Opioid use increases without improvements in treatment of pain

by Bruce Sylvester – Researchers report that, after a decade when prescription opioid use has grown dramatically, identification and treatment of pain has not improved, and, notably, the use of non-opioid analgesics has leveled out.

The study was published online September 13, 2013 in the journal Medical Care. The study is one of the first to focus on trends in pain treatment in office and clinic visits.

“There is an epidemic of prescription opioid addiction and abuse in the United States,” said investigator G. Caleb Alexander, MD, MS, co-director of the Johns Hopkins University Center for Drug Safety and Effectiveness, Baltimore, Maryland. “We felt it was important to examine whether or not this epidemic has coincided with improved identification and treatment of pain.”

Alexander and his team used data from the National Ambulatory Medical Care Survey, designed by the (US) Center for Disease Control- CDC/National Center for Health Statistics, to analyze trends from 2000 to 2010 among patients seeking medical treatment for non-cancer pain.

They found that there was no significant change in the proportion of pain visits (about half) which were treated with pain relievers. They also found that non-opioid prescriptions remained stable, at 26-29 percent of pain visits, but opioid (morphine-related) prescriptions nearly doubled, from 11 percent in 2000 to 19 percent in 2010.

They reported that out of about 164 million pain visits in 2010, approximately half were treated with a pain relieving drug, 20 percent with an opioid and 27 percent with a non-opioid pain reliever.

For new-onset musculoskeletal pain, the investigators found a significant decrease in non-opioid analgesics prescriptions, from 38 to 29 percent between 2000 and 2010, even without evidence that opioids are more effective than non-opioid treatments for such pain.

As background, the authors noted that, prescription opioid abuse in the United States has been increasingly identified in emergency department visits, and as a cause of death. “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,” they wrote.

“The majority of pain medications are prescribed by primary care physicians, who treat over half of the chronic pain in the United States,” said investigator Matthew Daubresse, MHS, of Johns Hopkins School of Public Health. “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,” added Alexander. “This suggests that efforts to improve the identification and treatment of pain have backfired, due to an over-reliance on prescription opioids that have caused incredible morbidity and mortality among patients, young and old alike.”

On September 10th, 2013, the Food and Drug Administration announced new labeling changes and post-marketing study requirements for extended-release and long-acting opioid analgesics. “These regulatory changes may help prescribers and patients to better appreciate the risks of these therapies,” said Daubresse. “Despite this, the ultimate impact of the FDA’s labeling change has yet to be seen.”

Alexander and his colleagues concluded, “Policy makers, professional organizations, and providers should re-evaluate prior efforts to improve the identification, treatment, and management of non-malignant pain and promote approaches that adequately reflect the importance on non-opioid and non-pharmacologic treatments.”