In light of the opioid epidemic, and the increased risk for opioid-related hospitalizations and deaths, the US Drug Enforcement Administration and the CDC were prompted to implement policies and guidelines for reducing opioid prescribing. As a result, opioid prescriptions declined, and some providers switched to prescribing gabapentinoids (GABA) for pain management, with the understanding that these were potentially safer alternatives to opioids.
Burn injury can cause significant and prolonged pain that can severely impact the patient’s QOL. While opioids remain the foundation of burn pain management, studies have shown that prescribing rates after burns have been steadily decreasing since 2015. It is important to understand whether this decline has been accompanied by an increase in GABA prescriptions or not for two reasons. First, burn pain often exhibits neuropathic characteristics and studies have shown that GABA drugs can be effective for those burn patients; therefore, these medications could potentially replace opioids for some patients while offering adequate pain control. Second, new evidence shows that co-prescribing of opioids and GABA may increase the risk for respiratory adverse events, warranting further monitoring of prescribing trends.
For an investigation published in Burns, our team conducted a retrospective cohort study using a national commercial insurance claims database to determine the impact of opioid restricting policies on GABA prescribing after burn injury.
Influence of Patient Characteristics & Clinical Factors
We found that, while prescribing of GABA as a first-line medication for burn injury pain remains limited, it increased substantially from 2012 to 2018 (adjusted OR, 1.44; 95% CI, 1.2-1.74). The increase, however, was not uniform across all age groups and regions (Figure). Patients older than 50 were prescribed GABA at a higher rate in later years, whereas for patients younger than 35, there was no change in prescribing rates over time. In regard to region of residence, the most pronounced increase in GABA prescribing was noted in the South, followed by the West. We did not find any significant change in the rates of co-prescribing of GABA and opioids in this patient population (adjusted OR, 1.11; 95% CI, 0.91-1.35).
When evaluating the patient and clinical factors associated with increased GABA prescribing, we found that patients with moderate or severe burns and those requiring hospitalization were more likely to get GABA. Also, patients with multiple comorbidities and those with a history of substance use disorder were prescribed GABA alone or with opioids at a higher rate.
Additional Guidance Needed For GABA Prescribing
There are several key takeaways from our study. First, while GABA medications are prescribed conservatively for burn pain, policy changes in the past decade, along with increased awareness of opioid adverse effects, appear to have led to a steady shift in prescribing practices. However, the change has not been uniformly distributed across the country, indicating the need for new burn pain guidelines and clinician education on which patients are more likely to benefit from non opioid alternatives. Second, co-prescribing of GABA and opioids, while limited, has not decreased in the past years; clinicians should closely monitor these patients as they are at higher risk for respiratory depression.
Future research should focus on better identifying those patients with burns and neuropathic pain that are more likely to respond to GABA, as well as the optimal dosing and timing for these medications in order to adequately manage burn pain. We would also like to see more research on co-prescription of opioids and GABA, both on potential benefits as well as side effects for this specific patient population.
