PURPOSE: Over 116 million Americans suffer from persistent chronic pain. Opioid analgesics have been used for centuries, and extensive research has demonstrated their ability to provide effective pain relief and improved quality of life among patients suffering from acute and chronic pain. Prescriptions for opiates in the United States have increased dramatically in the last decade and increasing attention has been placed on the risk of addiction and problematic use of prescription opioids. While most patients with chronic pain do not develop opioid addiction, pain specialists and primary care physicians face challenges in the treatment and management of pain in patients with opioid dependence. Further, many patients with chronic pain and opioid dependence present with other physical and psychiatric comorbidities and recent research highlights the importance of treating these comorbidities as part of a comprehensive treatment program for opioid dependence. A close collaboration between primary care physicians and pain, addiction, and psychiatric specialists is required to ensure optimal outcomes among these patients. To date, little research has addressed how prescription opioids and medications for various comorbidities have been used among patients being treated for opioid dependence. The objective of this study was to compare concomitant medication use, including narcotic pain medication and select central nervous system agents for treating depression, schizophrenia, and anxiety, before and after buprenorphine maintenance treatment initiation in a real-world sample of patients with opioid dependence.
METHOD: A retrospective analysis was conducted using administrative claims data from the Truven Health MarketScan Commercial Claims and Encounters and Medicaid Multi-State databases. Patients of any age with an outpatient pharmacy claim for buprenorphine (monotherapy or with naloxone) from 2008- 2014 were selected from the databases and the date of the earliest buprenorphine claim was set as the index date. To ensure initiation of a new buprenorphine treatment episode, patients were excluded if they had claims for buprenorphine in the 3 months prior to the index date. Patients were required to have a diagnosis of opioid dependence (ICD-9-CM 304.0x, 304.7x, 305.5x) prior to or on the index date and continuous enrollment with medical and pharmacy benefits for 6 months pre-index and post-index. Patients receiving less than 30 days of therapy at an average daily dose less than 4mg/day were excluded from the analysis because they may represent patients using buprenorphine solely for detoxification, as opposed to for maintenance therapy. Patient demographics were measured on the index date and clinical characteristics were examined during a 6-month pre-index period. Concomitant medication use including narcotic pain medications, antidepressants, antipsychotics, benzodiazepines, and other sedative/ hypnotics were measured from outpatient pharmacy claims in the 6 months pre-and post-index. Descriptive analyses were conducted to compare the utilization of concomitant medications before and after buprenorphine initiation.
RESULTS: A total of 22,563 Commercial and 7,811 Medicaid patients were included in the analyses. The Commercial patients were majority male (62.7%) with a mean age of 32.6 years. The Medicaid sample was predominantly female (72.0%) with a mean age of 32.3 years. Both patient samples had high rates of comorbid chronic pain conditions (45.2% Commercial, 56.7% Medicaid), depressive disorder (29.6% Commercial, 39.2% Medicaid) and non-opioid substance use disorders (28.6% Commercial, 37.7% Medicaid). The proportion of Commercial patients with a claim for a narcotic pain medication fell from 48.6% prior to buprenorphine initiation to 25.5% in the 6 months following treatment initiation. In the Medicaid sample, a similar decrease in prescription narcotic utilization was observed (63.0% pre-index to 38.8% post-index). The proportion of patients with a benzodiazepine claim decreased slightly from the pre-index to the post-index period (Commercial: 27.9% pre, 21.9% post; Medicaid: 31.8% pre, 28.5% post). Contrarily, use of other sedative/hypnotic agents increased from 22.1% of Commercial patients before treatment to 26.8% after treatment initiation and 22.5% of Medicaid patients pre-index to 27.2% of patients post-index. In the Commercial sample, the proportion of patients using antidepressants increased from 46.2% in the preindex period to 57.2% in the post-index period. Among Medicaid patients, antidepressant utilization also increased from 48.3% pre-treatment initiation to 57.6% post. The proportion of patients with at least one claim for an antipsychotic increased from 12.7% pre-index to 19.1% post-index in Commercial patients and from 18.6% pre-index to 22.9% postindex in Medicaid patients.
CONCLUSIONS: Patients diagnosed with opioid dependence had high prevalence of pain and psychiatric conditions. The rates of narcotic pain medication utilization observed in this analysis highlight the importance of careful management of prescription opioid use among patients with opioid dependence. The increase in non-benzodiazepine sedative/hypnotic utilization is not surprising since these agents are often used during early recovery to alleviate anxiety, but careful dosing and monitoring is needed. The increase in antidepressant and antipsychotic use after starting buprenorphine may indicate the identification of mental health conditions that are often masked by opioid misuse prior to initiating the buprenorphine assisted treatment program.
