Opioid Prescribing Is Down, Yet Alternative Pain Treatments Remain Underused

https://www.practicalpainmanagement.com/news/opioid-prescribing-is-down-yet-alternative-pain-treatments-remain-underused

New study confirms reduction in opioid prescribing for cancer pain and non-cancer pain but, surprisingly, no matching increase in opioid alternatives. So how is chronic pain being treated?

New study confirms reduction in opioid prescribing for cancer pain and non-cancer pain but, surprisingly, no matching increase in opioid alternatives. So how is chronic pain being treated?

Since the CDC issued its practice guideline on prescribing opioids for chronic pain in 2016, professional organizations, payers, and many physicians have been moving away from opioids and looking toward other, often multidisciplinary, treatments to manage pain, including cancer-related pain.

According to a brand new study, opioid prescribing is indeed down – however, opioids do not seem to have been replaced with other therapies. The research, published August 10 in PLoS ONE, was led by Sachini Bandara, PhD, and Emma McGinty, PhD, of Johns Hopkins Bloomberg School of Health, and Mark Bicket, MD, PhD, of the University of Michigan.

When the CDC released its initial guidelines on opioid prescribing for chronic pain, the recommendations were largely in line with guidance from professional organizations calling for physicians to write fewer prescriptions for opioids and to instead use non-opioid drugs and non-pharmacological therapies as first-line treatments, explained Dr. Bandara, assistant professor and drug policy researcher at Johns Hopkins and first author on the study.

At the time, she noted, physicians as well as pain-advocacy communities warned that reduced opioid prescribing could have a negative impact on patients with chronic non-cancer pain if their pain was not properly managed with non-opioid therapies. The aim of the present study, wrote Dr. Bandara and team, was to find out whether opioid prescribing was actually decreasing and if non-opioid treatments were increasing correspondingly.

Previous reports have demonstrated a decrease in opioid prescribing overall between 2010 and 2020, but individuals with cancer and palliative, end-of-life-care were specifically excluded from the CDC recommendations on opioid use for pain. Dr. Bandara’s team looked at data from between 2012 and 2019, focused on opioid prescribing for pain in people with and without cancer, and found that the number of privately insured adults who were prescribed opioids for pain (both cancer pain and chronic non-cancer pain, or CNCP) declined during that period.¹

So while their report aligns with prior data, what is new is that opioid alternative use has not increased, begging the question: are individuals living with chronic pain getting the pain relief they need?

Using the IBM Marketscan Research Databases from 2012 to 2019, which include insurance claims and encounters for between 26 million and 53 million individuals covered by private insurance companies Bandara et al identified individuals who were diagnosed during that period with cancer pain or non-cancer pain, including low-back pain, neuropathic pain, headaches, and arthritis.

Their records analysis showed that the number of people who received an opioid prescription declined from 49.7% to 30.5% for those with chronic non-cancer pain and from 86% to 78.7% for those with cancer pain. In addition, of those who did receive opioid prescriptions, fewer received extremely high doses or more than one week’s supply of the medication.

Meanwhile, non-opioid prescriptions remained steady (from 66.7% to 66.4%) for people with non-cancer pain and increased slightly (from 74.4% to 78.8%) for those with cancer pain. “We see opioid prescribing going down, while non-opioid prescribing is not increasing to fill that gap,” said Dr. Bandara.

Non-pharmacological therapies (eg, interventional procedures, physical therapy and exercise, mental health care) do not appear to be filling the gap either. A secondary analysis of the data, which looked at a subset of the sample of patients with CNCP, found that substitution of non-pharmacological therapies in place of opioid therapy in patients with CNCP was 3.5% in 2019, essentially unchanged from 2013, when it was 3.4%.

Mark Bailey, DO, PhD, was not surprised by these findings. “We’ve known this for a long time,” he said, pointing out that the trend of prescribing fewer opioids has been underway since about 2012. Dr. Bailey, director of the neurology pain division at University of Alabama at Birmingham School of Medicine, said his perception is that people with cancer are not getting less pain medicine, but he does note that oncologists seem to be less willing to write prescriptions for pain. “I’ve definitely seen this, because they’re sending me their dying patients to take care of their opioids for them.”

Dr. Bailey also pointed out that, while there is an abundance of data showing that doctors are prescribing fewer opioids, overdose deaths are still rising dramatically, suggesting that people (whether they are under care or not) may be just “changing the drug of choice from prescription drugs to street fentanyl.”

He added, “I think the take-home message is that prescribing less medicine has not curbed the overdose death rate; it has skyrocketed. But it’s not the drugs that we prescribe anymore. All the hoops and laws and regulations and guidelines that we put on ourselves have not fixed the problem they were designed to fix.”

And those efforts have created other problems. Jeffrey Bettinger, PharmD, clinical pharmacist and specialist in pain management at Saratoga Hospital Medical Group, pointed out that he is now seeing patients with non-cancer chronic pain and palliative care needs as well as cancer-related pain who are no longer able to get the same pain relief they got with opioids.

In this special series, Dr. Bettinger and Reed J. Yaras, DO, analyze the CDC opioid prescribing guideline revisions, including patient populations with and without cancer, which are expected to be released later this year.

Filed under: General Problems