Health Risks of NSAIDs Led to ‘Significant Under-Treatment of Pain’
/By Pat Anson, PNN Editor
The opioid crisis has been blamed on a lot of things, everything from pharmaceutical marketing to poor medical education to an epidemic of despair.
Now we can also blame NSAIDs.
A new study by researchers at Boston University School of Public Health (BUSPH) found that a decline in prescriptions for non-opioid analgesics — mostly non-steroidal anti-inflammatory drugs and COX-2 inhibitors -- coincided with a marked increase in opioid prescribing for people with chronic musculoskeletal pain.
Concerns about the cardiovascular side effects of Vioxx and other COX-2 inhibitors first came to light in the early 2000s. More was also being learned about heart disease, strokes and gastrointestinal problems associated with NSAIDs.
"While the opioid epidemic is complex and has many possible causes, our findings suggest that health risks associated with NSAIDs were one factor that led to increased prescribing of opioids," says lead author Dr. Andrew Stokes, assistant professor of global health at BUSPH.
Stokes and his colleagues looked at 1999-2016 prescription data for over 7,200 U.S. adults with back pain, neck pain or arthritis. Increases in opioid prescriptions matched the decrease in prescribing for non-opioid analgesics (predominantly NSAIDs and COX-2 inhibitors) between 2003 and 2006.
"We realized that the point at which increasing opioid prescriptions crossed over with the decrease in non-opioid prescriptions occurred when the cardiovascular risks of COX-2 inhibitors led to rofecoxib (Vioxx) coming off the market. The gastrointestinal risks of NSAIDs were also well-recognized by then,” says senior author Dr. Tuhina Neogi, a professor of epidemiology at BUSPH and Chief of Rheumatology at Boston Medical Center.
“Thus it appeared to us that an increase in opioid prescribing during that time was, at least in part, an unintended consequence of COX-2 inhibitors coming off the market and concerns about NSAID risk.”
‘Unmet Need for Pain Management’
The study, published in JAMA Network Open, also found that growing recognition of the opioid crisis after 2013 led to decreases in opioid and non-opioid analgesic prescriptions for people with chronic musculoskeletal pain, particularly among those with less education and lower socioeconomic status.
"Care is needed to ensure that our response to the opioid crisis does not leave people living with chronic pain behind. The abrupt decline in prescribing to those of low socioeconomic status is concerning given that these same individuals also face the greatest barriers to accessing alternative pain treatments, such as physical therapy," Stokes says.
"There's so much talk now about transitioning people away from opioids. But if that's happening without considering the barriers to non-pharmacologic treatments, there may be a significant problem of under-treatment of pain," adds study co-author Dielle Lundberg, a research fellow at BUSPH.
Between 2013 and 2106, researchers found an 11% decrease in prescriptions for both opioid and non-opioid pain relievers, suggesting a significant amount of pain was going untreated.
“Care is needed to ensure that our response to the opioid crisis does not leave people living with chronic pain behind.”
“The fact that the present study was restricted to patients with potential needs for pain management also raises the concerning possibility that an unmet need for pain management has increased over this period. Such a trend would be alarming given evidence that untreated chronic pain may prompt patients with chronic pain to seek out illicit heroin or fentanyl,” researchers concluded.
“In addition, several recent studies based on data from the National Violent Death Reporting System have found a high rate of chronic pain among suicide decedents, and recent research and commentary on opioid discontinuation have suggested that recent increases in the suicide death rate may be linked to changes in pain treatment.”
