A new study led by the Johns Hopkins Bloomberg School of Public Health finds that during a decade when prescription opioid use has skyrocketed, the identification and treatment of pain has failed to improve, and the use of non-opioid analgesics has plateaued, or even declined. The study was published online September 13 in the journal Medical Care.
"There is an epidemic of prescription opioid addiction and abuse in the United States," notes G. Caleb Alexander, MD, MS, associate professor of Epidemology and Medicine and co-director of the Johns Hopkins Center for Drug Safety and Effectiveness. "We felt it was important to examine whether or not this epidemic has coincided with improved identification and treatment of pain."
Alexander and his fellow researchers used the National Ambulatory Medical Care Survey, designed by the CDC/National Center for Health Statistics, to analyze trends from 2000 to 2010 associated with patients seeking medical treatment for non-cancer pain. They found no significant change in the proportion of pain visits -- approximately one-half -- treated with pain relievers.
During this time, non-opioid (analgesic) prescriptions remained stable, consisting of 26-29 percent of pain visits. However, opioid (morphine-related) prescriptions nearly doubled, from 11 percent in 2000 to 19 percent in 2010. Of approximately 164 million pain visits in 2010, roughly half were treated with some kind of pain relieving drug: 20 percent with an opioid and 27 percent with a non-opioid pain reliever.
Alexander and colleagues also examined visits for new-onset musculoskeletal pain and in spite of similar increases in opioid prescribing, the results showed a significant decrease in non-opioid analgesics prescriptions from 38 to 29 percent between 2000 and 2010, despite a lack of evidence showing opioids are more effective or safer than non-opioid treatments for such pain.
Chronic pain affects nearly 100 million U.S. adults and carries major costs in terms of health care and lost productivity. Initiatives designed to increase patient and provider awareness of pain have come with unintended consequences. Prescription opioid abuse has been increasingly documented in emergency department visits and deaths. "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 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 in the United States," notes Matthew Daubresse, MHS, lead author of the 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 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."
In response to the growing opioid epidemic, on September 10th, 2013, the Food and Drug Administration announced new labeling changes and postmarket 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," says Matthew Daubresse. "Despite this, the ultimate impact of the FDA's labeling change has yet to be seen."
Alexander and his 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 on non-opioid and non-pharmacologic treatments."
"Ambulatory Diagnosis and Treatment of Non-Malignant Pain in the United States, 2000-2010," was written by Matthew Daubresse, Hsien-Yen Chang, Shilpa Viswanathan, Nilay Shah, Randall Stafford, Stefan Kruszewski and G. Caleb Alexander.
The research was funded in part by the Agency for Healthcare Research and Quality (RO1 HS0189960).
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Medical Care