Opioid Prescriptions and Headache Patients in Primary Care

My Two Cent Summary of a Study Presented at AAN At this year’s annual American Academy of Neurology (AAN) meeting, a study was presented on the prevalence of primary care doctors prescribing opioids for Migraine patients. In the past few years, the abuse of opioids has been a growing concern. The CDC states that “the quantity of prescription painkillers sold to pharmacies, hospitals, and doctors’ offices was 4 times larger in 2010 than in 1999”.1 Enough prescription painkillers were prescribed in 2010 to medicate every American adult around-the-clock for a month. Due to the increased usage of opioids, there are large numbers of patients who become dependent on these painkillers and end up abusing them. Roughly 15,000 people die each year from prescription painkiller abuse. According to the CDC, for every 1 death there are 32 ER visits for abuse, 130 people who are dependent and 825 non-medical users of opioids.1 Because of these astonishing facts, one would assume that doctors would be extremely careful in prescribing opioids to Migraine patients, many of whom legitimately need this medication. However, a survey of 13 clinics between 2008 and 2010 showed that opioids tended to be prescribed more often than triptans to Migraine patients by primary care doctors.

Overview The objective of the study was to analyze how headaches are diagnosed and treated at the primary care level. A secondary question that arose was how the diagnostic code used for a patient influenced the treatment plan. The information collected did not include encounters (or appointments) with neurologists or Headache Specialists. Symptom Codes and Diagnostic Codes were used to find trends in opioid prescriptions. To understand the findings, here’s what you need to know about these medical billing codes. Symptom Code (784) - describes signs and symptoms a patient presents. For Headache patients the symptom code could describe tight muscles in the shoulders and neck, jaw pain and pain in various parts of the head (not confined to the area of distribution of any nerve). While these symptoms are common to Migraine, they could be caused by a hangover, Meningitis or Lyme’s disease.2 Diagnostic Code (346) - is used to group and identify diseases, disorders and adverse effects of drugs, chemicals and injuries. A diagnostic code is used when the doctor believes to have ruled out any other possible diagnosis and Migraine is determined to be the cause of the pain.3

The Findings
Statistic #1 55% of Headache patients received a symptom code (784). 42% of Headache patients received a diagnostic code of Migraine (346). 3% were categorized as “Other.” Statistic #2 30% of ALL Headache encounters were prescribed opioids. Of those who received a diagnostic code of Migraine (346), 36% received opioids while only 19% received triptans, which are considered non-addictive. A combination of opioids and triptans were more likely prescribed to patients who received a diagnostic code of Migraine (346) than a symptom code (784). Statistic #3 9% of Headache patients were classified as Heavy Users (having more than 7 encounters) and generated 45% of all total appointments in the 13 clinics surveyed. Heavy users are more likely to be prescribed opioids and less likely to receive triptans. Statistic #4 Heavy Opiate Prescribers (doctors who wrote more than 40 opioid prescriptions in 2 years) represented only 10% of the providers, but 65% of all opioid prescriptions written.

Study Conclusion

  • Symptom codes are used more often by primary care doctors than diagnostic codes.
  • The rate of opiate prescription by primary care doctors is high for headache patients, while the use of triptans is low.
  • There is an overwhelming need for an Electronic Medical Record based intervention in primary care clinics to monitor the overuse of opioids to treat headache patients.

My Two Cents The over-prescription of opioids is now limiting the access of the drug to those who are truly in need of it. Opioids are a quick and easy fix for a primary care doctor to prescribe who doesn’t have time or the resources to devote to every patient who is in pain. While they are a great medication for those truly need it, opioids don’t address the underlying problem. The Migraine still persists. If a primary care doctor diagnoses a patient with Migraines, but the patient does not respond to the first-line defense medications, a referral to a specialist should be the next step before these powerful addictive drugs are prescribed. An emphasis should be made on lifestyle changes, preventative meds, natural supplements and regular follow-up appointments. You can read the Abstract of this study here.

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