Conference Coverage
How to make the move away from opioids for chronic noncancer pain
How do physicians treat patients with chronic pain and guard against addiction?
SAN FRANCISCO –
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Dr. Justin S. Yu
“Given the opioid epidemic in the U.S. and the high prevalence of opioid use in migraine patients shown in our study, especially in those with chronic migraine, our results suggest that improved management of treatment is needed to optimize care,” said Justin S. Yu, PharmD.
“We’re seeing a lot of opioid use in these migraine patients. It may not all be due to migraine – some had comorbid nonheadache pain conditions – but this still represents an opportunity to look at these patients more closely, maybe treat them better, because there are opportunities to improve their care, their outcomes, and their quality of life,” added Dr. Yu of Allergan in Irvine, Calif.
He presented an in-depth retrospective observational study of opioid use in 129 chronic migraine patients as defined by more than 15 headache days per month (at least 8 of which fulfilled the diagnostic criteria for migraine) and 63 others with less frequent episodic migraine. In the previous 12 months, according to claims data, 54% of the chronic migraine patients and 37% of the episodic migraine patient filled one or more prescriptions for an opioid.
More impressively, fully one-third of the chronic migraine group and 16% of episodic migraineurs filled three or more opioid prescriptions within that 12-month interval. In fact, the mean number of filled opioid prescriptions over the year was 4.0 among all chronic migraine patients and 2.8 in the overall episodic migraine cohort.
“Opioids have been used for acute treatment of chronic migraine and episodic migraine but are not recommended for regular use due to the risk of medication overuse, tolerance, dependence, and opioid hyperalgesia,” Dr. Yu noted.
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Dr. Richard B. Lipton
Separately, Richard B. Lipton, MD, presented an analysis of 3,930 migraine patients currently using acute oral prescription headache medications who were among the larger group of 15,133 migraineurs who participated in the massive MAST (Migraine in America Symptoms and Treatment) study, an Internet-based epidemiologic survey of a nationally representative sample of patients with the disorder.
Topping the list of the most frequently used oral prescription acute headache medications were the oral triptans, used by 46% of subjects, followed by prescription NSAIDs, taken by 36%, and oral prescription opioids, used by 33.1%. And that eyebrow-raising rate of prescription opioid use is apparently par for the course.
“In lots of survey data now we’re seeing that among people with migraine who take acute prescription drugs, this one-third number is not unusual, although at least from my perspective it’s certainly a problem. Also, of people using oral acute prescription agents, a full 66% were also using OTC headache medications,” said Dr. Lipton, professor and vice chair of the department of neurology at Albert Einstein College of Medicine and director of the Montefiore Headache Center in New York.
In addition, oral prescription barbiturates were used for acute treatment of migraine by 11.2% of the MAST participants.
Acute medication overuse, as defined by use of oral prescription opioids and/or barbiturates on an average of more than 10 days per month, was identified in 8.1% of the total group. For them, the appropriate course of action is withdrawal of the overused medication, addition of a preventive agent – such drugs weren’t being used by the great majority of patients on acute prescription medications for migraine – and replacement of the opioid or barbiturate with a less problematic class of acute therapy, Dr. Lipton advised.
The MAST analysis identified a bevy of major unmet needs in people with migraine who are using acute prescription medications to treat their headaches. Fifty-three percent of participants said their severe headache attacks come on very rapidly, 50% indicated their attacks reach peak intensity in less than 2 hours no matter what they do, 39% said their head pain returns less than 24 hours after initial pain relief, and 41% complained of severe headache upon awakening. Nausea interfering with daily activities was frequently cited. Seventy-six percent of the sample had at least one of these major unmet needs.
Dr. Lipton stressed that although some of his colleagues have reacted defensively to these data highlighting numerous major unmet treatment needs in migraine patients, the MAST findings certainly aren’t an indictment that headache specialists are doing a poor job.
“I am not saying that. Of course, the vast majority of these people aren’t treated by headache specialists, they’re treated by primary care physicians. What I am saying is there are lots of opportunities to use new and emerging tools to improve the lives of our patients,” the neurologist said.
Dr. Yu noted that in his study, 14.7% of patients with chronic migraine and 15.9% with episodic migraine had been diagnosed with an anxiety disorder within the previous 12 months. Also, 24% with chronic and 11.1% with episodic migraine had been diagnosed with depression. A diagnosis of a comorbid nonheadache pain disorder was present in 13% of the chronic migraineurs and 8% of those with episodic migraine.
The MAST study was sponsored by Promius Pharma, a subsidiary of Dr. Reddy’s Laboratories. Dr. Lipton reported receiving research funding from and/or honoraria from that company and more than a dozen others.
Dr. Yu is employed by Allergan, which sponsored his study.
SOURCE: AHS annual meeting, Yu JS et al., Abstract PF11, and Lipton RB et al., Abstract OR02.