly/19YgSee.


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