Disclosures: McCoy reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
February 04, 2021
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Opioids most frequent prescription for newly diagnosed diabetic peripheral neuropathy

Disclosures: McCoy reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
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Among adults with newly diagnosed diabetic peripheral neuropathy treated at a multi-campus health system, 43.8% were prescribed opioids, whereas only 42.9% were prescribed a recommended first-line pain medication, according to study data.

Rozalina McCoy

“There are effective medications available to treat painful neuropathic symptoms in diabetic peripheral neuropathy. These are gabapentin, pregabalin and duloxetine,” Rozalina McCoy, MD, MS, associate professor of medicine at Mayo Clinic in Rochester, Minnesota, told Healio. “These medications are well tolerated and have few contraindications. I hope that with greater awareness about these safe and effective treatment options, clinicians will use them more. Opioids, which were used frequently in our study, should not be used as first-line or even second-line drugs. Thankfully, use of opioids in this context has decreased during the course of the study.”

Opioids were more frequently prescribed for adults with diabetic peripheral neuropathy than guideline-recommended medication and acceptable medication.

McCoy and colleagues conducted a retrospective cohort study of electronic health record data from three Mayo Clinic health systems. Researchers analyzed first-line analgesic medication prescribed to adults with newly diagnosed diabetic peripheral neuropathy from 2014 to 2018. Medications were included if they were prescribed in the first year after diagnosis and had not been prescribed in the previous 12 months for nonopioids or 3 months for opioids. Medications were classified as guideline recommended if they were pregabalin, gabapentin and serotonin-norepinephrine reuptake inhibitors. Topical analgesics, tricyclic antidepressants and other anticonvulsants were categorized as acceptable medications. Concurrent medications were defined as those prescribed within 2 weeks of each other. The findings were published in JAMA Network Open.

Of 3,495 adults with newly diagnosed diabetic peripheral neuropathy, 1,406 started pain medication after diagnosis. The proportion of adults starting a new pain medication decreased from 45.6% in 2014 to 35.2% in 2018. People with depression (OR = 1.61; 95% CI, 1.35-1.93), arthritis (OR = 1.21; 95% CI, 1.02-1.43) and back pain (OR = 1.34; 95% CI, 1.16-1.55) were most likely to receive new pain medication.

Among adults receiving treatment, 43.8% were prescribed opioids, 42.9% received recommended medications and 20.6% received acceptable medications. Men were more likely to be prescribed opioids compared with women (OR = 1.26; 95% CI, 1.01-1.59). The presence of fibromyalgia was associated with lower odds of an opioid prescription (OR = 0.67; 95% CI, 0.44-0.99), whereas those with comorbid arthritis were less likely to be prescribed a recommended medication (OR = 0.76; 95% CI, 0.59-0.99).

McCoy said there are several ways providers can limit opioid prescriptions for adults with diabetic peripheral neuropathy. Providers must understand their patient’s most bothersome symptoms and treat them early on. It is also important to discuss various treatment options with patients.

“We talk about the three medications that are recommended by the American Diabetes Association and supported by the evidence,” McCoy said. “I also talk about other treatment modalities that may be effective, including acupuncture and topical medications that may serve as adjuvant therapies. Opioids may be necessary in acute or emergent situations but should not be used when the others have not even been tried.”

McCoy said additional research is needed to explore the reasons opioids are prescribed from the perspective of both providers and patients.

“The potential harms associated with opioid therapy are well known, yet they are very frequently used for chronic pain nationwide,” McCoy said, “Why are patients with this very common neuropathic pain syndrome getting them so frequently? What are the barriers to using recommended medications that we know to be safe and effective?”

For more information:

Rozalina McCoy, MD, MS, can be reached at mccoy.rozalina@mayo.edu.