Prescribing of strong opioid medications for non-cancer pain in the United States has nearly doubled over the past decade, reports a study in the October issue of Medical Care, published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health.
At the same time, prescribing of non-opioid pain relievers has been stable or declined, according to the new research by Dr G. Caleb Alexander of Johns Hopkins Bloomberg School of Public Health, Baltimore, and colleagues. Dr Alexander comments, "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."
Opioid Prescribing for Non-Cancer Pain Increases
Using a nationally representative database of U.S. doctors' 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 non-cancer pain. The study was performed in affiliation with the Johns Hopkins Center for Drug Safety and Effectiveness, for which Dr Alexander serves as Co-Director.
The results showed no significant change in the proportion of doctor's office visits with pain. Throughout the decade, pain was consistently reported by patients or diagnosed by doctors at about one-fifth of visits. There was no change in the proportion of pain visits treated with pain relievers (analgesics).
However, there was a significant increase in prescriptions for opioid medications. The rate of opioid prescribing for pain visits increased from 11.3 percent in 2000 to 19.6 percent in 2010.
At the same time, prescribing of non-opioid pain-relieving drugs remained stable: between 26 and 29 percent throughout the decade. Out of approximately 164 million pain visits in 2010, about half were treated with some kind of pain-relieving drug: 20 percent with an opioid and 27 percent with a non-opioid pain reliever.
Analysis of visits for new-onset musculokeletal pain found a similar increase in opioid prescribing but a significant decrease in prescribing of non-opioid analgesics: from 38 to 29 percent. The percentage of patients receiving both opioid and non-opioid pain relievers also increased during the period studied.
Need for Increased Attention to Safer Alternatives for Pain Treatment
After adjustment for other factors, there were few patient, physician, or practice characteristics related to higher or lower rates of opioid use for non-cancer pain. Rather, "increases in opioid prescribing generally occurred non-selectively over time," Dr Alexander and coauthors write.
Chronic pain affects approximately 100 million U.S. adults, and carries major costs in terms of health care and lost productivity. A growing awareness of the high prevalence and impact of pain has prompted efforts to improve its identification and management -- for example, by routinely assessing pain as the "fifth vital sign."
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 emergency department 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," Dr Alexander and colleagues write. The new study is one of the first to focus on trends in pain treatment in ambulatory care -- that is, office and clinic visits.
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" comments Matthew Daubresse, MHS, lead author of the new report. "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," says Dr Alexander. "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 note that non-opioid prescribing decreased despite a lack of evidence showing that opioids are more effective or safer for the treatment of non-cancer pain. Dr Alexander and colleagues conclude, "Policy-makers, 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 non-pharmacologic treatments."
- Matthew Daubresse, Hsien-Yen Chang, Yuping Yu, Shilpa Viswanathan, Nilay D. Shah, Randall S. Stafford, Stefan P. Kruszewski, G. Caleb Alexander. Ambulatory Diagnosis and Treatment of Nonmalignant Pain in the United States, 2000–2010. Medical Care, 2013; 51 (10): 870 DOI: 10.1097/MLR.0b013e3182a95d86
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