Investigation Finds Geographic Variability in Opioid Use for Migraine

Results of a retrospective cohort study showed significant geographic variation in the use of opioids for migraine across the United States. Findings were published in Headache: The Journal of Head and Face Pain.

Despite recommendations from leading headache and neurological groups endorsing the use of triptans as first-line therapy for most migraine attacks, data show that “among new triptan users, 50% do not refill their prescription within 12 months after their first fill and fewer than 10% try more than 1 triptan agent in the 12-month follow-up period.” Among triptan-insufficient responders, opioids are often prescribed as next-line therapy.

Little is known on how opioid use for acute migraine varies geographically. However, with regard to overall opioid use, evidence has revealed large variations in prescribing practices when stratified by state.

To address this knowledge gap, the researchers analyzed geographic variations in triptan and opioid prescribing patterns for migraineurs using deidentified data from the IBM MarketScan Commercial and Medicare Supplemental databases.

Information on primary care physician (PCP) density was gleaned from the Area Health Resource Files, while data on neurologist density was collected from the IQVIA Nationwide Physician Specialties by State market insights report. Researchers also identified states with opioid use policies restricting the outpatient use of opioids for acute pain. Census Bureau–designated regions (n = 9) were used to classify location.

All migraineurs were required to have 12 months of continuous medical and prescription enrollment, before and after the index date. Those with at least 1 triptan claim were considered triptan users and those with at least 1 opioid claim were considered opioid users; use of either was not considered mutually exclusive. Data were analyzed between 2016 and 2018, and a 12-month follow-up period was defined.

A total of 113,921 individuals with a mean (SD) age of 43.8 (12.3) years were included in analysis; the majority of patients (83.9%) were female.

Analyses revealed:

• In the follow-up period, 52.9% (n = 60,247) of patients were triptan users and 41.0% (n = 46,708) of patients were opioid users, with significant differences across census divisions (P < .001)
• Triptan users had a mean (SD) of 4.8 (4.7) triptan claims annually, with no significant differences across divisions (P = .188)
• Opioid users had a mean (SD) of 5.4 (6.8) opioid claims annually, with significant differences across divisions (P < .001).
• The observed variation in opioid use stemmed from the proportion of patients using opioids in each region, not from the number of opioid prescriptions per user
• Approximately 42.9% of patients resided in a state with an opioid use policy; all states in the New England and Mid-Atlantic divisions had an opioid use policy in place during the study period
• The division with the largest proportion of patients was the South Atlantic (28.3%), and the division with the smallest proportion of patients was New England (3.6%)
• PCP density was highest in the New England and Mid-Atlantic divisions
• Neurologist density was highest in the Mid-Atlantic division

Overall, “the findings of our study suggest that triptan use was more homogeneous across geographic divisions than opioid use,” the researchers wrote, “suggesting that clinician education may be needed regarding the role of triptans versus opioids in migraine treatment.”

Results also showed low PCP and neurologist densities were associated with higher triptan and opioid use compared with areas with high densities. In addition, patients with higher numbers of comorbidities were more likely to be opioid users. This finding could bebecause triptans are contraindicated with cardiovascular disease and migraineurs with this comorbidity could have been prescribed opioids as an alternative, the authors hypothesized.

Potentially confounding variables such as race, income, education, and occupation were not reflected in the MarketScan database, marking a limitation to the study.

“With the recent influx of new treatment options, further research is warranted to understand the impact of novel acute medications and preventive treatments on triptan and opioid use among patients with migraine,” the researchers concluded.

Reference

Lee JH, Shewale AR, Barthold D, and Devine B. Geographic variation in the use of triptans and opioids for the acute treatment of migraine attacks. Headache. Published online November 28, 2021. doi:10.1111/head.14238