Dataset Information

Patterns in Nonopioid Pain Medication Prescribing After the Release of the 2016 Guideline for Prescribing Opioids for Chronic Pain.

ABSTRACT:

Importance

In 2016, the Centers for Disease Control and Prevention (CDC) released the evidence-based Guideline for Prescribing Opioids for Chronic Pain. How the release of this guideline coincided with changes in nonopioid pain medication prescribing rates remains unknown.

Objective

To evaluate changes in nonopioid pain medication prescribing after the 2016 CDC guideline release and to assess the heterogeneity in these changes as a function of patient demographic and clinical characteristics.

Design, setting, and participants

This cohort study constructed 7 (4 preguideline and 3 postguideline) annual cohorts using claims data from the national Optum Clinformatics Data Mart Database for the period January 1, 2011, through December 31, 2018. The cohorts included adults with commercial insurance, no cancer or palliative care claims, and 2 years of continuous insurance enrollment. Individuals could qualify for inclusion in multiple cohorts. Each cohort covered a 2-year period, with year 1 as the baseline period used to calculate opioid exposure and other clinical characteristics and year 2 as the follow-up period used to calculate prescribing outcomes. Data were analyzed in March 2022.

Exposures

The CDC guideline, which was released in March 2016.

Main outcomes and measures

The primary outcome was receipt of any nonopioid pain medication prescriptions (analgesics or antipyretics, anticonvulsants, antidepressants, and nonsteroidal anti-inflammatory drugs) during the follow-up period. This postguideline prescribing pattern was compared with estimates based on the preguideline prescribing pattern, and then the differences were stratified by patient clinical characteristics (chronic pain, recent opioid exposure, substance use disorder, anxiety disorder, and mood disorder).

Results

A total of 15 879 241 individuals (2015 mean [SD] age, 50.2 [18.6] years; 8 298 271 female patients [52.3%]) qualified for inclusion in 1 or more cohorts. Logistic regression models showed that nonopioid pain medication prescribing odds were higher by 3.0% (95% CI, 2.6%-3.3%) in postguideline year 1, by 8.7% (95% CI, 8.3%-9.2%) in postguideline year 2, and by 9.7% (95% CI, 9.2%-10.3%) in postguideline year 3 than the preguideline pattern-based estimates. The magnitude of the postguideline departures from the preguideline pattern varied by several clinical characteristics (chronic pain, recent opioid exposure, anxiety disorder, and mood disorder). The largest departure was found among those with chronic pain, with postguideline prescribing being higher than estimated in postguideline year 2 (13.6%; 95% CI, 12.7%-14.6%) and postguideline year 3 (14.9%; 95% CI, 13.8%-16.0%).

Conclusions and relevance

Results of this study showed increases in nonopioid pain medication prescribing after the release of the 2016 CDC guideline, suggesting that the guideline may be associated with an increase in guideline-concordant care, but additional studies are needed to understand the role of other secular changes in the opioid policy landscape and other sources of nonopioid medication use.

SUBMITTER: Goldstick JE

PROVIDER: S-EPMC9187961 | biostudies-literature | 2022 Jun

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Patterns in Nonopioid Pain Medication Prescribing After the Release of the 2016 Guideline for Prescribing Opioids for Chronic Pain.

Goldstick Jason E JE Guy Gery P GP Losby Jan L JL Baldwin Grant T GT Myers Matthew G MG Bohnert Amy S B ASB

JAMA network open 20220601 6

<h4>Importance</h4>In 2016, the Centers for Disease Control and Prevention (CDC) released the evidence-based Guideline for Prescribing Opioids for Chronic Pain. How the release of this guideline coincided with changes in nonopioid pain medication prescribing rates remains unknown.<h4>Objective</h4>To evaluate changes in nonopioid pain medication prescribing after the 2016 CDC guideline release and to assess the heterogeneity in these changes as a function of patient demographic and clinical char ...[more]

PMID: 35687334

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Project description:ImportancePrimary care clinicians find managing chronic pain challenging. Evidence of long-term efficacy of opioids for chronic pain is limited. Opioid use is associated with serious risks, including opioid use disorder and overdose.ObjectiveTo provide recommendations about opioid prescribing for primary care clinicians treating adult patients with chronic pain outside of active cancer treatment, palliative care, and end-of-life care.ProcessThe Centers for Disease Control and Prevention (CDC) updated a 2014 systematic review on effectiveness and risks of opioids and conducted a supplemental review on benefits and harms, values and preferences, and costs. CDC used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework to assess evidence type and determine the recommendation category.Evidence synthesisEvidence consisted of observational studies or randomized clinical trials with notable limitations, characterized as low quality using GRADE methodology. Meta-analysis was not attempted due to the limited number of studies, variability in study designs and clinical heterogeneity, and methodological shortcomings of studies. No study evaluated long-term (≥1 year) benefit of opioids for chronic pain. Opioids were associated with increased risks, including opioid use disorder, overdose, and death, with dose-dependent effects.RecommendationsThere are 12 recommendations. Of primary importance, nonopioid therapy is preferred for treatment of chronic pain. Opioids should be used only when benefits for pain and function are expected to outweigh risks. Before starting opioids, clinicians should establish treatment goals with patients and consider how opioids will be discontinued if benefits do not outweigh risks. When opioids are used, clinicians should prescribe the lowest effective dosage, carefully reassess benefits and risks when considering increasing dosage to 50 morphine milligram equivalents or more per day, and avoid concurrent opioids and benzodiazepines whenever possible. Clinicians should evaluate benefits and harms of continued opioid therapy with patients every 3 months or more frequently and review prescription drug monitoring program data, when available, for high-risk combinations or dosages. For patients with opioid use disorder, clinicians should offer or arrange evidence-based treatment, such as medication-assisted treatment with buprenorphine or methadone.Conclusions and relevanceThe guideline is intended to improve communication about benefits and risks of opioids for chronic pain, improve safety and effectiveness of pain treatment, and reduce risks associated with long-term opioid therapy.

Project description:ImportanceThe Centers for Disease Control and Prevention (CDC) released the "Guideline For Prescribing Opioids For Chronic Pain" (hereafter, CDC guideline) in 2016, but its association with prescribing practices for patients who are opioid naive is unknown.ObjectiveTo estimate changes in initial prescribing rates, duration, and dosage practices to patients who are opioid naive after the release of the CDC guideline.Design, setting, and participantsThis cohort study used 6 sequential cohorts to estimate preguideline trends in prescribing among patients who were opioid naive, project that trend forward, and compare it with postguideline prescribing practices. Participants included commercially insured adults without current cancer or hospice care diagnoses and with no past-year opioid claims in the US from 2011 to 2017. All adjusted models were controlled for patient demographics and state-fixed effects. Data were analyzed from January 2020 to May 2021.ExposuresThe release of the CDC guideline.Main outcomes and measuresIndicators of any opioid prescription fills during a 9-month period, the number of days' supply of the initial prescription, and the binary indicator of whether the initial prescription was for 50 or more morphine milligram equivalents (MMEs) per day.ResultsThere were 12 870 612 eligible unique patients across cohorts (mean [SD] age in 2016, 51.2 [18.7] years; 6 553 458 [50.9%] women); and the mean (SD) age of the cohorts increased annually, from 48.7 (17.9) years in the April 2011 to December 2012 cohort to 51.9 (19.2) years in the April 2016 to December 2017 cohort. The postguideline prescribing prevalence was 532 962 of 5 834 088 individuals (9.1%), which exceeded that projected from the preguideline trend, estimated at 9.0% (95% CI, 9.0%-9.1%). Among patients receiving prescriptions during follow-up, adjusted mean days' supply was 4.7% (95% CI, 4.3%-5.1%) lower in the first year after release of the guideline and 9.8% (95% CI, 9.3%-10.3%) lower in the second year after release, compared with the expected rate from the preguideline trend. The adjusted odds of receiving a high-dose (ie, ≥50 MME/d) initial prescription were lower in the first year (odds ratio, 0.97; 95% CI, 0.96-0.98) and in the second year (odds ratio, 0.94; 95% CI, 0.93-0.96) after the release of the CDC guideline compared with the odds expected from the preguideline trend.Conclusions and relevanceThis cohort study found that patients who were opioid naive continued to initiate opioid therapy after the release of opioid prescribing guidelines by the CDC, but trends in prescribing duration reversed and decreased, after increasing in each of 4 preguideline cohorts examined. High-dose prescribing rates were already decreasing, but those trends accelerated after the CDC guideline release. These results suggest that nonmandatory, evidence-based guidelines from trusted sources were associated with prescribing practices. Guideline-concordant care has potential to improve pain management and reduce opioid-related harms.

Project description:ImportanceEvidence suggests that opioid prescribing was reduced nationally following the 2016 release of the Guideline for Prescribing Opioids for Chronic Pain by the US Centers for Diseases Control and Prevention (CDC). State-to-state variability in postguideline changes has not been quantified and could point to further avenues for reducing opioid-related harms.ObjectiveTo estimate state-level changes in opioid dispensing following the 2016 CDC Guideline release and explore state-to-state heterogeneity in those changes.Design, setting, and participantsThis cross-sectional study included information on opioid prescriptions for US individuals between 2012 and 2018 from an administrative database. Serial cross-sections of monthly opioid dispensing trajectories in each US state and the District of Columbia were analyzed using segmented regression to characterize preguideline dispensing trajectories and to estimate how those trajectories changed following the 2016 guideline release. Data were analyzed January to March 2023.ExposureThe March 2016 CDC Guideline for Prescribing Opioids for Chronic Pain.Main outcomes and measuresFour measures of opioid dispensing: opioid dispensing rate per 100 000 persons, long-acting opioid dispensing rate per 100 000 persons, high-dose (90 or more morphine milligram equivalents [MME] per day) dispensing rate per 100 000 persons, and average per capita MME. All measures were calculated monthly, from January 2012 through December 2018.ResultsData from approximately 58 900 retail pharmacies were included in analysis, representing approximately 92% of US retail prescriptions. The overall monthly dispensing rate in the US in early 2012 was approximately 7000 per 100 000 population. Following the 2016 guideline release, the already-decreasing slope accelerated nationally for the overall dispensing rate (preguideline slope, -23.19; postguideline slope, -48.97; change in slope, 25.97 [95% CI, 18.67-32.95]), long-acting dispensing rate (preguideline slope, -1.03; postguideline slope, -5.94; change in slope, 4.90 [95% CI, 4.26-5.55]), high-dose dispensing (preguideline slope, -3.52; postguideline slope, -7.63; change in slope, 4.11 [95% CI, 3.49-4.73]), and per-capita MME (preguideline slope, -0.22; postguideline slope, -0.58; change in slope, 0.36 [95% CI, 0.30-0.42]). For all outcomes, nearly all states showed analogous acceleration of an already-decreasing slope, but there was substantial state-to-state heterogeneity. Slope changes (preguideline - postguideline slope) ranged from 9.15 (Massachusetts) to 74.75 (Mississippi) for overall dispensing, 1.88 (Rhode Island) to 13.41 (Maine) for long-acting dispensing, 0.71 (District of Columbia) to 13.68 (Maine) for high-dose dispensing, and 0.06 (Hawaii) to 0.91 (Arkansas) for per capita MME.Conclusions and relevanceThe 2016 CDC Guideline release was associated with broad reductions in prescription opioid dispensing, and those changes showed substantial geographic variability. Determining the factors associated with these state-level differences may inform further improvements to ensure safe prescribing practices.

Project description:PurposeTo generate an evidence-based opioid-prescribing guideline by assessing the pattern of total opioid consumption and the factors that may predict opioid consumption following arthroscopic release of elbow contracture and to investigate whether the use of continuous passive motion (CPM), as compared to physical therapy (PT), was associated with a decrease in pain and opioid consumption after arthroscopic release of elbow contracture.MethodsData collected from a randomized controlled trial that compared continuous passive motion (CPM) (n = 24) to physical therapy (PT) (n = 27) following arthroscopic release of elbow contracture was analyzed for opioid use. Fifty-one participants recorded their daily opioid consumption in a postoperative diary for 90 days. Multivariate analysis was performed to identify factors associated with opioid use. Recommended quantities for postoperative prescription were generated using the 50th percentile for patients without and the 75th percentile for patients with factors associated with higher opioid use.ResultsThe median total opioid prescription was 437.5-mg morphine milligram equivalents (MMEs) (58 pills of 5 mg oxycodone) and the median total opioid consumption was 75 MMEs (10 pills of 5-mg oxycodone). Twenty-two percent of patients took no opioid medication, 53% took ≤10 pills, 69% took ≤20 pills and 75% took ≤30 pills. Predictors of higher opioid use were preoperative opioid use, age <60 years and inflammatory arthritis. The total opioid consumption appeared similar between the CPM and the PT group. Seventy-five percent of patient's home opioid requirements would be satisfied using the following guideline: Patients undergoing contracture release for osteoarthritis or post-traumatic contracture should be given a prescription for 10 pills of 5 mg oxycodone or its equivalent at discharge. Patients with inflammatory conditions or those taking preoperative opioids should be prescribed 30 pills of 5 mg oxycodone or its equivalent.ConclusionThis study suggests that most patients undergoing arthroscopic release of elbow contracture use relatively few opioid pills after surgery. Use of an evidence-based guideline could decrease opioid prescriptions substantially, while still effectively treating patients' pain.

Project description:ImportanceGuidelines recommend deprescribing opioids in older adults due to risk of adverse effects, yet little is known about patient-clinician opioid deprescribing conversations.ObjectiveTo understand the experiences of older adults and primary care practitioners (PCPs) with using opioids for chronic pain and discussing opioid deprescribing.Design, setting, and participantsThis qualitative study conducted semistructured individual qualitative interviews with 18 PCPs and 29 adults 65 years or older prescribed opioids between September 15, 2022, and April 26, 2023, at a Boston-based academic medical center. The PCPs were asked about their experiences prescribing and deprescribing opioids to older adults. Patients were asked about their experiences using and discussing opioid medications with PCPs.Main outcome and measuresShared and conflicting themes between patients and PCPs regarding perceptions of opioid prescribing and barriers to deprescribing.ResultsIn total, 18 PCPs (12 [67%] younger that 50 years; 10 [56%] female; and 14 [78%] based at an academic practice) and 29 patients (mean [SD] age, 72 [5] years; 19 [66%] female) participated. Participants conveyed that conversations between PCPs and patients on opioid use for chronic pain were typically challenging and that conversations regarding opioid risks and deprescribing were uncommon. Three common themes related to experiences with opioids for chronic pain emerged in both patient and PCP interviews: opioids were used as a last resort, opioids were used to improve function and quality of life, and trust was vital in a clinician-patient relationship. Patients and PCPs expressed conflicting views on risks of opioids, with patients focusing on addiction and PCPs focusing on adverse drug events. Both groups felt deprescribing conversations were often unsuccessful but had conflicting views on barriers to successful conversations. Patients felt deprescribing was often unnecessary unless an adverse event occurred, and many patients had prior negative experiences tapering. The PCPs described gaps in knowledge on how to taper, a lack of clinical access to monitor patients during tapering, and concerns about patient resistance.Conclusions and relevanceIn this qualitative study, PCPs and older adults receiving long-term opioid therapy viewed the use of opioids as a beneficial last resort for treating chronic pain but expressed dissonant views on the risks associated with opioids, which made deprescribing conversations challenging. Interventions, such as conversation aids, are needed to support collaborative discussion about deprescribing opioids.

Dataset Information

Patterns in Nonopioid Pain Medication Prescribing After the Release of the 2016 Guideline for Prescribing Opioids for Chronic Pain.

Importance

Objective

Design, setting, and participants

Exposures

Main outcomes and measures

Results

Conclusions and relevance

Publications

Patterns in Nonopioid Pain Medication Prescribing After the Release of the 2016 Guideline for Prescribing Opioids for Chronic Pain.

Similar Datasets

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