Disabled Patients Face Barriers to First-Line, Nonopioid Pain Meds

Pauline Anderson

May 02, 2018

VANCOUVER, British Columbia — Patients with disabilities such as spinal cord injury or stroke who need nonopioid pain medications face increasing financial and regulatory barriers to these first-line treatments, new research suggests.

The study, which analyzed drug formulary data, showed that all nonopioid pain medications except tricyclic antidepressants (TCAs) had quantity restrictions and were more likely to require prior insurance authorizations compared with opioid medications.

Dr Allison Glinka Przybysz

"It's important to know that our patients may have less access to medications that are nonaddictive and might be better at controlling pain in patients with disabilities, such as those with spinal cord injury or stroke," lead author, Allison Glinka Przybysz, MD, MPH, a resident at Schwab Rehabilitation Hospital and Care Network, University of Chicago, Illinois, told Medscape Medical News.

The study was presented here at the American Academy of Pain Medicine (AAPM) 2018 Annual Meeting.

Medicare Data

Using Medicare registry data, researchers analyzed prescription drug plan formularies in Illinois during 2017. They looked at first-line pharmacologic pain therapies in patients with spinal cord injuries, post-stroke pain, phantom pain and neuropathies.  

They examined opioid medications, including Norco (Teva), a combination opioid/acetaminophen agent, and OxyContin (Purdue; oxycodone); various TCAs that are often used for neuropathic pain; and topical pain medications.

"We looked at how each drug was covered under each plan, whether there were restrictions on the number that you could prescribe; and whether there were restrictions in terms of prior authorizations, which would require more paper work and time both for the physician and for the patient and can result in delays in receiving appropriate treatment,' said Glinka Przybysz.

The researchers also looked at "tiers" that represent cost sharing between insurers and patients. Higher-tier level drugs are costlier for patients.

Prior authorization, quantity restrictions, and cost were a proxy for access to pain medications.

Across all drug plans, the study found quantity restrictions on the anticonvulsant pain medication gabapentin 47% of the time and such restrictions for the related drug pregabalin 76% of the time There were no such restrictions for TCAs.

There were also quantity restrictions for the topical cream Lidoderm (Teikoku) (85.7%), for the oral opioid tramadol (95.2%), and for Norco (95.2%).

TCAs were 2.5 times more likely than opioid pain medications to require prior authorization, but this finding was not statistically significant. On the other hand, transdermal lidocaine products were 33 times more likely to require prior authorizations, and this was statistically significant compared with opioids (P < .05).

The extra paperwork and clinic appointments these authorizations create are "a big deal" for patients, some of whom must use a power wheelchair or other assistive device to get to these appointments, said Glinka Przybysz.

This, she added, contributes to delays in accessing important treatments.

Higher Costs

Higher cost seems to be another barrier. The investigators found that more than half of drug plans (57.1%) place lidocaine products in the highest tier level.

While transdermal lidocaine products were at the highest tier level across all plans, "there was more variability with respect to tier levels for other types of medication, such as opioids, TCAs, and gabapentinoids," said Glinka Przybysz.

She would like clinicians to be "sensitive" to the fact that their patients with disabilities may be dealing with added restrictions to accessing pain medications.

"We need to do extra work to try to make sure that patients are actually getting the pain treatments they need," she said.

This could mean, among other things, preparing paperwork in advance of the clinic appointment, to at least save some time.

Glinka Przybysz and her rehabilitation medicine colleagues work in an underserviced area of Chicago where the level of violence may lead to traumatic brain and spinal cord injuries.

"It's a population that doesn't have a lot of access to care to begin with" and was an "inspiration" to do this study, she said.

In 2016, about 16,000 overdose deaths in the United States involved prescription opioids. Pain management physicians are among the highest prescribers of these drugs.

Findings "Important" and "Concerning"

After the presentation, session moderator Patrick J. Tighe, MD, associate professor of anesthesiology, and program director, Perioperative Analytics Group, University of Florida, Gainesville, asked the investigators about factors that are preventing patients from accessing these treatments.

"The first step here was to determine if there were differences between the classes of medications, but the really interesting question is why is this happening," said Glinka Przybysz. "That may be more at the level of policy, but I think it is something we will be investigating going forward."

Although the pain medications included in this retrospective review are most commonly used by patients with spinal cord injuries or post-stroke pain, Glinka Przybysz noted that the data apply to all patients, not just those with disabilities.

Which patients face barriers to accessing treatment "is an important question that needs further investigation," Tighe told Medscape Medical News.

"We need to find out which disabilities and which at-risk populations suffer from what types of impediments to access to appropriate care. This study reflects a microcosm of broader issues in healthcare in America, but it's certainly an incredibly important microcosm."

The findings of this new study are "very important" as well as "very concerning," said Tighe. "These are the issues that our patients suffer from on a day-to-day basis that don't receive a lot of attention yet drastically impact the quality of care they receive."

Tighe added that it is his opinion that factors affecting patient access to critical treatments can be fixed. 

The investigators and Tighe have disclosed no relevant financial relationships.

American Academy of Pain Medicine (AAPM) 2018 Annual Meeting. Abstract  287. Presented April 28, 2018.

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