Complexity of pain management among patients with nociceptive or neuropathic neck, back, or osteoarthritis diagnoses.
BACKGROUND
Approaches to pain management are diverse, requiring prescribers to evaluate an array of clinical issues and potential solutions. In addition to the difficult task of selecting a treatment option, pain treatment may be further complicated by multiple prescribers, multiple medications, and multiple mechanisms of pain origination.


OBJECTIVE
To describe patient demographics (e.g., age, gender); comorbidities; office visits (e.g., physician, chiropractor, physical therapy, psychiatry, allergist); number of different prescribers overall prescription use; pain medications as classified by the World Health Organization's (WHO) pain ladder; adjuvant medications; nonpharmacologic procedures; and potential drug interactions in a broad sample of patients with nociceptive or neuropathic neck or back diagnoses, or osteoarthritis diagnoses, in a commercial population.


METHODS
This claims-data analysis used a cross-sectional cohort comparison with a fixed 2-year observation period from September 1, 2006, to August 31, 2008, for patients in the PharMetrics national managed care database. The assigned cohorts were neuropathic-related neck/back diagnoses (NEURO); neuropathic and nociceptive neck/back diagnoses (NEURO/NOCI); nociceptive neck/back diagnoses without a neuropathic-related diagnosis (NOCI); and only osteoarthritis (OA) diagnoses. All analyses were conducted by cohort. The analysis included the following patient-descriptive variables: patient demographics, comorbidities, office visits, most frequent medical providers and number of different prescribers, all medications, pain medications as classified by the WHO pain ladder, adjuvant medications, adjuvant procedures and potential drug interactions. The goal for selecting these variables was to describe a range of data that might provide insight into the complexity of pain management decisions faced by clinicians.


RESULTS
The study included 85,014 patients, classified as NEURO (n = 2,375), NEURO/NOCI (n = 37,019), NOCI (n = 39,496), and OA (n = 6,124). The most frequently occurring comorbidities (observed in > 40% of patients) included cardiovascular and neuropathic pain conditions. Considering all types of medication claims observed among all cohorts, the overall mean prescription claim count for the 2-year observation period was 57.9 claims (standard deviation 56.2). Weak opioids (WHO pain relief ladder rung 2) accounted for the majority of pain medication claims across all cohorts. Across cohorts, 25.7% of patients had 10 or more days of overlapping drug availability (for inducers or inhibitors of the cytochrome P450 system concomitantly), a measure of potential for drug interactions.


CONCLUSIONS
Choosing the appropriate pain treatment involves assessing currently used medications for existing illnesses and deciding on the appropriate types of pain medications. However, potentially serious drug-drug interactions are a consequence of multiple drug use, and such a potential requires thoughtful consideration by those involved in patient care.
84 Tomahawk Trail, St. Helena Island, SC 29920. ckozma@c-k-consulting.com.
Chris M
CM
Kozma
David A
DA
Provenzano
Terra L
TL
Slaton
Aarti A
AA
Patel
Carmela J
CJ
Benson
D000328:Adult; D000700:Analgesics / Q000009:adverse effects / Q000627:therapeutic use*; D001416:Back Pain / Q000175:diagnosis / Q000188:drug therapy* / Q000453:epidemiology; D015897:Comorbidity; D003430:Cross-Sectional Studies; D003661:Decision Support Techniques; D004347:Drug Interactions; D004359:Drug Therapy, Combination; D017723:Drug Utilization Review; D005260:Female; D006801:Humans; D007356:Insurance, Pharmaceutical Services; D008297:Male; D008329:Managed Care Programs; D008875:Middle Aged; D019547:Neck Pain / Q000175:diagnosis / Q000188:drug therapy* / Q000453:epidemiology; D009437:Neuralgia / Q000175:diagnosis / Q000188:drug therapy* / Q000453:epidemiology; D059226:Nociceptive Pain / Q000175:diagnosis / Q000188:drug therapy* / Q000453:epidemiology; D009819:Office Visits; D010003:Osteoarthritis / Q000175:diagnosis / Q000188:drug therapy* / Q000453:epidemiology; D059408:Pain Management / Q000009:adverse effects / Q000379:methods*; D018579:Patient Selection; D019338:Polypharmacy; D010818:Practice Patterns, Physicians'; D018570:Risk Assessment; D012307:Risk Factors; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology
D000700:Analgesics