Non-opioid medication on the rise as U.S. combats opioid crisis

Use of opioid-alternative pain medications is surging as the U.S. tries to wean off the addictive painkillers, giving physicians concern that the opioid crisis will be substituted by a new prescription drug epidemic, according to a new report.

Nearly two-thirds of primary-care physicians shared that sentiment while nearly three-quarters worry that chronic pain patients will turn to illicit drugs if they do not have access to prescription opioids, according to a new report from Quest Diagnostics, which polled 500 primary-care doctors and analyzed 4.4 million lab test results. The report reflects physicians' apprehension that the healthcare system is ill-equipped to properly transition from an over-utilization of opioids.

"What most fail to realize is that we have a dual crisis in this country," said Dr. Jeffrey Gudin, a senior medical advisor for Quest and a pain management specialist at Englewood Hospital and Medical Center in New Jersey. "There is no question that people misuse substances that make them feel good, but there is also a crisis of chronic pain, of which there is no cure."

Providers worry that the opioid manufacturing caps and restrictions from insurers and providers are cutting off the much-needed supply for cancer patients and others with chronic pain.

It is considerably harder to treat chronic pain patients, 83% of physicians surveyed in the report said. A similar share said they are reluctant to take on patients who are currently prescribed opioids.

"Not a day passes that a patient doesn't shed real tears about having opioid doses tapered," said Gudin, adding that guidelines the Centers for Disease Control and Prevention issued in 2016 led to a widespread reduction in opioid doses without alternative treatment options.

More than 70% of doctors said that although there will likely be a decrease in opioid-related deaths, more patients will not have their pain properly managed.

Meanwhile, gabapentin—an anticonvulsant that can be used to relieve neuropathic pain and is often prescribed as an alternative to opioids for managing chronic pain—was detected in more than half of opioid overdose deaths, according to the CDC. Quest's data show that 13.4% of patient test results showed non-prescribed gabapentin in 2018, up from 9.6% in 2017. Gabapentin trailed only marijuana and alcohol at 14% each.

There needs to be a more comprehensive approach and plan addressing emerging drugs like fentanyl and other alternative pain medications, said Dr. Georges Benjamin, executive director of the American Public Health Association.  

“We still don’t have this issue right,” he said. 

Gabapentin is one of only three drug groups for which misuse—often improper combinations of drugs—increased from 2017 to 2018. The other two were alcohol and non-prescribed fentanyl. Physicians were also concerned about the abuse of benzodiazepines and amphetamines.

Overdose deaths involving fentanyl and other synthetic opioids, excluding methadone, increased almost 47% from 2016 to 2017, according to the CDC.

"Pain patients have learned if their psychiatrist gives them Valium, then they don't tell their doctor because they won't give them opioids," Gudin said. Part of it is on the patient; part is on the clinician, he said, adding that Quest has been promoting a major educational campaign about drug mixing.

Physicians may be overconfident in their ability to recognize prescription drug misuse and drug mixing is often underestimated, the report indicated. Nearly all doctors felt confident in their ability to discuss risks associated with prescription drug misuse with patients, but only 55% said they actually addressed it with most of their patients who were prescribed controlled substances in the past month.

Physicians recognized that they need help monitoring prescription drug use. At least seven out of 10 doctors said that they wish they had more training on how to taper off opioids, when to refer patients to pain specialists, how to spot addictive behavior and what to do after the fact.

Prescription drug monitoring helps, the vast majority of physicians said, but half indicated that there are cost and access obstacles.

“We need to enhance our surveillance systems that track the drugs, utilization and health outcomes in as close to real time as possible so we can make data-driven public health decisions,” said Benjamin, who stressed a system-wide focus rather than drilling down on just the clinical aspects. 

Many chronic pain patients would benefit from multimodal treatment, including non-pharmacologic therapy, Ellenbogen said.

More patients are using acupuncture, physical therapy, massage and other pain-management alternatives, although payer coverage issues remain, Gudin said.

"These are things that are not taught in medical school," he said. "I think the medical society needs to do a better job educating doctors on the front line, which are primary-care clinicians."