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

Goldstick, Jason E.; Guy, Gery P.; Losby, Jan L.; Baldwin, Grant T.; Myers, Matthew; Bohnert, Amy S. B.

doi:10.1001/jamanetworkopen.2022.16475

Cited by 16 publications

(13 citation statements)

References 31 publications

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“…Treatments for Acute Pain. The contextual evidence review found limited evidence suggesting variability in patient values and preferences regarding treatments for acute pain ( 60 , 61 ), with some evidence of high satisfaction when postoperative pain was managed using an opioid-sparing pathway ( 62 ). Also, there was variability in clinician values and preferences regarding acute pain treatments that were affected by clinical specialty, knowledge regarding effectiveness, and costs; negative attitudes toward acute pain conditions were associated with less likelihood of using or redosing opioids ( 63 – 67 ).…”

Section: Primary Clinical Questionsmentioning

confidence: 99%

“…The timing of this release was associated with accelerated decreases in overall opioid prescribing and declines in potentially high-risk prescribing (e.g., high-dosage opioid prescribing and concurrent prescribing of opioid pain medication and benzodiazepines) ( 58 , 59 ). The release of the 2016 CDC Opioid Prescribing Guideline also was temporally associated with modest increases in the prescribing of nonopioid pain medication ( 60 ). Although not the intent of the 2016 CDC Opioid Prescribing Guideline, design and implementation of new laws, regulations, and policies also appeared to reflect its recommendations.…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

CDC Clinical Practice Guideline for Prescribing Opioids for Pain—United States, 2022

Dowell¹,

Ragan²,

Jones³

et al. 2022

MMWR Recomm. Rep.

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799

465

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Summary This guideline provides recommendations for clinicians providing pain care, including those prescribing opioids, for outpatients aged ≥18 years. It updates the CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016 (MMWR Recomm Rep 2016;65[No. RR-1]:1–49) and includes recommendations for managing acute (duration of <1 month), subacute (duration of 1–3 months), and chronic (duration of >3 months) pain. The recommendations do not apply to pain related to sickle cell disease or cancer or to patients receiving palliative or end-of-life care. The guideline addresses the following four areas: 1) determining whether or not to initiate opioids for pain, 2) selecting opioids and determining opioid dosages, 3) deciding duration of initial opioid prescription and conducting follow-up, and 4) assessing risk and addressing potential harms of opioid use. CDC developed the guideline using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Recommendations are based on systematic reviews of the scientific evidence and reflect considerations of benefits and harms, patient and clinician values and preferences, and resource allocation. CDC obtained input from the Board of Scientific Counselors of the National Center for Injury Prevention and Control (a federally chartered advisory committee), the public, and peer reviewers. CDC recommends that persons with pain receive appropriate pain treatment, with careful consideration of the benefits and risks of all treatment options in the context of the patient’s circumstances. Recommendations should not be applied as inflexible standards of care across patient populations. This clinical practice guideline is intended to improve communication between clinicians and patients about the benefits and risks of pain treatments, including opioid therapy; improve the effectiveness and safety of pain treatment; mitigate pain; improve function and quality of life for patients with pain; and reduce risks associated with opioid pain therapy, including opioid use disorder, overdose, and death.

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Section: Primary Clinical Questionsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

CDC Clinical Practice Guideline for Prescribing Opioids for Pain—United States, 2022

Dowell¹,

Ragan²,

Jones³

et al. 2022

MMWR Recomm. Rep.

Self Cite

799

465

View full text Add to dashboard Cite

show abstract

“…Overall, there is a paucity of studies analyzing the trend of opioid usage for CLBP in the advent of CDC guidelines. In a prospective national cohort study Goldstick et al 40 found an increase in non‐opioid medication usage suggesting adoption of concordant care practices among a generalized adult patient population with known or recent opioid exposure. Our report highlights the contrary where opioid therapy, at least for the treatment of CLBP, not only remains as a mainstay of treatment but also is increasing despite the CDC 2016 guidelines.…”

Section: Discussionmentioning

confidence: 99%

Chronic low back pain comorbidity count and its impact on exacerbating opioid and non‐opioid prescribing behavior

Moses-Hampton

Povieng

Ghorayeb³

et al. 2022

Pain Practice

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Research Objectives The objective of the study was to determine the characteristics of chronic low back pain (CLBP) comorbidity and its impact on opioid and non‐opioid treatments among Chicagoland patients with CLBP. Design A retrospective cross‐sectional study comparing differences in comorbidity and treatment patterns among Chicagoland patients with CLBP against a matched control arm without chronic low back pain (NCLBP). Setting Academic hospital system outpatient services. Participants Using the International Classification of Diseases, 10th Revision codes (ICD 10) 9589 patients were identified with CLBP with a median age of 57 years old and 62.32% female distribution. The NCLBP group comprised 9589 age‐, sex‐, race‐, and region‐matched patients. Results An increased prevalence across all 17 studied comorbidities was found in CLBP patients as compared to NCLBP patients. CLBP patients carried an average of 3.5 comorbidities compared with 2.4 comorbidities in NCLBP patients. Rheumatoid arthritis (RA), joint arthritis, and obesity had the strongest relationship with CLBP. Additionally, we found that the most prescribed treatment for CLBP were opioids, which ranked above NSAIDs and physical therapy. 56% of CLBP patients were prescribed opioids as compared to 36% of NCLBP patients (Odds Ratio = 2.28, 95% CI: 2.16–2.42). Tramadol was the agent with the strongest relationship to CLBP. CLBP patients were more likely to use two or more opioids concomitantly. The number of total treatments was positively associated with the number of comorbidities in both CLBP and NCLBP patients (Cochran‐Armitage trend test p < 0.0001). Conclusions Chronic low back pain patients showed a higher number of comorbidities than their NCLBP counterparts. Comorbidity count trended positively with higher treatment burden with opioids being the most prescribed treatment, often with poly‐opioid use, over conservative modalities such as NSAIDs and physical therapy.

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“…Similar patterns were found when examining specific subpopulations, including those with chronic pain, previous opioid exposure, substance use disorder, anxiety disorder, or mood disorder. 5 These shifts suggest that nonopioid medications replaced opioid medications, but the overall increase in nonopioid prescribing rates was small. On the other hand, claims data analysis cannot account for commonly used over-the-counter medications (eg, nonsteroidal anti-inflammatory drugs and acetaminophen).…”

mentioning

confidence: 99%

“…In particular, the insurance claims data set from this study did not include patients with public insurance (eg, Medicaid) or no insurance, nor were demographic subgroups analyzed. 5 Previous studies found that patients of Black race, with low income, without insurance, and with Medicaid coverage received fewer opioids, nonopioids, and referrals for nonpharmacologic treatment for pain. 7,8 Therefore, a related but unanswered question is whether the 2016 CDC guideline played a role in nonopioid prescribing among historically minoritized populations.…”

mentioning

confidence: 99%

Nonopioid Treatments for Chronic Pain—Integrating Multimodal Biopsychosocial Approaches to Pain Management

2022

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Chronic pain is a major health burden in the US, with recent estimates indicating that 1 in 5 adults has chronic pain. 1 Nearly 40% of these individuals experience substantial impairments in function or daily activities as a result of their pain. 1 The prevalence of chronic pain has been growing in the past 2 decades, accompanied by an increase in opioid prescribing for pain. However, the exponential increase in opioid-related deaths prompted the development of the 2016 Centers for Disease Control and Prevention (CDC) guideline to reduce opioid prescribing for chronic pain. 2 This guideline, along with several other efforts to limit opioids, has been associated with decreased opioid prescribing rates across multiple settings and patient populations. 3,4 Although promising, minimizing the use of 1 treatment strategy without ensuring access to other effective and viable alternatives may expose patients to inadequate treatment and worsening of chronic pain. The CDC guideline attempts to address this issue by recommending nonopioid medication and nonpharmacologic pain management as first-line treatments for chronic pain. 2 However, a major question remains: has the reduced use of opioids been accompanied by greater use of alternative treatments for chronic pain?The study by Goldstick et al 5 takes a major step toward answering this question. The authors assessed the prescribing rates of several classes of nonopioid pain medications before and after the release of the 2016 CDC guideline. They included a large nationwide cohort of commercially insured patients with some of the most common types of chronic pain: neck or back pain, osteoarthritis, nonmigraine headaches, and fibromyalgia. The analysis focused on specific medication classes that have been commonly prescribed for chronic pain: nonsteroidal anti-inflammatory drugs, acetaminophen, gabapentinoid and carbamazepine anticonvulsants, and antidepressants. These medications have been shown to provide small-to-moderate short-term benefit and are recommended by guidelines for chronic pain treatment. 6 Medications whose evidence was primarily for acute pain management (eg, skeletal muscle relaxants) were not included. The authors constructed sequential cohorts to analyze the prescribing patterns over time for the overall population and for specific subpopulations.Similar to previous work, the study by Goldstick et al 5 found greater reductions in opioid prescribing after the release of the 2016 CDC guideline compared with the preguideline pattern. The authors also found that, although nonopioid prescribing rates had remained relatively constant over the 4-year period before the release of the guideline, these rates steadily increased during the 2 years after the release. Similar patterns were found when examining specific subpopulations, including those with chronic pain, previous opioid exposure, substance use disorder, anxiety disorder, or mood disorder. 5 These shifts suggest that nonopioid medications replaced opioid medications, but the overall increase in nonopio...

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

Abstract: This cohort study examines the preguideline and postguideline prescribing rates of nonopioid vs opioid pain medication among individuals with commercial insurance.

Cited by 16 publications

References 31 publications

CDC Clinical Practice Guideline for Prescribing Opioids for Pain—United States, 2022

CDC Clinical Practice Guideline for Prescribing Opioids for Pain—United States, 2022

Chronic low back pain comorbidity count and its impact on exacerbating opioid and non‐opioid prescribing behavior

Nonopioid Treatments for Chronic Pain—Integrating Multimodal Biopsychosocial Approaches to Pain Management

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