If you go to the doctor complaining of pain, don’t be surprised if your doctor prescribes anti-epileptic drugs, or an antidepressant, or even plain old Tylenol or ibuprofen.
As healthcare providers move away from addictive opioid painkillers, other classes of drugs with pain-relieving properties are filling the gap. A Buffalo News review of nearly 10 years of prescription painkillers among Medicaid patients highlights evolving trends.
Prior to 2016, narcotic pain relievers were the leading type of prescription pain reliever by far compared to any other type of prescription drug, according to the Erie County Medicaid Inspector General’s Office.
But now, healthcare professionals are prescribing other types of pain medication far more often than they are prescribing opioid-based pain medications.
This includes medications such as gabapentin, a drug designed to treat epilepsy but is now commonly used to treat a wide range of nerve-related pain problems. Gabapentin is one of the most prescribed Medicaid drugs in Erie County, ranked sixth overall, although there are national concerns about gabapentin addiction and abuse.
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Also high among the non-narcotic pain relievers are drugs such as duloxetine, better known to many by the trade name Cymbalta, which is classified as an antidepressant but is often prescribed to treat certain types of nerve and muscle pain.
Then there are much more commonly known pain relievers that can be purchased in lower dosages over the counter, such as ibuprofen, the most prescribed Medicaid drug for pain relief. Ibuprofen has consistently made the top 10 Medicaid prescription drugs countywide.
Medicaid prescription data is publicly available, and Erie County data shows that one-third of all county residents receive health care through Medicaid, a government-sponsored health insurance program for low-income residents. This suggests that prescribing patterns should be similar for other residents across the region.
The change in how doctors treat pain is evident in the county’s annual Medicaid reports produced by Medicaid Inspector General Michael Szukala.
For example, the opioid-based combination pain reliever hydrocodone-acetaminophen, marketed under brand names such as Vicodin and Lortab, topped the list of Medicaid’s most prescribed drugs from 2008 to 2014. top 12 most prescribed drugs Medicaid drugs since 2018.
The opioid-related overdose drug crisis began nearly a decade ago and originated with doctors and their prescription pads.
Treating pain was previously considered such a high priority that doctors were taught to consider it “the fifth vital sign,” said Dr. John Fudyma, acting division chief of geriatrics and palliative medicine at the University at Buffalo Jacobs School of Medicine and Biomedical Sciences.
In 2015, hundreds of thousands of prescriptions for opioid-based narcotic pain relievers were written in Erie County alone. The painkillers were effective and falsely marketed as safe. The following year, three times as many county residents would die from drug overdoses as in previous years. The same story played out in communities across the United States.
That national crisis led to government action and medical restraint to limit patients’ access to narcotic pain relievers. But the patient’s need for pain relief has not gone away. So healthcare providers started substituting other types of non-addictive painkillers to meet the needs of patients.
Now, Fudyma said, doctors should spend more time tracking down the cause of a patient’s pain to prescribe safer, more targeted types of painkillers.
“Is this a musculoskeletal pain syndrome? Is there a neuropathic component?” Fudyma said. “And what is the best combination of both pharmaceutical and non-pharmaceutical interventions to reduce pain?”
Instead of narcotic pain relievers, healthcare professionals are increasingly prescribing pills from a class of drugs intended to address seizures and seizures, such as gabapentin, lamotrigine and topiramate. These drugs are now commonly used to calm nerve-related pain signals. This class of drugs has seen an 84% increase in Medicaid prescriptions in Erie County since 2013.
Some antidepressant and anti-anxiety medications, also designed to treat symptoms of related physical pain, such as fibromyalgia, have also risen sharply. This includes drugs like duloxetine, amitriptyline and nortriptyline, which all saw an 83 percent increase in prescriptions during the same period.
Nonsteroidal anti-inflammatory drugs, or NSAID-class drugs, including over-the-counter brands like Advil and Aleve, also continue to stick around in the pain-relieving mix. So are non-narcotic pain relievers, a broad category of pain relievers that includes acetaminophen, better known as Tylenol. These classes of drugs, which exist in prescription and over-the-counter form, have all seen an increase in use since narcotic pain relievers fell out of favor.
Fudyma noted that health care providers also employ other types of pain management that don’t involve pills. These can be pain relief gels or patches or other holistic therapy treatments.
Local anesthetics, for example, which are applied directly to the site of pain, have increasingly been prescribed as a source of relief for many patients, he said.
A common example is lidocaine, a local anesthetic available in prescription and over-the-counter form. It can be applied as a spray, extended-release patch, cream, ointment, or lotion, among other delivery methods. Between 2015, when narcotic painkiller prescriptions were at their peak, and last year, lidocaine prescriptions increased by 64 percent.
Despite changing trends, the opioid drug crisis has not gone away. What began as a wave of addiction and deaths from overprescribing opioid painkillers has turned into a street drug overdose death crisis from synthetic opioid drugs such as fentanyl derivatives.
Last year marked an all-time high for opioid-related drug deaths in Erie County, and the numbers for this year remain high to this day.
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