A new study from Jungwei Fan, PhD of Mayo Clinic and colleagues derived from a retrospective review of Mayo Clinic electronic health data and published online in JAMA Network Open has found “prescriptions for opioids as a first-line treatment for painful diabetic peripheral neuropathy (DPN) outnumbered those for other medications between 2014 and 2018, despite the fact that the former is not recommended,” the authors wrote.  This means, despite The American Diabetes Association DPN guidelines advising that opioids only be given as a “tertiary option for refractory pain,” patients have been receiving them as a first-line therapy.The JAMA study analyzed records from 3495 adults with newly diagnosed DPN from all three Mayo Clinic locations in Rochester, Minnesota; Phoenix, Arizona; and Jacksonville, Florida during the four-year span from 2014 to 2018. Of those, the researchers found, “40.2% (1406) were prescribed a new pain medication after diagnosis, and that proportion dropped from 45.6% in 2014 to 35.2% in 2018.”

Photo by Mykenzie Johnson on Unsplash

"We know that for any kind of chronic pain, opioids are not ideal,” explained senior author Rozalina G. McCoy, MD, an endocrinologist and primary care clinician at the Mayo Clinic in Rochester, Minnesota, said, adding, “They're not very effective for chronic pain in general and they're definitely not safe…There's a myth that opioids are the strongest pain meds possible.  For painful neuropathic pain, duloxetine [Cymbalta], pregabalin [Lyrica], and gabapentin [Neurontin] are the most effective pain medications based on multiple studies and extensive experience using them.  But I think the public perception is that opioids are the strongest.  When a patient comes with severe pain, I think there's that kind of gut feeling that if the pain is severe, I need to give opioids."Therefore, many physicians, she surmises, have turned immediately to opioids to ensure the patient’s pain is well-managed from the start.  What's more, she noted, "Evidence is emerging for other harms, not only the potential for dependency and potential overdose, but also the potential for opioid-induced hyperalgesia.  Opioids themselves can cause chronic pain.  When we think about using opioids for chronic pain, we are really shooting ourselves in the foot.  We're going to harm patients."The data also revealed that while opioid prescribing dropped over the study period, likely due to increasing information about the opioid epidemic and careful prescribing practices, there wasn't a comparable rise in prescriptions of recommended pain medications.  McCoy believes this suggests that physicians have scaled too far back on pain management efforts or patients who want opioid alternatives simply aren’t getting the best options available to them."The proportion of opioids among new prescriptions has been decreasing.  I'm hopeful that the rates are even lower now than they were two years ago.  What was concerning to me was the proportion of people receiving treatment overall had gone down," McCoy explained.  "So, while it's great that opioids aren't being used, it's doubtful that people with DPN are any less symptomatic…I worry that there's a proportion of patients who have pain who aren't getting the treatment they need just because we don't want to give them opioids.  There are other options.”

Sources:

Opioids Prescribed for Diabetic Neuropathy Pain, Against AdviceTrends in Pain Medication Initiation Among Patients With Newly Diagnosed Diabetic Peripheral Neuropathy, 2014-2018