In addition, due to the dramatic reductions in opioid prescribing since 2011, led by –58% for meperidine and –28% for both hydrocodone and oxymorphone, “the high visibility and frequency of the terms ‘opioid epidemic’ or ‘opioid crisis’ in the media continue to be surprising,” Dr. Piper said. “The ‘opioid epidemic’ should be viewed in the context of the number of deaths caused each year by cigarette smoking or alcohol.”
Most Prescription Opioid Use in the U.S. Fell from 2011 to 2016
Compared with both 2006 and 2016, prescription opioid use peaked in 2011 and has declined rapidly since then, according to a study of 10 opioids.
But buprenorphine bucked the trend by being the only opioid that showed an increase during the 10-year study period.
“A prior publication examining use and misuse of opioids in Maine made it abundantly clear that there were substantial gaps in state prescription drug monitoring programs [PDMPs],” said lead study author Brian Piper, PhD, an assistant professor of neuroscience at Geisinger Commonwealth School of Medicine, in Scranton, Pa. “Members of our research team began to suspect that estimates of the morphine milligram equivalents [MMEs] per capita in the United States, although highest in the world, were underestimated.” Three other authors of the current study, which was published in the American Journal of Preventive Medicine (2018;54[5]:652-660) are a psychiatric pharmacist, geriatric pharmacist and specialist in addiction medicine.
image
The findings that medical use of opioids reached its apex in 2011 and has been decisively on the retreat ever since reflects that “the culture surrounding opioid prescribing continues to change,” Dr. Piper said. “But an important exception to this general pattern has been the pronounced increase of 75% in buprenorphine.” Buprenorphine is an opioid partial agonist that is most often used to treat opioid addiction.
A prior publication by the CDC estimated that the MME per year was 640. “However, by using a data source that overcame earlier data gaps and included the Veterans Affairs, Indian Health Services and, most importantly, narcotic treatment programs, we found that the MME was 93% higher [1,237 MMEs],” Dr. Piper said.
When expressed as a percentage of total MMEs, the most prevalent opioid was methadone, which accounted for over 40% of MMEs in 2016 in the United States.
“Given the high profile of opioids and the substantial gaps in other data sources like PDMPs, it was surprising that someone else had not conducted the same study already,” Dr. Piper said.
The study authors were also surprised by the tremendous differences between states in opioid use. “There was a fivefold difference between the highest state, Rhode Island, and the lowest state, North Dakota,” Dr. Piper said. “Pain is a biopsychosocial condition, but there is no reason to believe that the citizens of Rhode Island are biologically different than those from North Dakota. Hence, there is much left to learn about the sociocultural and economic factors that are responsible for the substantial opioid prescribing differences across states.”
In addition, due to the dramatic reductions in opioid prescribing since 2011, led by –58% for meperidine and –28% for both hydrocodone and oxymorphone, “the high visibility and frequency of the terms ‘opioid epidemic’ or ‘opioid crisis’ in the media continue to be surprising,” Dr. Piper said. “The ‘opioid epidemic’ should be viewed in the context of the number of deaths caused each year by cigarette smoking or alcohol.”
The authors advocate three strategies that should be considered to curb opioid use: thoroughly vetting potential policymakers who make decisions about opioids at a state or national level for their conflicts of interest; the ability to report methadone from narcotic treatment programs in PDMPs; and eliminating direct-to-consumer marketing for controlled substances.
“Not being able to report methadone is a barrier for pharmacoepidemiological research, adversely impacts evidence-based medicine, and, most crucial, is an impediment to informed decision making and communication for the health providers of the 345,000 methadone patients in the U.S.,” Dr. Piper said.
Meanwhile, methadone and buprenorphine are two important evidence-based treatments for opioid use disorder that save lives, according to Dr. Piper. “These two medications are as effective as medications for other chronic diseases like diabetes. However, there continues to be too many barriers to treatment access, both economic and social-like stigma.”
Dr. Piper said methadone and buprenorphine work best when combined with psychological interventions, such as contingency management, “which are too often unavailable.”
Charles E. Argoff, MD, the director of the Comprehensive Pain Center at Albany Medical Center, in New York, said the analysis of prescribing trends is very interesting, but the data do not support that opioids are being misused or abused—prescribed or illicit use—any less.
“In fact, the number of people dying from opioid abuse and misuse has actually increased during the study period,” he said, noting that the increase in buprenorphine use also parallels increased abuse. “But the paper does not tell us why people are abusing buprenorphine, nor does it adequately address the increase in illicit use.”
However, reducing the amount of opioid used “does not correlate per se with the effective treatment of pain,” said Dr. Argoff, who also is a Pain Medicine News editorial advisory board member. “The analysis says nothing about the quality of pain management during the study period.”
Overall, the analysis provides quantitative information but scant qualitative information, according to Dr. Argoff. “For instance, is whatever is still being prescribed being used appropriately?” he said. “Similarly, is some of that reduction harming people who previously benefited from these medicines?”
—Bob Kronemyer
Most Prescription Opioid Use in the U.S. Fell from 2011 to 2016
Compared with both 2006 and 2016, prescription opioid use peaked in 2011 and has declined rapidly since then, according to a study of 10 opioids.
But buprenorphine bucked the trend by being the only opioid that showed an increase during the 10-year study period.
“A prior publication examining use and misuse of opioids in Maine made it abundantly clear that there were substantial gaps in state prescription drug monitoring programs [PDMPs],” said lead study author Brian Piper, PhD, an assistant professor of neuroscience at Geisinger Commonwealth School of Medicine, in Scranton, Pa. “Members of our research team began to suspect that estimates of the morphine milligram equivalents [MMEs] per capita in the United States, although highest in the world, were underestimated.” Three other authors of the current study, which was published in the American Journal of Preventive Medicine (2018;54[5]:652-660) are a psychiatric pharmacist, geriatric pharmacist and specialist in addiction medicine.
image
The findings that medical use of opioids reached its apex in 2011 and has been decisively on the retreat ever since reflects that “the culture surrounding opioid prescribing continues to change,” Dr. Piper said. “But an important exception to this general pattern has been the pronounced increase of 75% in buprenorphine.” Buprenorphine is an opioid partial agonist that is most often used to treat opioid addiction.
A prior publication by the CDC estimated that the MME per year was 640. “However, by using a data source that overcame earlier data gaps and included the Veterans Affairs, Indian Health Services and, most importantly, narcotic treatment programs, we found that the MME was 93% higher [1,237 MMEs],” Dr. Piper said.
When expressed as a percentage of total MMEs, the most prevalent opioid was methadone, which accounted for over 40% of MMEs in 2016 in the United States.
“Given the high profile of opioids and the substantial gaps in other data sources like PDMPs, it was surprising that someone else had not conducted the same study already,” Dr. Piper said.
The study authors were also surprised by the tremendous differences between states in opioid use. “There was a fivefold difference between the highest state, Rhode Island, and the lowest state, North Dakota,” Dr. Piper said. “Pain is a biopsychosocial condition, but there is no reason to believe that the citizens of Rhode Island are biologically different than those from North Dakota. Hence, there is much left to learn about the sociocultural and economic factors that are responsible for the substantial opioid prescribing differences across states.”
In addition, due to the dramatic reductions in opioid prescribing since 2011, led by –58% for meperidine and –28% for both hydrocodone and oxymorphone, “the high visibility and frequency of the terms ‘opioid epidemic’ or ‘opioid crisis’ in the media continue to be surprising,” Dr. Piper said. “The ‘opioid epidemic’ should be viewed in the context of the number of deaths caused each year by cigarette smoking or alcohol.”
The authors advocate three strategies that should be considered to curb opioid use: thoroughly vetting potential policymakers who make decisions about opioids at a state or national level for their conflicts of interest; the ability to report methadone from narcotic treatment programs in PDMPs; and eliminating direct-to-consumer marketing for controlled substances.
“Not being able to report methadone is a barrier for pharmacoepidemiological research, adversely impacts evidence-based medicine, and, most crucial, is an impediment to informed decision making and communication for the health providers of the 345,000 methadone patients in the U.S.,” Dr. Piper said.
Meanwhile, methadone and buprenorphine are two important evidence-based treatments for opioid use disorder that save lives, according to Dr. Piper. “These two medications are as effective as medications for other chronic diseases like diabetes. However, there continues to be too many barriers to treatment access, both economic and social-like stigma.”
Dr. Piper said methadone and buprenorphine work best when combined with psychological interventions, such as contingency management, “which are too often unavailable.”
Charles E. Argoff, MD, the director of the Comprehensive Pain Center at Albany Medical Center, in New York, said the analysis of prescribing trends is very interesting, but the data do not support that opioids are being misused or abused—prescribed or illicit use—any less.
“In fact, the number of people dying from opioid abuse and misuse has actually increased during the study period,” he said, noting that the increase in buprenorphine use also parallels increased abuse. “But the paper does not tell us why people are abusing buprenorphine, nor does it adequately address the increase in illicit use.”
However, reducing the amount of opioid used “does not correlate per se with the effective treatment of pain,” said Dr. Argoff, who also is a Pain Medicine News editorial advisory board member. “The analysis says nothing about the quality of pain management during the study period.”
Overall, the analysis provides quantitative information but scant qualitative information, according to Dr. Argoff. “For instance, is whatever is still being prescribed being used appropriately?” he said. “Similarly, is some of that reduction harming people who previously benefited from these medicines?”
—Bob Kronemyer
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