Chronic Pain: Opioids No Longer Treatment of Choice

— Nondrug therapies increased markedly in wake of 2016 CDC guidance

MedpageToday
 A photo of a senior man wincing in pain as a physicial therapist stretches his neck muscles.

One of the CDC's goals in its notorious 2016 guidance on opioids for chronic noncancer pain appears to have been met, but it wasn't a reduction in actual opioid prescribing, federal survey data indicated.

In an analysis of Medical Expenditure Panel Survey (MEPS) data from 2011 to 2019, use of nondrug approaches such as physical therapy and chiropractic care increased dramatically beginning in 2017, reported Kevin T. Pritchard, MS, OTR, of the University of Texas Medical Branch in Galveston, and colleagues.

From 2011 to 2016, the percentage of chronic pain patients using nondrug therapies without opioids stayed relatively steady at 20%, but this figure rose rapidly thereafter, reaching 40% in 2019, the researchers noted in JAMA Network Open. The CDC guidance had stipulated that "non-opioid therapy is preferred for treatment of chronic pain." (A revision published last week still recommends that opioids be kept to a minimum, but with more emphasis on flexibility and individualized management.)

The 2016 guidance, however, was not accompanied by any significant reduction in use of opioids for chronic pain, either by themselves or in conjunction with nondrug treatments. In fact, use of opioids alone rose slightly from 2016 to 2018 (from approximately 10% to 15% of patients) while about 3% to 4% of patients used opioids alongside nonpharmacologic therapies through the entire study period.

Notably, the study came with a major limitation: Pritchard and colleagues did not count use of nonsteroidal anti-inflammatory drugs (NSAIDs), antidepressants, and gabapentinoids as pharmacologic. The MEPS data showed that chronic pain patients using "nonpharmacologic" therapies were using non-opioid medications at rates of about 15% to 16%. Among patients classified as using neither "nonpharmacologic" treatment or opioids, and thus appearing at first glance to be completely untreated, up to one-third in fact were taking NSAIDs or other medications.

As for what "nonpharmacologic treatment" did mean, interventions included physical and occupational therapy, chiropractic care, massage, and acupuncture. (Psychological treatments such as cognitive behavioral therapy were not included.) It appeared that the 2016 guidance was a bonanza for chiropractors: about 13% of chronic pain patients made use of their services that year, which grew to 25% in 2019. Occupational and physical therapy also nearly doubled over that interval, surpassing 15% by 2019.

MEPS is conducted annually with about 30,000 respondents. Pritchard and colleagues excluded all those with cancer diagnoses. Roughly 15% reported experiencing chronic pain. For statistical analysis, the researchers weighted results from each year to be representative of the non-institutionalized general adult population.

Pritchard and colleagues were particularly interested in correlations between pain treatments received and respondents' self-ratings of the degree to which pain interfered with daily life. Two-thirds of those with chronic pain said it interfered only a little or not at all; 15% reported moderate interference, 13% characterized it as "quite a bit," and 6% called it extreme.

After adjustment for a host of socioeconomic and medical covariates, it appeared that experiencing substantial interference tended to predict no receipt of either nondrug interventions or opioids in the years following the 2017 CDC guidance. In 2018 to 2019, odds that a person reporting extreme interference from pain would be getting neither nondrug therapy nor opioids had roughly tripled from 2011; the odds doubled among respondents saying pain interfered "quite a bit."

In light of this finding, Pritchard and colleagues expressed concern that patients with the most interference were facing "barriers to safer alternatives" to opioids. "Accessing regular outpatient services is expensive, difficult with functional limitations impeding community mobility, problematic due to disparities in care access, and may conflict with occupational demands," the group observed.

The researchers also found that acupuncture and massage therapies were the least-used interventions, "likely due to poor coverage from private and public payers," and that may be a problem, too. "The restrained use of acupuncture, massage, and [occupational therapy] highlights an opportunity to further expand nonpharmacologic treatments," they wrote.

In an invited commentary, Richard L. Nahin, MPH, PhD, of the National Institutes of Health in Bethesda, Maryland, pointed out additional findings that the investigators had included in tabular matter but skipped over in their commentary. In particular, Nahin highlighted that participants who were nonwhite and had lower incomes and education were less likely than others to use opioids and nonpharmacologic therapies together.

"Many factors might be associated with these disparities including past experiences, familial factors, comorbidities, cultural background, psychological and environmental factors, access to healthcare, and discrimination," he wrote, adding that future studies should examine them in more detail.

More broadly, Nahin noted that clinicians have been encouraged to pursue "multimodal multidisciplinary approaches" (MMAs) for managing chronic pain, as laid out in a variety of official policies. However, how well they work has been difficult to evaluate insofar as the idea encompasses countless potential combinations of treatments. "Earlier studies provided little detail about (1) the care provided (e.g., dose, frequency), (2) patient and clinician characteristics associated with the use of MMAs, (3) whether the MMA is initiated by the patient or clinician, and (4) the amount of communication between clinicians," he wrote.

Although the new study did not delve into them deeply either, Nahin said it was nevertheless "a step toward our understanding of the extent to which pain management MMAs are used by U.S. adults."

  • author['full_name']

    John Gever was Managing Editor from 2014 to 2021; he is now a regular contributor.

Disclosures

The study was funded by U.S. government grants.

Study authors and Nahin declared they had no relevant financial interests.

Primary Source

JAMA Network Open

Source Reference: Pritchard KT, et al "Trends in the use of opioids vs nonpharmacologic treatments in adults with pain, 2011-2019" JAMA Netw Open 2022; DOI: 10.1001/jamanetworkopen.2022.40612.

Secondary Source

JAMA Network Open

Source Reference: Nahin RL "Use of multimodal multidisciplinary pain management in the US" JAMA Netw Open 2022; DOI: 10.1001/jamanetworkopen.2022.40620.