Overprescribing of Barbiturates and Opioids for Migraine a Major Concern

VBCN - July 2015 Volume 2, No 2 - Headache Management
Rosemary Frei, MSc

Washington, DC—New evidence of continued overprescribing of barbiturates and opioids for patients with migraine was presented by Mia T. Minen, MD, MPH, Director, Headache Services, New York University Langone Medical Center, New York City, and colleagues at the 2015 American Headache Society annual meeting.

A survey of 218 patients with migraine who presented to a headache center in May and June 2014 revealed that 19.4% of patients were currently receiving an opioid, 20.7% were currently taking a barbiturate, and 6.9% were taking both. Emergency physicians accounted for the highest percentage (20.2%) of the first prescribers of the opioids, and general neurologists comprised the largest portion (37.8%) of first prescribers of barbiturates. The American Board of Internal Medicine’s “Choosing Wisely” initiative recommends not using opioid- or butalbital-containing medications as first-line therapy for recurrent headache disorders, such as migraine.

“Those medications are okay if patients have significant contraindications to triptans, which guidelines say should be the first-line drugs for migraine, or as a last resort to prevent patients from going to the emergency department, but they’re not to be prescribed to most patients or on a chronic basis,” Dr Minen told Value-Based Care in Neurology.

Dr Minen noted there can be significant negative consequences for patients with migraine taking barbiturates and/or opioids, including an increased risk for fatal overdoses and for medication overuse headache and combination analgesic overuse headache, which are treatment-refractory conditions.

“The physician might say, ‘You can only take 4 tablets of Fioricet [the combination of butalbital, acetaminophen and caffeine] per month and only 8 tablets of sumatriptan,’ and the patient will take both of those, and also take Excedrin, because it’s an over-the-counter medication. And they’ll think they’re following the doctor’s instructions, but in fact, they’re taking too many pills,” said Dr Minen.

Study Details

A total of 217 completed surveys were included in the analysis. Most (78.7%) were women, and 83.9% reported that they had been diagnosed with migraine. Furthermore, 9.7% had a diagnosis of posttraumatic headache, 6.9% had been diagnosed with medication overuse headache, and 60.3% self-reported as having another headache diagnosis.

Overall, 119 (54.8%) patients had been prescribed an opioid at some point since their diagnosis, with 34.6% (N = 75) saying the opioids were effective in reducing their symptoms. In addition, 123 (56.7%) patients had been prescribed a barbiturate, of whom 79 (64.2%) found it to be effective.

Most patients (24.6%) who had previously taken an opioid had been using them for more than 2 years. Only 33% (N = 14) of the patients had taken them for less than 1 week.

Emergency physicians (20.2%) were the most frequent prescribers of opioids for these surveyed patients. Family physicians and general neurologists each accounted for 17.5% of first prescriptions of opioids. General neurologists also comprised 37.8% of first prescribers of barbiturates, followed by headache specialists (26.7%) and internists (22.2%).

Dr Minen said that she has applied for a grant to study a comprehensive migraine treatment program for patients who present with migraine to the emergency department as part of the development of effective interventions to improve guideline-congruent prescribing among physicians.

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