In the US, the opioid epidemic has led to a crisis, with chronic use associated with increased morbidity and mortality. Though gastroenterologists are prescribing fewer opioids for Medicare patients, they should also prescribe more neuromodulators because there is more high-quality evidence supporting their efficacy for conditions causing chronic abdominal pain conditions, according to a study published in Gastroenterology.
This retrospective, cross-sectional, population-based study used data from the 2013-2017 Medicare Part D Prescription Drug Program prescriber database to characterize gastroenterologists’ use of opioids, antispasmodics, and neuromodulators (mirtazapine, serotonin and norepinephrine reuptake inhibitors, selective serotonin reuptake inhibitors, tricyclic antidepressants [TCAs], and delta ligand agents) to determine if they have modified their prescription patterns in response to the most recent wave of the opioid epidemic. The primary study outcome was the proportion of gastroenterologists prescribing >10 opioids, antispasmodics, or neuromodulators annually and the average number of prescriptions in each medication class prescribed by the doctors in that category. Multivariate logistic regression analysis was used to evaluate the associations between provider and patient characteristics and prescribing >10 of these medications annually.
The proportion of gastroenterologists prescribing >10 opioids, antispasmodics, or neuromodulators annually decreased from 26% of providers in 2013 to 15% in 2017 (P <.001). The proportion of gastroenterologists prescribing any opioids decreased from 75% of providers in 2013 to 59% in 2017 (P <.001). The majority of non-opioid prescriptions were written for antispasmodics and TCAs (73% and 14%, respectively in 2017). Although the proportion of gastroenterologists prescribing >10 neuromodulator prescriptions annually remained stable, from 24% in 2013 to 23% in 2017 (P =.07), the average number of prescriptions for neuromodulators decreased by 4% between 2013 and 2017 (P <.001).
Because TCAs accounted for the majority of neuromodulators prescribed in 2017 (51%), a researchers performed a subanalysis that found that the proportion of gastroenterologists prescribing >10 TCAs annually (16% in 2013 to 17% in 2017; P =.15) and the average number of TCA prescriptions (31 from 2013-2017; P =.08) remained unchanged. However, the proportion prescribing >10 antispasmodics annually increased from 42% in 2013 to 51% in 2017 (P <.001), and the average number of antispasmodic prescriptions increased by 23% between 2013 and 2017 (P <.001).
Further subgroup analyses showed that gastroenterologists in the South were associated with increased odds of prescribing opioids (OR, 1.61) and antispasmodics (OR, 1.69), but with decreased odds of neuromodulator prescriptions (OR, 0.79), compared with providers in the West. Male gastroenterologists were associated with increased odds of opioid (OR, 1.41) and antispasmodic (OR, 2.34) prescribing. For every additional year since medical school graduation, the odds of opioid prescribing increased by 2%, the odds of neuromodulator prescribing increased by 1%, and antispasmodic prescribing decreased by 1%.
Limitations of the study included using a Medicare dataset, which cannot account for prescription use in younger adults, and the fact that although opioids are already classified together, prescriptions for neuromodulators and antispasmodics were likely to be underestimated because the researchers relied on count summations across numerous medications.
Study investigators concluded, “our population-level analysis provides evidence that gastroenterologists are prescribing fewer opioids among Medicare patients. This is accompanied by a simultaneous increase in antispasmodic rather than neuromodulator prescriptions. Although gastroenterologists prescribe opioids in modest amounts, educational interventions, policy changes like prescription drug monitoring programs, and greater adoption of guidelines, particularly with high-volume prescribers, may help further reduce these levels. Gastroenterologists should consider use of neuromodulators as the quality of evidence to support their efficacy for chronic abdominal pain conditions is high while that of antispasmodics is low.”
Chen FW, LeBrett WG, Yang L, Chang L. Opioid prescription patterns among US gastroenterologists from 2013 to 2017 [published online October 21, 2019]. Gastroenterology. doi: 10.1053/j.gastro.2019.10.017