Message Heard? Pain Med Prescribing Down Second Year in Row

May 04, 2017

Acetaminophen/hydrocodone, the opioid pain reliever commonly sold under the brand name Vicodin, was the most dispensed prescription medicine in 2007.

And 2008. And 2009. And every year after through 2013, according to the QuintilesIMS Institute, which tracks medicine use and spending.

Then, in 2014, this staple of the opioid abuse epidemic fell to second place behind levothyroxine, which treats hypothyroidism. By 2016, acetaminophen/hydrocodone was the fourth most prescribed drug in the nation, with the volume of prescriptions down 7.2% from 2015 and 34% from 2012.

This downhill story helps capture a trend for pain medications in general and the clinicians who prescribe them. The volume of dispensed prescriptions for all pain meds has decreased for 2 straight years now, falling 2.7% in 2015, and 1.7% in 2016, QuintilesIMS reports in its annual review of medicine use and spending, which was released today. Pain meds include both narcotic and non-narcotic analgesics as well as muscle relaxants and topical pain treatments.

The study attributes the decline to more controls placed on pain meds in response to the opioid abuse epidemic. These controls include more stringent prescribing guidelines in recent years, particularly a set issued for primary care in March 2016 by the Centers for Disease Control and Prevention (CDC). The CDC cautioned that opioids are not first-line therapy for chronic pain, and that clinicians initially should consider nonopioid pain relievers and nonmedicine options such as exercise and cognitive behavioral therapy. When clinicians do prescribe opioids, they should start patients off at the lowest dose possible and limit treatment for acute pain to no more than 7 days. In addition, clinicians should monitor patients to ensure the drugs are helping with pain and function without inflicting harm.

"The CDC guidelines have been very powerful in changing physician behavior because they've had a larger audience," said Steven Stanos, DO, president of the American Academy of Pain Medicine, in an interview with Medscape Medical News.

Media and political attention paid to the tragedy of opioid overdose deaths also has made physicians more judicious in their prescribing habits, said Dr Stanos, medical director of pain services at the Swedish Health System in Seattle, Washington. At the same time, he said, physicians are catching on to therapies that complement or replace opioids in pain management — everything from counseling and yoga to spinal cord stimulation.

"We'll continue to see a reduction in opioid prescriptions," Dr Stanos predicted.

The Tsunami in Hepatitis C Prescribing Is Receding

Pain med trends were just one element of a big-picture look at drug prescribing and spending last year in the QuintilesIMS report.

The volume of dispensed prescriptions in 2016 increased 2% just as it did in previous years, according to the report. When adjusted to count each 3-month prescription as three prescriptions, volume increased 3.3%. In contrast, growth in what the United States spent on prescription drugs — $323 billion, after adjusting for off-invoice discounts and rebates — slowed down to 4.8%, less than half the growth rate in both 2014 and 2015. QuintilesIMS cited intensified competition among drug manufacturers and efforts by third-party payers to limit price increases as reasons why. The growth in prescription drug spending still exceeded the nation's inflation rate.

Patients are catching some Rx breaks, however. The average out-of-pocket cost for patients was $8.47 per prescription compared with $9.66 in 2013.  Contributing factors include greater use of generics, copay assistance coupons issued by commercial health insurers, and provisions in the Affordable Care Act that do not require patient payments for preventive care, QuintilesIMS said.

The report also found that:

  • The tsunami of new patients receiving hepatitis C drugs with extremely high cure rates is receding. That number rose from 19,000 in 2013 to 170,000 in 2014, and hit 249,000 in 2015. Last year, 226,000 new patients received those drugs for a 9% decrease. QuintileIMS notes that the recent surge reflects a backlog of "warehoused" patients who were diagnosed with hepatitis C, but not yet treated. There are still an estimated 2.4 million to 4.4 million infected patients — most of them undiagnosed — who could be treated.

  • Prescriptions for cholesterol-lowering medications have increased almost 10-fold over the past 2 decades, and at the same time shifted to generics. Of the 264 million prescriptions for lipid regulators in 2016, only 220,000, or less than 1%, were for alirocumab (Praluent, Sanofi/Regeneron Pharmaceuticals) and evolocumab (Repatha, Amgen), both PCSK9 inhibitors that treat very high LDL levels.  QuintilesIMS said the low figure for the two drugs stems partly from strict eligibility conditions that insurance company formularies impose on patients.

  • Individuals aged 50 years or older accounted for 70% of dispensed prescriptions in 2016, with that number adjusted to count a script for 84 or more days as three scripts. 


Follow Robert Lowes on Twitter @LowesRobert


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