Determinants of Opioid Prescribing for Nonmalignant Chronic Pain in US Outpatient Settings.

Study Objectives: Identify prescribing trends for opioid use in non-malignant chronic pain (NMCP) from the National Ambulatory Medical Care Survey (NAMCS). Determine predictors of opioid use based on patient-specific factors. Design: This cross-sectional study analyzed NAMCS data from 2000 to 2007. Pain medications prescribed were retrieved using NAMCS drug codes. Multivariate logistic models examined determinants of opioid prescribing among NMCP patients. Subjects: Patients included in the study were age 18 years or older with NMCP diagnosis based on ICD-9 codes identified as reason for visits. Results: Approximately 690 million weighted outpatient visits related to NMCP were reported in the US between 2000 to 2007. Reported opioid use was 14.3%. Compared with patients age 18 to 34 years, patients age 35 to 49 years were 1.47 times more likely (odds ratio [OR] = 1.47, 95% confidence interval [CI] = 1.17-1.86) and patients age 65 years or older were 0.61 times less likely (OR = 0.39, 95% CI = 0.27-0.55] to receive opioids. Patient visits from primary care physicians were 1.83 times more likely to report opioids (OR = 1.83, 95% CI = 1.50-2.25) than specialty physicians. Hispanic ethnicity and patients with private insurance were less likely to receive opioids, while patients having five or more medications, publicly funded insurance, the ICD-9 code of general chronic pain, established patients, and the southern prescribing region were more likely to receive opioids. Conclusions: Differences exist between those prescribed and not prescribed opioids. Results from this study paired with increased education and further research regarding the appropriate prescribing and monitoring of opioids may help enhance awareness, diminish treatment disparities and improve safe and appropriate use of opioids in the NMCP population.

Assessing Prescribing Trends of Adjuvant Medication Therapy in Outpatients With a Diagnosis of Noncancer Chronic Pain.

BACKGROUND: Chronic pain affects over 100 million adults in the United States, yet continues to be difficult to treat. Concerns continue to mount over the use of opioids to treat noncancer chronic pain (NCCP). Guidelines support the use of adjuvant medications as one of the preferred options for treating chronic pain over opioids. OBJECTIVES: To examine reported usage of adjuvants in the treatment of chronic pain via the National Ambulatory Medical Care Survey (NAMCS). MATERIALS AND METHODS: A retrospective, cross-sectional study evaluating reported usage of adjuvant pain medications for the treatment of NCCP was conducted using NAMCS data from 2000 to 2007. Weighted samples were analyzed with regard to several patient variables. Logistic regression models provided 95% confidence intervals and an adjusted odds ratio to determine statistically significant differences in reported usage for the evaluated patient variables. RESULTS: In total, 244,797,406 weighted visits were included for analysis. The analysis showed an almost 2-fold increase in adjuvant use during the study period. Statistically significant differences were identified for several factors evaluated. Younger age, female sex, care from a nonprimary care physician, comorbidities with pain, and >5 current medications were associated with higher rates adjuvant therapy use. DISCUSSION: Overall adjuvant usage dramatically increased during the study period. Analysis of data demonstrated adjuvant use in chronic pain varied based patient-specific characteristics. These results may allow clinicians, policy makers, and medical educators to identify potential gaps in adjuvant use in certain populations and target areas for clinical, populations-based, and educational improvements in managing NCCP.

Persistent nonmalignant pain management using nonsteroidal anti-inflammatory drugs in older patients and use of inappropriate adjuvant medications.

OBJECTIVE: Due to the high risk of life-threatening side effects, nonsteroidal anti-inflammatory drugs (NSAIDs) are not favored for treating persistent nonmalignant pain in the elderly. We report national prescription trends with determinants of NSAIDs prescription for persistent nonmalignant pain among older patients (age 65 and over) in the US outpatient setting. METHODS: A cross-sectional analysis was performed using National Ambulatory Medical Care Survey data. Prescriptions for NSAIDs, opioids, and adjuvant agents were identified using five-digit National Ambulatory Medical Care Survey drug codes. RESULTS: About 89% of the 206,879,848 weighted visits in the US from 2000 to 2007 recorded NSAIDs prescriptions in patients (mean age =75.4 years). Most NSAIDs users had Medicare (75%), and about 25% were prescribed with adjuvant medications considered inappropriate for their age. Compared to men, women were 1.79 times more likely to be prescribed NSAIDs. CONCLUSION: The high percentage of NSAIDs prescription in older patients is alarming. We recommend investigating the appropriateness of the high prevalence of NSAIDs use among older patients reported in our study.

Effects of changes in patient cost sharing and drug sample policies on prescription drug costs and utilization in a safety-net-provider setting.

PURPOSE: The impact of cost-containment strategies on prescription drug utilization and costs in an ambulatory care safety-net-provider setting was studied, along with the impact of these strategies on patient out-of-pocket expenditures. METHODS: Aggregate monthly prescription drug cost and utilization data were obtained from a health system's outpatient pharmacy computer system for the targeted clinic. The data represented approximately 42,000 patient visits over 38 months. Univariate and multivariate statistics were used to evaluate the influence of copayment increases and changes in prescription drug sample policies on prescription drug costs, prescription drug utilization, and patient expenditures. RESULTS: Prescription drug copayment increases were associated with significant decreases in prescription drug utilization and costs. An average per visit prescription drug copayment increase of $5 was associated with a significant reduction in prescription drug utilization per visit and a $26.07 reduction in prescription drug expenditures per visit per month. Removal of samples from the clinic did not result in a significant decrease in either prescription drug costs or utilization. The presence of samples, however, was associated with a significant reduction in per visit patient expenditures by an amount similar to the copayment for one brand-name prescription drug per visit. CONCLUSION: An increase in patient copayments was associated with reductions in a clinic's drug expenditures and prescription drug utilization per visit. Removal of prescription drug samples had no effect except increasing patients' out-of-pocket drug costs.

Cost of pain medication to treat adult patients with nonmalignant chronic pain in the United States.

BACKGROUND: Nonmalignant chronic pain (NMCP) is a public health concern. Among primary care appointments, 22% focus on pain management. The American Academy of Pain Medicine guidelines for NMCP recommend combination medication therapy (including analgesics, nonsteroidal anti-inflammatory drugs [NSAIDs], opioids, antidepressants, and anticonvulsants) as a key component to effective treatment for many chronic pain diagnoses. However, there has been little evidence outlining the costs of pain medications in adult patients with NMCP in the United States, an area that necessitates further consideration as the nation moves toward value-based benefit design. OBJECTIVES: To estimate the cost of pain medication attributable to treating adult patients with NMCP in the United States and to analyze the trend of outpatient pain visits. METHODS: This cross-sectional study used the National Ambulatory Medical Care Survey (NAMCS) data from 2000-2007. The Division of Health Care Statistics, National Center for Health Statistics, and the Centers for Disease Control and Prevention conducted the survey. The study included patients aged ≥18 years with chronic pain diagnoses (identified by the ICD-9-CM codes: primary, secondary, and tertiary). Patients prescribed at least 1 pain medication were included in the cost analysis. Pain-related prescription medications prescribed during ambulatory care visits were retrieved by using NAMCS drug codes/National Drug Code numbers. National pain prescription frequencies (weighted) were obtained from NAMCS data, using the statistical software STATA. We created pain therapy categories (drug classes) for cost analysis based on national pain guidelines. Drug classes used in this analysis were opioids/opioid-like agents, analgesics/NSAIDs, tricyclic antidepressants, selective serotonin reuptake inhibitors, antirheumatics/immunologics, muscle relaxants, topical products, and corticosteroids. We calculated average prices based on the 3 lowest average wholesale prices reported in the Red Book 2009 for maximum recommended daily dose. Total pain medication costs were calculated in 2009 and 2013 dollar values. The study analyzed NMCP-related outpatient visit trends and used time series analysis to forecast visits using U.S. population data and statistics. RESULTS: The total costs of prescription medications prescribed for pain were $17.8 billion annually in the United States. Cost estimates were captured based on a total of 690,205,290 (~690 million) weighted outpatient visits made for chronic pain from 2000 to 2007 in the United States. Of those patients, 99% received a medication that could be used for NMCP. Among the patients, 29% reported taking ≥5 medications. A linear trend of pain visits is visible, reporting change (from 11% to 14%) from 2000 to 2007 in the United States. All agents except opioids/opioid-like agents and analgesics/NSAIDs were further categorized as adjuvant therapy to create 3 major drug class categories. The largest 3 categories of pain therapy for the United States (annually) were analgesics/NSAIDs ($1.9 billion), opioids ($3.6 billion), and adjuvants ($12.3 billion). Despite having the highest prescription frequency nationally, analgesics/NSAIDS accounted for about 11% of the overall pain medication costs. This study found that adjuvant therapy accounted for 69% of the total pain medication costs. Among adjuvants, 33.5% of the cost was contributed by antirheumatics/immunologics. Other adjuvants included muscle relaxants (4.4%), topical products (8.6%), and corticosteroids (9.4%). CONCLUSIONS: This study demonstrated national prescribing costs and use within various drug categories of pain medications in a large outpatient population over an 8-year period in the United States. Policymakers, stakeholders, and health plan decision makers may consider this cost analysis, since they need to know how drug costs are being allocated. Moreover, information about costs and use of pain medications is valuable for the practitioner making individual patient care decisions, as well as for those who make population based decisions. This study reported an increasing trend of outpatient pain visits in the United States. Therefore, policymakers and health plan decision makers may expect a growing number of pain-related outpatient visits in coming years and allocate resources accordingly to meet the need.

Assessing chronic pain treatment practices and evaluating adherence to chronic pain clinical guidelines in outpatient practices in the United States.

UNLABELLED: Chronic pain is a major health concern in the United States. Several guidelines have been developed for clinicians to promote effective management and provide an analytical framework for evaluation of treatments for chronic pain. This study explores sample population demographics and the utilization of various therapeutic modalities in an adult population with common nonmalignant chronic pain (NMCP) indications in U.S. outpatient settings. A cross-sectional study using the National Ambulatory Medical Care Survey (NAMCS) data from 2000 to 2007 was used to analyze various treatment practices for the management of NMCP and evaluate the results in comparison with guidelines. The study population of 690,205,290 comprised 63% females, with 45.17% of patient visits occurring in primary care settings. Treatment with at least 1 chronic pain medication was reported in 99.7% of patients. Nonsteroidal anti-inflammatory agents were the most common treatment prescribed, with use reported in approximately 95% of the patient visits. No other pain medication drug class or nonmedication therapy was prescribed more than 26.4%. These results point to a potential underutilization of many recommended NMCP treatments including combination therapies and the need for enhanced education of chronic pain guidelines. PERSPECTIVE: This study, representing over 690 million patient visits, contributes to the relative paucity of data on the use of therapeutic modalities in the management of NMCP. These results may assist clinicians and healthcare policymakers in identifying areas where practices are at odds with guidelines with the goal to improve care.