DUR: Long-Acting Opioids for Chrionic Pain
Effective management of chronic pain has become an increasingly critical issue in health care. Opioid agonists are among the most effective analgesics available for reducing pain perception; however, their use for chronic pain has been controversial. This is due primarily to regulatory barriers, misunderstanding about pain management among primary caregivers, fear of adverse effects and misconceptions about risks of addiction.1
The last 10 years have brought acceptance that opioids can be used as a component of the management of chronic (lasting more than six months) non-cancer pain when other approaches have failed and quality of life is poor because of the pain. A number of pain-related organizations and experts have recently expressed support for the judicious use of sustained-release or long-acting opioids in patients with chronic pain. The American Academy of Pain Medicine and the American Pain Society have issued a statement that supports the use of opioids in selected patients with chronic non-cancer pain.2 Although these recommendations include both pharmacological and non-pharmacological approaches, several recommendations can be supported by Medi-Cal DUR activities when treating chronic pain:
- Administer opioids primarily via oral or transdermal routes, using long-acting medications when possible
- Use a fixed dose (“around-the-clock”) regimen
- Perform careful drug titration, balancing analgesia against side effects
- Continue efforts to improve analgesia via complementary approaches (e.g., behavioral approaches, formal rehabilitation programs, other medications)
- Monitor for evidence of drug hoarding, unauthorized dose increases and other aberrant behavior
Medi-Cal Chronic Opioid Medication Use Evaluation (MUE)
The narcotic analgesics continue to rank among the top 10 therapeutic classes by
total costs in the Medi-Cal fee-for-service population. In February 2004,
narcotic analgesics accounted for over 156,000 paid prescriptions at a cost of
over $8.5 million for that month. To assess the patterns of opioid use in the
Medi-Cal population, a Medication Use Evaluation (MUE) was conducted.
The population was identified using the pharmacy claims database for Medi-Cal fee-for-service recipients between November 1, 2003 and April 30, 2004. Patients were selected based having claims paid for Long-Acting Opioids (LAO) and/or Short-Acting Opioids (SAO). Duplicate, denied or reversed claims were excluded in order to reflect true usage.
Findings
The average monthly Medi-Cal fee-for-service eligible population selected for
the study period was 3,137,741. In the six-month time frame, a total of 39,948
patients were identified as having a paid claim for one or more LAO or chronic
SAO (defined as greater than 90 days of use). There were 48,299 unique
prescription claims for opioids for the study population.
The Good...
- The percentage of patients on LAO therapy is 70.4 percent while 29.6 percent continue to receive SAO after 90 days of treatment. Of the patients on LAO therapy, 32.3 percent are receiving therapy via transdermal patches. This data suggests that the Medi-Cal prescribers are appropriately dosing LAO agents in the majority of patients.
- The age distribution of opioid users is very similar to national benchmarks with the majority of usage in the 35-64 year old group.
The Not-So-Bad...
- There were 2,832 patients (6.2 percent) taking more than one LAO or chronic SAO at the same time. While there is no evidence from randomized trials to support the use of two LAOs or two SAOs at the same time, prescribers appear to be appropriately treating the majority of patients on multiple agents (78.81 percent) with an LAO and SAO for “rescue” or “breakthrough” analgesia.
| Combination | Events | Percent of Total | |
LAO; LAO |
620 |
21.9 |
|
SAO; SAO |
150 |
5.30 |
|
SAO; LAO |
2062 |
78.81 |
- Approximately 25 percent of patients are receiving chronic SAO for long-term therapy.
- There were 15,857 unique claims for patients receiving an acetaminophen-containing agent. In a small number of cases (5 percent) the daily dose of acetaminophen exceeded the maximum dose of 4.1 grams.
- The daily average consumption for LAOs is slightly higher than the recommended doses for all agents except Duragesic.
The Ugly...
- The data shows that greater than 7.5 percent of opioid recipients receive drugs from four or more prescribers. The accuracy of this finding is limited by the quality of the prescriber data provided by pharmacies at the point of service (prescriber data is incomplete, inaccurate or missing). Nevertheless, it indicates a potentially serious problem of patients doctor-shopping.
Commentary
The results of the Medi-Cal chronic opioid MUE suggest that the patterns of
LAO and SAO use in the
fee-for-service population are largely consistent with recommended standards.
The information regarding multiple prescribers requires further exploration and
intervention.
Opioids can be beneficial and safe as a component of long-term pain
management. Restrictions on their use have been recently changed to increase
appropriate patient access to pain medication and prevent the diversion of
controlled substances for illicit use.
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1 Garner-Nix, J. (2003) Principles of Opioid Use in Chronic
Noncancer Pain. Can Med Assoc J; 169(1); 38-43.
2 Haddox JD, et.al. (1997) The Use of Opioids for the Treatment
of Chronic Pain. A Consensus statement from the
American Academy of Pain Medicine and the American Pain Society.
Glenview, IL: American Pain Society.