Initiating Opioid Therapy for Chronic Pain: Does Which Medication Matter?

Methodology. The retrospective study examined patterns of use of approximately 40 000 tramadol, 141 000 hydrocodone, and 45 000 oxycodone initiators. Patients were considered to have chronic pain if they were diagnosed with at least 1 of the following: back pain, neck pain, or osteoarthritis in the 90 days prior to index date when the opioid was first prescribed.

Study population. Over 70% of the patients had osteoarthritis and 35% had back pain. Participants with back pain were prescribed tramadol more frequently than oxycodone or hydrocodone.

Factors linked with persistent use. Any surgery during the 6-month period prior to the index date was associated with a lower risk of persistent use of hydrocodone and oxycodone but did not affect the risk for tramadol. In contrast, the use of a skeletal muscle relaxant during the baseline period was associated with a lower risk of persistent use among tramadol users but was associated with a higher risk of persistent use among hydrocodone and oxycodone users.

Higher initial supply raises likelihood of persistent use. In all 3 medication groups it was found that the greater the initial days’ supply prescribed, the greater the likelihood of persistent use. Persistent use of all 3 medications was also associated with older age, Medicaid, more comorbidities, benzodiazepine use, gabapentinoid use, and antidepressant use.

Oxycodone users more likely to receive long-acting form. Oxycodone users were more likely to be prescribed long-acting opioids over the course of the year than were either hydrocodone or tramadol users. This may indicate that over time oxycodone users found less benefit from the short-acting form. Among persistent medication users, oxycodone users utilized a higher average weekly dose of medication than the tramadol or
hydrocodone users.

Conclusions: Use of SNRIs may be beneficial. Although tramadol is often presented as a “safer” opioid due to its lower DEA classification as compared to hydrocodone and oxycodone, it appears that the likelihood of its persistent use is no less than for the 2 other medications. The intermittent trajectory seen with tramadol may reflect the drug’s specific composition. Tramadol combines an opioid with SNRI, and it is this latter action that appears to provide most of the medication’s analgesia. These results suggest that utilizing a SNRI—such as a tricyclic antidepressant, venlafaxine, or duloxetine—might be as beneficial as oxycodone and hydrocodone for this study population without the risks of abuse and addiction associated with the use of opioids.

Conclusions: Higher pain levels may drive persistent use. Some of the factors predictive of persistent use of the medications may reflect a continuing higher level of pain, including more comorbidities and older patients and concomitant use of antidepressants and gabapentinoids.