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Ambulatory Diagnosis and Treatment of Nonmalignant Pain in the United States, 2000–2010

Daubresse, Matthew MHS*,†; Chang, Hsien-Yen PhD; Yu, Yuping PharmD; Viswanathan, Shilpa MS*; Shah, Nilay D. PhD§; Stafford, Randall S. MD, PhD; Kruszewski, Stefan P. MD¶,#; Alexander, G. Caleb MD, MS*,†,**

doi: 10.1097/MLR.0b013e3182a95d86
Original Articles

Background: Escalating rates of prescription opioid use and abuse have occurred in the context of efforts to improve the treatment of nonmalignant pain.

Objective: The aim of the study was to characterize the diagnosis and management of nonmalignant pain in ambulatory, office-based settings in the United States between 2000 and 2010.

Design, Setting, and Participants: Serial cross-sectional and multivariate regression analyses of the National Ambulatory Medical Care Survey (NAMCS), a nationally representative audit of office-based physician visits, were conducted.

Measures: (1) Annual visit volume among adults with primary pain symptom or diagnosis; (2) receipt of any pain treatment; and (3) receipt of prescription opioid or nonopioid pharmacologic therapy in visits for new musculoskeletal pain.

Results: Primary symptoms or diagnoses of pain consistently represented one-fifth of visits, varying little from 2000 to 2010. Among all pain visits, opioid prescribing nearly doubled from 11.3% to 19.6%, whereas nonopioid analgesic prescribing remained unchanged (26%–29% of visits). One-half of new musculoskeletal pain visits resulted in pharmacologic treatment, although the prescribing of nonopioid pharmacotherapies decreased from 38% of visits (2000) to 29% of visits (2010). After adjusting for potentially confounding covariates, few patient, physician, or practice characteristics were associated with a prescription opioid rather than a nonopioid analgesic for new musculoskeletal pain, and increases in opioid prescribing generally occurred nonselectively over time.

Conclusions: Increased opioid prescribing has not been accompanied by similar increases in nonopioid analgesics or the proportion of ambulatory pain patients receiving pharmacologic treatment. Clinical alternatives to prescription opioids may be underutilized as a means of treating ambulatory nonmalignant pain.

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*Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health

Center for Drug Safety and Effectiveness, Johns Hopkins University

Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD

§Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN

Program on Prevention Outcomes and Practices, Stanford Prevention Research Center, Stanford University School of Medicine, Palo Alto, CA

Stefan P. Kruszewski, MD & Associates, Harrisburg, PA

#Department of Mental Health, Johns Hopkins Bloomberg School of Public Health

**Department of Medicine, Division of General Internal Medicine, Johns Hopkins Medicine, Baltimore, MD

G.C.A. is supported by the Agency for Healthcare Research and Quality (RO1 HS0189960). These funding sources had no role in the design and conduct of the study, analysis or interpretation of the data, and preparation or final approval of the manuscript before publication.

G.C.A. is an ad hoc member of the FDA’s Drug Safety and Risk Management Advisory Committee, serves as a paid consultant to IMS Health, and serves on an IMS Health scientific advisory board. This arrangement has been reviewed and approved by the Johns Hopkins University in accordance with its conflict of interest policies. S.P.K. has served as general and case-specific expert for multiple plaintiff litigation involving OxyContin, Neurontin and Zyprexa and has had false claims settled as co-plaintiff with the United States against Southwood Psychiatric Hospital, Pfizer (Geodon) and AstraZeneca (Seroquel). The remaining authors declare no conflict of interest.

Reprints: G. Caleb Alexander, MD, MS, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615N. Wolfe Street W6035, Baltimore, MD 21205. E-mail:

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© 2013 by Lippincott Williams & Wilkins.