Sullivan MD, Edlund MJ, Fan MY, Devries A, Brennan Braden J, Martin BC. Trends in use of opioids for non-cancer pain conditions 2000-2005 in commercial and Medicaid insurance plans: the TROUP study. Pain. 2008;138:440-449
Opioids are widely prescribed for non-cancer pain conditions (NCPC), but there have been no large observational studies in actual clinical practice assessing patterns of opioid use over extended periods of time. The TROUP (Trends and Risks of Opioid Use for Pain) study reports on trends in opioid therapy for NCPC in two disparate populations, one national and commercially insured population (HealthCore plan data) and one state-based and publicly-insured (Arkansas Medicaid) population over a six year period (2000-2005). We track enrollees with the four most common NCPC conditions: arthritis/joint pain, back pain, neck pain, headaches, as well as HIV/AIDS. Rates of NCPC diagnosis and opioid use increased linearly during this period in both groups, with the Medicaid group starting at higher rates and the HealthCore group increasing more rapidly. The proportion of enrollees receiving NCPC diagnoses increased (HealthCore 33%, Medicaid 9%), as did the proportion of enrollees with NCPC diagnoses who received opioids (HealthCore 58%, Medicaid 29%). Cumulative yearly opioid dose (in mg. morphine equivalents) received by NCPC patients treated with opioids increased (HealthCore 38%, Medicaid 37%) due to increases in number of days supplied rather than dose per day supplied. Use of short-acting Drug Enforcement Administration Schedule II opioids increased most rapidly, both in proportion of NCPC patients treated (HealthCore 54%, Medicaid 38%) and in cumulative yearly dose (HealthCore 95%, Medicaid 191%). These trends have occurred without any significant change in the underlying population prevalence of NCPC or new evidence of the efficacy of long-term opioid therapy and thus likely represent a broad-based shift in opioid treatment philosophy.
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"However, there is a lack of robust evidence supporting the longterm opioid use in CNCP (Chapman et al., 2010), as the majority of the randomized controlled trials are of short duration (Chou et al., 2003, 2009; Noble et al., 2010). In addition, population-based research on the extent and characteristics of exposure to long-term opioids are also limited (Sullivan et al., 2008; Trescot et al., 2008). A variety of opioids are available on the market with different clinical potencies, which can be roughly estimated by an equianalgesic ratio table (Gordon et al., 1999). "
[Show abstract][Hide abstract] ABSTRACT: Background
This study evaluated the prescribing trends of four commonly prescribed strong opioids in primary care and explored utilization in non-cancer and cancer users.Methods
This cross-sectional study was conducted from 2000 to 2010 using the UK Clinical Practice Research Datalink. Prescriptions of buprenorphine, fentanyl, morphine and oxycodone issued to adult patients were included in this study. Opioid prescriptions issued after patients had cancer medical codes were defined as cancer-related use; otherwise, they were considered non-cancer use. Annual number of prescriptions and patients, defined daily dose (DDD/1000 inhabitants/day) and oral morphine equivalent (OMEQ) dose were measured in repeat cross-sectional estimates.ResultsIn total, there were 2,672,022 prescriptions (87.8% for non-cancer) of strong opioids for 178,692 users (59.9% female, 83.9% non-cancer, mean age 67.1 ± 17.0 years) during the study period. The mean annual (DDD/1000 inhabitants/day) was higher in the non-cancer group than in the cancer group for all four opioids; morphine (0.73 ± 0.28 vs. 0.12 ± 0.04), fentanyl (0.46 ± 0.29 vs. 0.06 ± 0.24), oxycodone (0.24 ± 0.19 vs. 0.038 ± 0.028) and buprenorphine (0.23 ± 0.15 vs. 0.008 ± 0.006). The highest proportion of patients were prescribed low opioid doses (OMEQ ≤ 50 mg/day) in both non-cancer (50.3%) and cancer (39.9%) groups, followed by the dose ranks of 51–100 mg/day (26.2% vs. 28.7%), 101–200 mg/day (15.1% vs. 19.2%) and >200 mg/day (8.25% vs. 12.1%).Conclusions
There has been a huge increase in strong opioid prescribing in the United Kingdom, with the majority of prescriptions for non-cancer pain. Morphine was the most frequently prescribed, but the utilization of oxycodone, buprenorphine and fentanyl increased markedly over time.
Full-text · Article · Oct 2014 · European journal of pain (London, England)
"Sullivan and colleagues have concluded that these trends have occurred without any significant change in the underlying population prevalence of CNCP and without new evidence for the efficacy of long-term opioid therapy . These increases may be explained, in part, by aggressive marketing of sustained-release opioid formulations and public efforts to encourage clinicians to become more proactive in identifying and treating chronic pain [17-19]. "
[Show abstract][Hide abstract] ABSTRACT: Opioids are prescribed frequently and increasingly for the management of chronic non-cancer pain (CNCP). Current systematic reviews have a number of limitations, leaving uncertainty with regard to the benefits and harms associated with opioid therapy for CNCP. We propose to conduct a systematic review and meta-analysis to summarize the evidence for using opioids in the treatment of CNCP and the risk of associated adverse events.Methods and design: Eligible trials will include those that randomly allocate patients with CNCP to treatment with any opioid or any non-opioid control group. We will use the guidelines published by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) to inform the outcomes that we collect and present. We will use the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system to evaluate confidence in the evidence on an outcome-by-outcome basis. Teams of reviewers will independently and in duplicate assess trial eligibility, abstract data, and assess risk of bias among eligible trials. To ensure interpretability of our results, we will present risk differences and measures of relative effect for all outcomes reported and these will be based on anchor-based minimally important clinical differences, when available. We will conduct a priori defined subgroup analyses consistent with current best practices.
Our review will evaluate both the effectiveness and the adverse events associated with opioid use for CNCP, evaluate confidence in the evidence using the GRADE approach, and prioritize patient-important outcomes with a focus on functional gains guided by IMMPACT recommendations. Our results will facilitate evidence-based management of patients with CNCP and identify key areas for future research.Trial registration: Our protocol is registered on PROSPERO (CRD42012003023), http://www.crd.york.ac.uk/PROSPERO.
Full-text · Article · Aug 2013 · Systematic Reviews
"The simulation curves in Figure 2 show a steep decrease in the number of acute users. This is due to the exit rate of M being significantly greater than the exit rates of the other compartments, which is consistent with the data . It displays the populations of the respective compartments over the course of 40 months. "
[Show abstract][Hide abstract] ABSTRACT: Vicodin is the most commonly prescribed pain reliever in the United States.
Research indicates that there are two million people who are currently abusing
Vicodin, and the majority of those who abuse Vicodin were initially exposed to
it via prescription. Our goal is to determine the most effective strategies for
reducing the overall population of Vicodin abusers. More specifically, we focus
on whether prevention methods aimed at educating doctors and patients on the
potential for drug abuse or treatment methods implemented after a person abuses
Vicodin will have a greater overall impact. We consider one linear and two
non-linear compartmental models in which medical users of Vicodin can
transition into the abuser compartment or leave the population by no longer
taking the drug. Once Vicodin abusers, people can transition into a treatment
compartment, with the possibility of leaving the population through successful
completion of treatment or of relapsing and re-entering the abusive
compartment. The linear model assumes no social interaction, while both
non-linear models consider interaction. One considers interaction with abusers
affecting the relapse rate, while the other assumes both this and an additional
interaction between the number of abusers and the number of new prescriptions.
Sensitivity analyses are conducted varying the rates of success of these
intervention methods measured by the parameters to determine which strategy has
the greatest impact on controlling the population of Vicodin abusers. From
these models and analyses, we determine that manipulating parameters tied to
prevention measures has a greater impact on reducing the population of abusers
than manipulating parameters associated with treatment. We also note that
increasing the rate at which abusers seek treatment affects the population of
abusers more than the success rate of treatment itself.