Pain Medications in Newly Diagnosed DPN

How often are opioids being initiated for diabetic peripheral neuropathy (DPN) in newly diagnosed patients? 

About half of those living with diabetes are affected by diabetic peripheral neuropathy (DPN). Due to their demonstrated effectiveness and safety, clinical recommendations recommend using anticonvulsants, antidepressants (serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants), or topical analgesics for painful DPN. In previous research, anticonvulsants were most often administered to newly diagnosed patients with DPNP. Many patients received lower dosages than prescribed, potentially leading to poor results. Initial therapies were also discontinued, reflecting low satisfaction levels and poor tolerability. This study explored pain medication initiation among adults with newly diagnosed DPN to facilitate healthy and evidence-based pain management. 

Electronic health record data from the Mayo Clinics in Rochester, Minnesota; Phoenix, Arizona; and Jacksonville, Florida, health systems are used in this retrospective cohort analysis. Between January 1, 2014, and December 31, 2018, we reviewed first-line analgesic drugs prescribed to adults with a new diagnosis of DPN. The Mayo Clinic institutional review board approved this report. Due to the use of pre-existing population-level electronic health record data, informed consent was waived. The research followed the reporting guide for Improving the Reporting of Observational Studies in Epidemiology (STROBE). The drugs used were prescribed for the first year after diagnosis and were not used for the previous 12 months (nonopioids) or three months (opioids). Medicinal drugs were deemed to be concomitant if they were administered within two weeks of each other and were graded as recommended guidelines (pregabalin, gabapentin, and serotonin-norepinephrine reuptake inhibitors); not recommended opioids; and appropriate opioids (topical analgesics, tricyclic antidepressants, and other anticonvulsants) 

Researchers reported 3,495 adults with newly diagnosed DPN, and 1,406 (40.2 percent) began a new pain treatment after diagnosis. The adjusted chances of starting a new pain drug dropped by 35 percent between 2014 and 2018, from 45.6 percent (287 of 630) of the cohort in 2014 to 35.2 percent (243 of 691) in 2018. The likelihood of initiation of treatment was highest among patients with depression (odds ratio [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) and substantially decreased over time among all patients. Of 1406 patients undergoing treatment, 616 (43.8 percent) were prescribed opioids, 603 (42.9 percent) were recommended drugs, and 2899 were appropriate medications (20.6%). Compared with other medicines, the male sex was associated with higher chances of opioid use, and the prevalence of fibromyalgia was associated with lower events of opioid use. Comorbid arthritis has been associated with decreased cases of medication use is recommended. Over time, crude opioid use rates declined, while rates of recommended medication rose. However, after adjustment for demographic and clinical factors, trends were not significant. 

Initiation of pain medication for patients with newly diagnosed DPN decreased by 35% between 2014 and 2018. Overall, opioids were prescribed to 43.8 percent of patients initiating therapy, compared with 42.9 percent prescribed guideline-recommended drugs. Such high opioid use rates are of concern to patients with DPN, a condition of lifelong pain, since there are better alternatives for successful care. Opioid usage rates surpassed those previously recorded because the researchers did not exclude patients with pre-existing pain or mood conditions prevalent in this demographic, rendering the research results more generalizable.  

This study was constrained by the failure to analyze the clinical context of pain control, including the severity of pain and other possible reasons for opioid treatment or the contraindications of prescribed guideline therapies. The sample size may be underpowered to ascertain factors associated with the choice of specific treatment regimens. The data could not capture the length of opioid treatment; therefore, some prescriptions could have been short-term rather than long-term use. Furthermore, the patients included in the study were treated in 3 hospitals and may not, as such, be representative of all DPN patients. Further research is required to analyze DPN management’s national patterns, identify factors associated with the use of opioids and obstacles to evidence-based alternatives, and establish approaches in clinical practice to enhance DPN management. 

Practice Pearls: 

• Opioids are being prescribed more for newly diagnosed diabetes patients experiencing DPN. 
• Such high opioid use rates are of concern to patients with DPN, a condition of lifelong pain, since there are better alternatives for successful care. 
• Further research is required to analyze national patterns in DPN management, identify factors associated with the use of opioids and obstacles to evidence-based alternatives, and establish approaches in clinical practice to enhance DPN management 

Jungwei Fan, Ph.D. “Pain Medication in Patients With Newly Diagnosed Diabetic Peripheral Nephropathy.“ JAMA Network Open, JAMA Network, January 28, 2021.  

Yang, Mei, et al. “Suboptimal Treatment of Diabetic Peripheral Neuropathic Pain in the United States.“ OUP Academic, Oxford University Press, November 17, 2015.  

Shalonda Kimble, PharmD Candidate, South College School of Pharmacy