gms | German Medical Science

Background: More than half of men and two-thirds of women in Germany reported in an interview to have had pain within one year [1]. Since both acute as well as chronic pain can be very stressful and reduce quality of life, pain management in outpatient care is very important. There are guidelines on pain therapy [2], [3], [4] with which doctors can align their therapy. The study aimed to quantify non-opioid and opioid pain therapy in outpatient care and to analyse possible safety risks.

Materials and methods: Database: BARMER health insurance data of 6,771,075 persons aged 18 years or older continuously insured during the observation period in 2021 or one year before death in 2021 without diagnosis of malignant neoplasms (ICD codes C00-C97) were included [5]. Therapy with analgesics prescribed in outpatient care was analyzed including opioids (ATC code N02A) and non-opioids (ATC codes M01A, N02B) without herbal or homoeopathic agents and (levo-)methadone (mainly used in addiction treatment). Long-term therapy was defined as prescribing of over 91 DDD in a period of over 91 days, i.e. over 91 days between first and last prescription filled at a pharmacy.

Results: In 2021 32.7% of the persons included (men 28.9%, women 35.4%) received at least one prescription with an analgesic. 31.6% received non-opioids (age 18–64 years: 27.8%, 65–79: 36.7%, 80+: 47.8%) and 5.7% opioids (age 18–64 years 3.3%, 65–79 8.0%, 80+ 18.1%). Long-term therapy was present in 5.8% of the insurees, in 4.6% with non-opioids and in 1.9% with opioids.

Ibuprofen (16.7%) and metamizole (14.2%) were the by far most frequently prescribed non-opioids within the year 2021. The prescription of metamizole more than tripled from the age-group 18–64 years (11.4%) to the age-group 80+ (37.9%) whereas the prescription of ibuprofen slightly declined from 17.8% to 13.8%. The most frequently prescribed opioids overall and in long-term therapy (LT) were tilidine (2.8%, LT 0.8%) and tramadol (1.3%, LT 0.3%).

Potentially harmful drug therapy safety risks were identified, e.g. NSAIDs were prescribed to patients suffering from heart failure (5.0% of those with NSAID had ICD-diagnosis I50) or renal insufficiency (2.4% had ICD-diagnoses N18.3 or N18.4) despite guidelines advice against. Opioid therapy should be combined with a laxative but 30.7% of the patients with long-term therapy had no prescription. The combination of opioids with tranquilizers causes severe side effects but on average in every tenth patient with opioids this combination was found.

Patients with opioid prescriptions very often had polypharmacy (79.6% five or more drugs at the same time within one year) and multimorbidity (12.9 chronic diseases in the first year of therapy). Accordingly, they visited an average of 10.3 different doctors’ offices and received prescriptions of 4.2 offices in the first two years of pain therapy.

Conclusion: Pain therapy with analgesics in non-oncological patients proved to be everyday business in outpatient care. Within one year, one third of the adults received a prescription of an analgesic, almost six percent in long-term therapy. Women are more likely to receive pain therapy and the proportion of treated persons considerably increases with age. Patients with pain therapy often suffer from several diseases especially the older ones. Thus, the physicians have to consider a variety of patient-specific factors and preferences and weigh the risks of the different therapy options against each other. A complete and up-to date overview of the patient’s medication and medical history, available for the treating physicians and the patient, and digital support in decision making and checking drug therapy safety is essential for avoiding risks in pain therapy and beyond. Scientific studies have shown the benefits of these measurements but implementation in healthcare has not yet taken place.