Treating chronic pain: Could antidepressants be the solutions?

October 18, 2023

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A potentially groundbreaking meta-analysis of 176 studies was published earlier this year in the Cochrane Database of Systematic Reviews that assessed individual antidepressant medications and whether they proved effective in treating chronic pain in adult patients. In this blog, I will explore the results and how they might soon impact chronic pain treatment methodologies in complex pharmacy management (CPM). 

The far-reaching effects of chronic pain

Chronic pain is any long-standing pain — on-and-off or continuous — that persists beyond the usual recovery period of three months. The type of pain can be due to a primary condition or occur in the context of a disease. According to the American Academy of Pain Medicine, more than 1.5 billion people around the world suffer from chronic pain, and it is the most common cause of long-term disability in the U.S., affecting about 100 million Americans.

Chronic pain often has detrimental impacts on a person’s overall well-being, ability to work and physical capabilities. Consequently, it is one of the global leading causes for sickness-related absence and people being unable to work or return to work. Chronic pain is also one of the costliest health problems in the U.S., as it often results in medical expenses, lost income and productivity and compensation payments. 

Effective chronic pain management can result in significant improvements in quality of life — including decreased anxiety and depression — and is essential for improvement of pain, mood, sleep and physical function.

Could antidepressants improve chronic pain? 

Although antidepressant medications were originally developed to treat medical illnesses like depression, it can also be used “off-label” in clinical practice to treat other conditions, including chronic pain. Research suggests that antidepressants may be effective for pain because the same chemicals that affect mood might also affect pain, according to the meta-analysis. 

However, not all medications are created equal — different class types of antidepressants work in different ways. Previous research has shown that certain antidepressants may be effective in reducing chronic pain with some benefit; however, this was the first review that examined first-line antidepressants across most common chronic pain conditions. 

Meta-analysis details

The Cochrane analysis leveraged relevant studies that compared any antidepressant with any other treatment for chronic pain, then compared all treatments against each other — allowing researchers to rank the effectiveness of different antidepressants from best to worst. The study excluded patients with depression and anxiety, as those mental health conditions already often accompany chronic pain.

Among the 176 studies reviewed across medical databases, the most common pain conditions examined were fibromyalgia (59 studies), neuropathic pain (49 studies) and musculoskeletal pain (40 studies). The three most common antidepressant drug classes investigated for their effects on chronic pain were selective norepinephrine reuptake inhibitors (SNRIs), selective serotonin reuptake inhibitors (SSRIs), and tricyclic antidepressants (TCAs). Each class targets a different pathway and helps manage various mental health diseases. 

Primary outcomes of the analysis included substantial (50% or higher from baseline) pain relief, and improvements in terms of pain intensity, mood and adverse effects, while secondary outcomes of the analysis included moderate improvements (between 30% and 50% higher than baseline) in terms of pain relief, physical function, sleep and quality of life.

Key findings

One anti-depressant medication consistently ranked highest and proved superior to all others across efficacy outcomes: duloxetine (otherwise known by its brand name, Cymbalta). The analysis explained that duloxetine (Cymbalta), “probably has a moderate effect on reducing pain and improving physical function.” For every 1000 people taking standard-dose (60 mg) duloxetine, 425 will experience 50% — or substantial — pain relief, the study found. Additionally, the standard dose was equally as effective as a high dose (>60 mg) for most outcomes. 

One alternate medication, milnacipran, often ranked as the next most efficacious antidepressant in chronic pain treatment, although the certainty of evidence was lower than that of duloxetine. Across all secondary efficacy outcomes (including moderate pain relief, physical function, sleep and quality of life), duloxetine and milnacipran again ranked highest with moderate-certainty evidence.

The study’s primary conclusion states that despite investigating 25 different antidepressants, the only medication researchers are certain about for treating chronic pain is duloxetine. Some evidence for milnacipran is promising, although further high-quality research is needed to be confident about any conclusions. Evidence for all other antidepressants was low certainty.

While the findings from this meta-analysis can be pertinent for future chronic pain treatment, many questions remain. As the average study included in the meta-analysis lasted 10 weeks, there is no usable data beyond that period. This information would be crucial to understanding long-term effects as most chronic pain lasts beyond 10 weeks. To that end, there is no reliable evidence concerning the safety of taking antidepressants for chronic pain, for example, and there is not enough data to be certain about subsequent unwanted effects of taking it and the length of treatment.

What this review could mean for CPM

Cochrane reviews can be particularly helpful in re-examining generic medications that have little new research surrounding its efficacy since the medication attained FDA-approved labeling years or decades earlier. That allows us to look at, for example, TCA’s — among the earliest antidepressant class developed, introduced in the early 1950’s — in comparison to duloxetine (Cymbalta), an SNRI medication that the FDA approved in 2004. In comparing the two, we can analyze: What have we seen in each drug’s history? What works, what doesn’t? Which patient profile might benefit from SNRIs, instead of TCAs, and vice versa? 

In assessing any patient’s treatment, several factors must be weighed to find the right balance. No two patients are exactly alike — making it critical to adopt a people-focused approach. At Sedgwick, we focus on individualizing care while ensuring prescribing patterns are in line with evidence-based guidelines and that employees are receiving optimal support to facilitate their recovery.

We view patients’ cases retrospectively, and holistically. CPM nurses and pharmacists make recommendations to the injured worker’s prescribing physician with this goal in mind. Each recommendation is bolstered by sharp clinical reasoning and lies within the framework of current guidelines — all while aligning with the context of the patient’s medical history. 

New research is critical, as evidence-based discoveries can inform future updates to the national guidelines used daily to recommend treatments to patients. Due to the guidelines’ ever-changing nature, CPM clinicians consistently reassess best practices to ensure the best possible treatment is in place.

Moving forward

Sedgwick’s complex pharmacy team is in the process of reviewing best practices and routing rules, while watching closely for updated national/state guidelines considering this analysis. The potential impact this might have is yet to be determined — until then, we will continue adapting our best practices to better support injured workers.

Learn more  read about Sedgwick’s pharmacy solutions for U.S. workers’ compensation claims.

Pharmacy trends: pain management in workers’ compensation

September 14, 2023

Pharmacists recording data in the lab.
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Pain is one of the most common reasons adults seek medical care in the United States. According to the Centers for Disease Control and Prevention (CDC), American healthcare providers write 259 million prescriptions for opioid pain medication each year — enough for every adult in the country to have their own bottle of pills. Meanwhile, there is insufficient evidence to support the long-term benefits of opioid therapy for chronic pain.

This longtime rise in opioid prescriptions has occurred in tandem with sharp increases in opioid-related overdose deaths and widespread opioid use disorder (OUD). Due to alarming reports regarding this epidemic, opioid use is finally trending down, according to the CDC — except for synthetics like fentanyl. Guidelines have changed in recent years to curb the use of opioids as a first-line approach to pain treatment not associated with cancer.

Prescribers are moving away from opioids and searching for safer pain treatment options. At the same time, patient prescriptions and workers’ compensation claims are seeing an uptick in opioid dependency management medications.

From opioids to alternatives: trends

As prescribers shift to alternative pain management methods, opioid prescription trends are moving in the right direction, as suggested in a 2023 Enlyte LLC report. From 2021 to 2022, the proportion of opioid scripts and costs dropped 1.3% and 2.5%, respectively. The number of injured employees using opioids has continued to decline (down 2.7%) as well.

Opioid potency in prescriptions has also dropped. Morphine milligram equivalents (MME) and morphine equivalency doses (MED), values used to compare the potency of an opioid dose relative to milligrams of morphine, determine a person’s cumulative intake of opioids in 24 hours and are helpful indicators of dose-related risk for adverse reactions, including overdose.

Dosages higher than 50 MME per day increase the risk of overdose at least twofold, compared to smaller ones, says the CDC. Importantly, opioid claims with high MED decreased from 2021, and average daily MED levels per script decreased as well (down 5.3% and 2.8%, respectively).

Opioid dependency/reversal medications on the rise

Even as workers’ comp claims involving opioid decline, there has been a notable rise in prescriptions for managing opioid use disorder (including in workers’ comp). These drugs, commonly referred to as medication-assisted treatment (MAT) or medications for opioid use disorder (MOUD), do not cure OUD — there is no known cure. It merely quells withdrawal symptoms. The drugs are, however, demonstrably safe and effective in treating OUD in combination with psychotherapy, such as cognitive behavioral therapy (CBT).

For patients using MAT, there is no real “exit plan” once beginning the treatment and no clear guidelines on how long to continue taking such medications. The Enlyte report found that claims involving prescriptions of MAT medications increased 11.6% from 2021 to 2022, while costs fell during that period. The increase can be attributed in part to injured workers staying on those medications indefinitely and the subsequent push for MAT treatment to be part of their workers’ comp benefits. It also reflects healthcare providers’ efforts to take a proactive and preventive stance on opioid dependency.

Naloxone, a drug used to reverse opioid overdose, is also on the rise in workers’ compensation claims. In 2022, 7.3% of injured workers prescribed opioids with MED>50 (an opioid dosage that increases the risk of overdose twofold) received naloxone, up from 2.5% since the year prior.

Recent regulatory changes likely influenced this trend. In some states, providers are now required to prescribe the drug anytime a high-dosage opioid prescription is filled. This is positive news. Naloxone can act as a safety net for patients — including injured workers — if they do overdose on opioids, and at the very least prevent the financial burden of an emergency room visit.

Effective pain management options

Solutions that have emerged to replace opioids include anti-convulsants (the generic prescription medications gabapentin and pregabalin), nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen, acetaminophen (i.e., Tylenol) and anti-depressants (duloxetine, for one). These medications have proven effective at improving symptoms of chronic pain and garner less dependence, which explains the significant increase in prescriptions.

There is still, however, potential for misuse or abuse. Use of gabapentinoids, specifically gabapentin and pregabalin, have raised concerns — even being FDA approved to treat neuropathic pain — that the medicines are being overprescribed. Both medications can be taken recreationally to produce a high. Some misuse the medications alongside opioids, which significantly increases the risk of unintentional opioid poisoning and death. Still, clinicians are increasingly prescribing both drugs for pain instead of opioids. A 2021 Workers’ Compensation Research Institute (WCRI) report explored the growing use of gabapentinoids for managing pain arising from work-related injuries, and according to a 2022 WCRI study, anti-convulsants are one of the top-three categories of medications by payment share that are prescribed to injured workers.

It is best to consider every patient holistically, as there are often psychological comorbidities that underlie pain and interfere with its resolution. Extensive evidence points to the benefits of nonpharmacologic treatments, such as behavioral health, coupled with non-opioid pharmacologic treatments. Exercise or stretching can increase function, and CBT has been shown to reduce pain intensity in chronic-pain sufferers.

Other types of pain management treatments, such as spinal cord stimulation and nerve blockers, come up in the context of workers’ comp claims, but few studies support their medical use.

Safety, regulatory concerns

Since opioids have fallen out of favor, some physicians have begun prescribing and dispensing over-the-counter, private-label topical medications that are not just expensive and contain higher than recommended strengths of active ingredient; they are also not FDA-approved. Private label topicals are considered specialized products and bypass established pharmacy safety measures with little-to-no utilization review. Drug companies are marketing directly to providers to dispense and prescribe their products — posing a clear financial conflict of interest and safety risk. Many states do not have regulations in place to address these concerns, and any state allowing physician dispensing cannot control how these medications are distributed.

To address such concern, Sedgwick’s dedicated and highly trained team of nurses and pharmacists uses our established proprietary risk analysis indicators and evidence-based medical treatment guidelines to identify unsafe medications, drug combinations and dosages. They utilize evidence-based practices to evaluate medication regimens and collaborate with prescribers to ensure patient safety and medication compliance on our clients’ workers’ compensation claims. Our team of pharmacy experts is here to help employers protect injured workers from harmful medications, treat their symptoms safely and effectively, and control prescription drug costs.

> Learn more — read about Sedgwick’s pharmacy solutions for U.S. workers’ compensation claims.

Chiropractic care in workers’ compensation

September 12, 2022

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By David Kessler, D.C., M.H.A. CHCQM, SVP and medical director, Sedgwick Managed Care Ohio (MCO)

The Workers’ Compensation Research Institute (WCRI) recently published the findings of its study on the use of chiropractic care to treat injured workers in the United States suffering from lower back pain.

As a chiropractor by training and a longtime practitioner in the Ohio workers’ compensation and managed care arena, I was intrigued by this publication. The findings themselves are quite interesting and signal that further research on today’s physical medicine landscape is well warranted; however, their primary significance is, in my mind, to highlight the renewed role of chiropractic care in workers’ compensation.

The researchers found that average per-claim costs — both medical and indemnity — for low-back pain incurred on the job were lower for those treated exclusively by chiropractors, rather than other clinical specialists. Further, the injured workers studied who were treated exclusively by chiropractors were significantly less likely to be prescribed opioid drugs or to receive diagnostic imaging scans. (For detailed findings, refer to the study report.)

History and context

The 1990s were marked by rapidly rising healthcare costs. This spike, of course, strained workers’ compensation systems across the U.S. Multiple studies conducted during that decade found that chiropractic utilization was a significant driver of workers’ compensation healthcare spending — leaving many questioning its cost-effectiveness. This skepticism led a number of states to implement workers’ comp policy reforms and cost control measures limiting the use of chiropractic care in favor of other treatments viewed as more evidence-based and economical.

The results of the recent WCRI paint a far more encouraging picture of chiropractic care for injured workers than the findings of the 90s-era research.

What changed?

I believe there are a few factors contributing to the disparate findings.

  • Patient empowerment: Historically, patients remained under chiropractors’ care for extended periods, and progress toward recovery was dependent on adjustments or manipulation administered in the office. (The traditionally prolonged duration of chiropractic treatment and cost increases that began in the ‘90s are other reasons why it fell out of favor.) Today’s outcomes-based chiropractor focuses more on evidence-based guidelines and structured treatment plans with functional goals that ultimately transition patients to self-care in order to hasten improvement and alleviate reliance on in-office care. They educate injured workers on stretching and strengthening exercises to perform at home, as well as strategies for safe return to work and prevention of further strain, such as appropriate biomechanics and lifting techniques.
  • Continuing education: Many chiropractors now undertake training in complementary specialties and treatment approaches, such as sports injury management, orthopedics, neurology and more. This enables outcomes-based practitioners to leverage the knowledge and practices of other areas in physical medicine, as well as interdisciplinary care plans, and offers them additional tools to help injured workers achieve relief from back pain and greater productivity.
  • Multidisciplinary care: Although the recent WCRI study primarily highlighted injured workers treated exclusively by chiropractors, some of the greatest successes I’ve seen of late were in complex cases that warranted an integrated model of care when patients did not achieve the anticipated evidence-based recovery measures after chiropractic treatment alone. There is a burgeoning trend of multidisciplinary clinics opening to treat high-severity musculoskeletal issues — where orthopedists, family physicians, nurse practitioners, neurologists, physical therapists, chiropractors, massage therapists, surgeons and other specialists work together to deliver holistic care under one roof. Rather than presuming that any one specialty has all the answers for a given individual, this integrated approach covers a variety of treatment protocols and allows for quality, collaborative care for complex injuries. However, enlisting multiple practitioners can increase the medical costs on a claim, so it should be done prudently and only when warranted by the severity and complexity of the case.

Opportunities in the WC arena

Many in the workers’ compensation, managed care and employer arena still hold onto longstanding perceptions of chiropractors as providing care for extended durations without evidence of measurable or functional benefits. As a result, they tend to shy away from including chiropractic care in injured workers’ treatment plans, for fear of increasing medical costs with little return on investment and potentially extending lost work time. While some continue to distrust the effectiveness of chiropractic treatment, millions of people achieve healing and pain relief under the care of evidence-based chiropractors. (The WCRI study pointed out that individuals with non-occupational back injuries are much more likely to seek chiropractic care than those injured on the job.)

In light of escalating concerns over addictive pain medications, long-term side effects and rising pharmacy and surgery costs, chiropractic care offers a non-invasive way to help injured workers improve their quality of life and their productivity. Some people respond well to chiropractic treatment, others may not, and particularly complex cases may require multiple treatment approaches. However, chiropractic intervention is an overall low-risk and comparatively low-cost treatment option that merits further consideration.

Workers’ comp in the U.S. may present a unique opportunity for optimal utilization of chiropractic care because of the system structure. Unlike individuals seeking treatment for non-occupational injuries, workers’ comp patients have a claims examiner, often a nurse case manager and others assisting in the coordination of their care. These professionals are trained in managing complex cases, asking the right questions, and facilitating communication and cooperation between treatment providers. Since occupational injuries are covered under workers’ comp, patients don’t have to worry about copays to multiple specialists and meeting medical plan deductibles. Instead, they and their claims team can focus on pursuing the right care from the right treatment providers at the right time.

I hope that WCRI’s publication opens the door to greater consideration of chiropractic care with physical medicine modalities in workers’ compensation cases and to a reexamination of the regulations currently limiting the access of injured workers in certain states to high-quality, evidence-based chiropractic care.