Opioid Use in the Management of Diabetic Peripheral Neuropathy (DPN) in a Large Commercially Insured Population

Abstract

Objective To examine the proportion of diabetic peripheral neuropathy (DPN) patients receiving pharmacologic DPN treatments and specifically to identify the rates and factors associated with opioid use and first line opioid use. Methods A 10% sample of IMS-LifeLink claims data from 1998 through 2008 was used. The study population consisted of diabetic patients who met DPN criteria using a validated DPN algorithm. Multivariable logistic regression controlling for demographics, comorbidities, and other clinical characteristics was used to identify factors associated with any DPN pharmacologic treatment, any opioid use, and first-line opioid treatment. Sensitivity analyses were conducted to explore variations in exclusion criteria as well as opioid use definitions. Results 666 DPN patients met inclusion criteria and pharmacologic treatment was received by 288 subjects (43.24%) and of those, 154 (53.47%) had DPN related opioid use and 96 (33.33%) received opioid as first line treatment. Persons with diabetic complications were more likely to use opioids (OR=4.53, 95% CI=1.09-18.92). FDA approved DPN agents duloxetine 1.04% (n=3) and pregabalin 5.56% (n=16) had much lower rates of use. DPN related drug use and DPN related opioid usage increased as we used less restrictive samples in sensitivity analyses. Conclusion Opioids were the most frequently prescribed first line agents for DPN. More than 50 % of DPN patients remained untreated with pharmacologic agents one year after a DPN diagnosis.

Epidemiology of Peripheral Neuropathy and Lower Extremity Disease in Diabetes

“…Despite a large body of evidence and professional treatment guidelines on the medical management of painful diabetic peripheral neuropathy [1, 60], current medication prescribing patterns are inconsistent. In a study of claims-based data among a cohort of 666 patients with diabetic peripheral neuropathy, 43% received pharmacologic agents within one year of diagnosis [72]. Of these, 53% were prescribed an opioid, including 33% who were prescribed an opioid as a first-line agent.…”

“…Antidepressants were prescribed in 26% of cases, followed by anticonvulsants (23%), non-steroidal anti-inflammatory drugs (19%), and muscle relaxants (5%). FDA-approved duloxetine and pregabalin were only prescribed in 1% and 6% of cases, respectively [72]. Continuous treatment with duloxetine has been shown to be associated with a reduction in opioid use compared to treatment with other modalities [73, 74], and higher average daily doses of duloxetine are associated with higher treatment compliance and lower healthcare costs [74].…”

Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use — United States, 2006–2015

“…A random 10% sample of patient records during 2006–2015 was drawn from the IMS Lifelink+ database, which includes commercial health plan information from a large number of managed care plans and is representative of the U.S. commercially insured population ( 3 ). The data are provided in a deidentified format and the institutional review board at the authors’ institution deemed the study was not human subject research.…”

Mechanisms, Predictors, and Challenges in Assessing and Managing Painful Chemotherapy-Induced Peripheral Neuropathy

“…This practice is cautiously supported by American Society of Clinical Oncology and other experts because duloxetine may be ineffective, contraindicated, or poorly tolerated in some patients. 12,123,124 Although opioids are frequently used to treat neuropathic pain, [125][126][127] they should not be used as first-line treatment for chronic CIPN pain because of the risk of addiction, overdose-associated mortality, 128 and opioid-induced hyperalgesia-a condition whereby opioids make pain worse. 129 Several other promising pharmacologic agents might be effective for painful CIPN but require further testing.…”