Efforts to Reduce Opioid Prescribing May Not Be Reaching Appropriate Patients

By Marilynn Larkin

NEW YORK (Reuters Health) - Recent reductions in opioid prescribing have occurred mainly among patients with moderate or severe pain, rather than those with less severe pain, who might be managed with non-opioid alternatives, researchers say.

"We were surprised to learn that there has been a larger decrease in opioid prescribing to adults with more rather than less severe pain," Dr. Mark Olfson of Columbia University's Vagelos College of Physicians and Surgeons in New York City told Reuters Health by email.

His team analyzed data on more than 64,000 U.S. adults 18 years and older who responded to the Medical Expenditure Panel Survey: 21,213 in 2014; 21,633 in 2015; and 21,706 in 2016.

As reported in Health Affairs, approximately 6 million fewer participants were prescribed schedule II or III opioids in 2016 than in 2014: 3.75 million fewer reporting moderate or more severe pain, and 2.20 million fewer reporting less-than-moderate pain.

For those who reported moderate or more severe pain, the percentage prescribed opioids dropped from 32.8% to 25.5%; the decrease for those with less-than-moderate pain was from 8% to 6.6%.

In a sensitivity analysis, there was also a significant decline in opioid prescribing to adults who reported pain that caused quite a bit or extreme interference with their daily activities, from 41.2% in 2014 to 32.9% in 2016.

Overall, the share of adults with persistent prescribing decreased from 3.1% in 2014 to 2.3% in 2016. The decrease was 13.2% to 10.2% for those with moderate-to-severe pain, which was significantly greater than the relative decrease in persistent prescribing to adults who reported less-than-moderate pain.

Of note, in 2014-2016, approximately one in five adults (19.3% - 20.2%) reported moderate or more severe pain. Those individuals were significantly more likely to be female, older, and non-Hispanic white or African American, and to have a lower family income and less formal education than those with less severe pain.

Among adults with less-than-moderate pain, significant declines in prescription opioids were seen in men, adults ages 18-29, non-Hispanic white and Hispanic adults, and those with family incomes below the poverty level.

Dr. Olfson said, "Instead of evaluating opioid prescription control policies based on the sheer number of prescriptions dispensed, the results underscore the importance of evaluating pain management in a more clinically nuanced manner. In practice, this might involve increasing the availability of non-opioid pain management interventions, such as acetaminophen, NSAIDs, exercise, physical therapy, yoga, or other non-medication options for adults with less severe pain."

Dr. David Edwards, Pain Medicine Division Chief at Vanderbilt University Medical Center in Nashville, noted in an email to Reuters Health, "There was indeed a decline in prescribing of opioids to those with less-than-moderate pain, just not as much of a decline as in those with moderate-to-severe pain. This suggests to me that alternative pain treatments are either being used, or less-than-moderate pain is not being treated."

"What providers really want to know," he said, "is that with the decrease in the number or quantity of opioid prescriptions, patients with moderate-to-severe pain are not worse off. Are alternatives being used, or is nothing at all being provided?"

Providers also want to know which patients are doing well and the type of support they've received, he said, as well as "which patients with severe pain are not being treated in the emergency rooms because providers are afraid to treat them?"

"We know that when some patients on high-dose opioids cut back on their own, they do not have worsened pain and they do really well," he noted. "We also have reports of patients forced off opioids becoming depressed and suicidal."

"The sheer number of patients with pain requires that everyone in healthcare have some competence in basic pain care, but also have (names) of colleagues who can offer alternatives," he said. "Clinicians are horrible at detecting when opioid use has become opioid use disorder (addiction). The screening tools we have are not that great, and sometimes undermine the trust we try to build with our patients."

"There are a few types of pain - nociceptive, inflammatory, and pathological - and everyone should have a working knowledge of a few treatments for each pain type," he added. "These treatments include non-medications and non-opioids first."

SOURCE: https://bit.ly/2QAFKGY Health Affairs, online January 6, 2020.

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