Was progress toward reversing the opioid epidemic set back by the pandemic and increasing prescribing of narcotics?

That was the question asked in a recent study published in JAMA Network Open. University of Indiana Bloomington—led researchers sought to determine if nonpharmacologic therapy such as physical therapy and complementary medicine—lower risk alternative treatments for acute and chronic pain—were replaced by prescription opioid analgesics during the COVID-19 pandemic.

The cross-sectional study of weekly claims data from 24 million commercially insured patients in the United States uncovered evidence of substitution of nonpharmacologic therapy with increased opioid prescribing. More potent and longer prescriptions were identified, especially during the early months of the COVID-19 pandemic.

"These findings suggest that progress toward reversing the opioid epidemic may have been stalled by the pandemic as practitioners resorted to higher levels of opioid prescribing to control pain in the absence of less risky alternatives," the authors write.

The study points out that during the pandemic, access to medical care unrelated to COVID-19 was limited because of worries about viral spread and policies put in place to prevent that.

"It is critical to assess how these conditions affected modes of pain treatment, given the addiction risks of prescription opioids," according to the researchers who assessed trends in opioid prescription and nonpharmacologic therapy for pain management during the COVID-19 pandemic in 2020 compared with the patterns in 2019.

To do that, the retrospective, cross-sectional study used weekly claims data from 24 million U.S. patients in a nationwide commercial insurance database (Optum's deidentified Clinformatics Data Mart Database) from January 1, 2019, to September 31, 2020. The focus was on patients with diagnoses of limb, extremity, joint, back, and neck pain; for each week, patterns of treatment use were identified and evaluated. Data analysis was performed from April 1, 2021, to September 31, 2021.

The study team quantified weekly rates of opioid prescriptions, the strength and duration of related opioid prescriptions, and the use of nonpharmacologic therapy. Also assessed were transition rates between different treatment options before the COVID-19 outbreak and during the early months of the pandemic.

For the first 3 quarters of 2019, approximately 21.4 million patients (mean [SD] age, 48.6 [24.0] years; 10.9 million [51.1%] female; 909,061 [4.2%] Asian, 1.6 million [7.9%] Black, 2.2 million [10.6%] Hispanic, 11.2 million [52.2%] White, and 5.3 million [25.0%] unknown) were enrolled. During the comparable time period in 2020, approximately 20.7 million (mean [SD] age, 47.0 [23.8] years; 10.6 million [51.5%] female; 798,037 [3.8%] Asian; 1.5 million [7.3%] Black, 2.0 million [9.5%] Hispanic, 10 million [48.5%] White, and 6.4 million [30.9%] unknown) were enrolled.

Results indicated that during the COVID-19 pandemic, the proportion of patients receiving a pain diagnosis was smaller than that for the same period in 2019 (mean difference, -15.9%; 95% CI, -16.1% to -15.8%), but patients with pain were more likely to receive opioids (mean difference, 3.5%; 95% CI, 3.3% to 3.7%) and less likely to receive nonpharmacologic therapy (mean difference, -6.0%; 95% CI, -6.3% to -5.8%). In addition, the authors point out that opioid prescriptions were longer and more potent during the early pandemic in 2020 relative to 2019 (mean difference, 1.07 days; 95% CI, 1.02 to 1.17 days; mean difference, 0.96 morphine mg equivalents; 95% CI, 0.76 to 1.20).

The study team's analysis of individuals transitions between treatment options for pain found that patients were more likely to transition out of nonpharmacologic therapy, replacing it with opioid prescriptions for pain management during the COVID-19 pandemic than in the year before.

They concluded, "Nonpharmacologic therapy is a benign treatment for pain often recommended instead of opioid therapy. The decrease in nonpharmacologic therapy and increase in opioid prescriptions during the COVID-19 pandemic found in this cross-sectional study, especially given longer days of prescription and more potent doses, may exacerbate the U.S. opioid epidemic. These findings suggest that it is imperative to investigate the implications of limited medical access on treatment substitution, which may increase patient risk, and implement policies and guidelines to prevent those substitutions."

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