Prescribing Opioid Analgesics: Are We Going in the Right Direction?

There are probably few health care professionals who are unaware of the concerns about the apparent overprescription of opioids. However, we have had only limited information on how good a job physicians may actually be doing in prescribing these medications.

The report of a new study by the pharmacy benefit manager Express Scripts provides a useful picture of how opioids are currently being prescribed in the US.¹ The study examined the pharmacy claims of 6.8 million patients who filled at least one prescription for an opioid between 2009 and 2013. Sadly it offers very little good news about prescription of these drugs and many reasons to be concerned about what physicians are doing and their level of knowledge.

The only piece of what could be considered good news is that between 2009 and 2013 there was a 9.2% decrease in the number of patients filling prescriptions for opioids. Although at first glance this may appear to be a positive step, it is impossible to determine whether this was due to physicians being more appropriately discerning in prescribing these drugs or whether they are denying patients who may benefit from these drugs because of fears of drawing attention from regulatory authorities. That it might at least to some degree involve the latter is the finding that the reduction occurred among patients receiving prescriptions for a shorter term, defined by the study as the drugs being taken for less than 30 days over the course of the year. There was little change in the number of patients taking opioids for 30 or more days, considered by the study to be longer-term users.

Of great concern is the finding that 47% of new opioid users who were taking these medications for more than 30 days continued using them for at least 3 years. There is currently a debate over whether extended use of opioids is beneficial for chronic pain; there is limited evidence to support that it is. Findings from the Express Scripts study indicate that in many cases physicians are not reevaluating whether the opioid is effective but are simply continuing to prescribe it. It also raises the very real issue of the possibility that some of this ongoing use is due to addiction to the drugs.

That abuse and addiction is a problem is highlighted by the finding regarding the benefits of prescription drug monitoring programs. Only one state, Missouri, has not instituted such a program. (A New York Times article reported that opposition to doing so was led by a state senator who is also a family physician; he argues that drug monitoring programs are an invasion of privacy.² The article also noted that this same physician-senator had expressed the not exactly enlightened opinion that if substance abusers “overdose and kill themselves, it just removes them from the gene pool.”) The report notes that residents of the 7 states neighboring Missouri filled opioid prescriptions in Missouri at 4 times the rate that residents of Missouri filled such prescriptions out of state. This suggests that those out-of-staters might be trying to avoid their opioid use being monitored even though doing so would provide useful information to their caregivers.

In the Express Scripts study, among patients taking opioids for more than 30 days, the use of codeine, OxyContin (long-acting oxycodone), and fentanyl declined approximately 14% for each drug. In contrast, in this same group of patients, prescriptions for short-acting oxycodone products increased more than 7% and prescriptions for tramadol increased more than 32%.

The report does not offer explanations for these findings, but I believe that there are probable explanations for at least some of the findings. The decline in OxyContin use and the increase in short-acting oxycodone use may be due to the widespread publicity about the abuse potential of the former resulting in its use being replaced with the latter either because physicians are concerned about possible abuse or because they do not want to draw the attention to themselves from regulatory authorities by continuing to prescribe OxyContin.

The increase in tramadol prescriptions may reflect physician anxi-ety about prescribing opioids that are Drug Enforcement Administration schedule II or III and instead turning to tramadol, a schedule IV drug. Tramadol is now the second most prescribed opioid, although its share of the market, at 14.7%, is dwarfed by that of hydrocodone with acetaminophen (Vicodin), at 46%.

I find this increase in tramadol use disturbing. I have never been a fan of this drug and have only prescribed it for patients who are already taking it and for whom it is demonstrably beneficial by an improvement in functioning and not just a reported decrease in pain. Tramadol is a weak µ-opioid receptor agonist combined with a weak SNRI. Studies have demonstrated that virtually all its analgesic effect is due to the action of the latter. However, because of the opioid there is a risk of abuse and dependence. I have always felt that it is better to use an SNRI instead, which will usually provide better analgesia without the very significant negative aspects.

It is quite likely that the 2014 decision to change hydrocodone combination products from schedule III to schedule II will result in a decrease in their use. Since there is nothing to indicate that they provide better analgesia than other short-acting opioid formulations, the only apparent reason for the widespread use of the hydrocodone products was the difference in classification level.

Not too surprisingly, almost 50% of opioids are prescribed by primary care physicians (PCPs). Only 3.3% were prescribed by pain specialists (although the study does not state how it defined these). Multiple studies have demonstrated that most PCPs receive limited education on pain management during their residencies, which raises the question as to how knowledgeable they are about the use of opioids, especially for chronic pain.

This lack of education is reflected in other findings as well. In more than 29% of longer-term opioid users, benzodiazepines were also prescribed within the same month. There are multiple reasons that the concurrent use of these two classes of drugs is contraindicated:

• Co-prescribing increases the risk of mortality

• Benzodiazepines can interfere with the analgesic actions of opioids

• Extended benzodiazepine use can result in a lower pain threshold

Over 27% of the longer-term opioid users were taking 2 or more short-acting opioids concurrently, although this practice is generally contraindicated, since there is nothing to demonstrate that doing so provides any better analgesia than taking only 1 at a time.

The study also found that of the 25 cities with the highest prevalence of longer-term opioid use, 24 had populations of less than 100,000. Such cities would be less likely to have any pain specialists and more likely to have to rely on PCPs to manage pain. It is also worth noting that cities with smaller populations are less likely to have many practicing psychiatrists, which may make it difficult for PCPs to find assistance in managing patients whom they believe may be running into problems with the medications.

Overall, the report indicates that despite the widespread attention being paid to problems associated with the use of prescription opioids and especially their long-term use, many physicians are still apparently not prescribing them on the basis of our current state of knowledge regarding the best practices for doing so.

References:

1. The Express Scripts Lab. A Nation in Pain: Focusing on U.S. Opioid Trends for Treatment of Short-Term and Longer-Term Pain. An Express Scripts Report; December 2014. http://lab.express-scripts.com/publications/a-nation-in-pain. Accessed March 18, 2015.

2. Schwarz A. Missouri alone in resisting prescription drug database. New York Times. July 20, 2014. http://www.nytimes.com/2014/07/21/us/missouri-alone-in-resisting-prescription-drug-database.html?_r=0. Accessed March 18, 2015.