Opioid dispensing for people living with sickle cell disease in the United States has started climbing again, according to a new study published in JAMA Network Open, reversing a decline that ran through most of the 2010s.

A large study spanning more than a decade

Researchers from Washington University School of Medicine and colleagues tracked opioid prescribing among 48,760 people with sickle cell disease enrolled in commercial or Medicaid insurance between 2011 and 2023. Just over half, 50.6%, were on Medicaid, and most patients, 60.3%, were female. The team looked at six commonly used opioids: hydromorphone, hydrocodone, morphine, tramadol, oxycodone and methadone.

A decade of decline, then a turn

For most of the study period, opioid dispensing moved in one direction: down. Between 2016 and 2020, prescribing fell for every one of the six drugs, in both commercial and Medicaid populations. That trend lines up with the years following the 2016 CDC guideline on opioid prescribing, when clinicians across the country grew more cautious about opioid use for chronic pain.

From 2021 to 2023, though, the picture shifted. Among Medicaid beneficiaries, opioid dispensing rose significantly for all six drugs. The steepest increases were seen with methadone, up 1.76% a month, and hydromorphone, up 1.43% a month, which works out to annual rises of roughly 23% and 19% respectively. Commercially insured patients saw smaller but still notable increases, particularly for oxycodone and morphine, while tramadol dispensing among this group kept falling.

More prescriptions, not bigger doses

What the study did not find is just as important as what it did. Even as total dispensing went up, the researchers saw no broad increase in how much opioid medication individual patients were receiving. The number of prescriptions per person, the number of days a prescription covered, and the average daily dose measured in morphine milligram equivalents (MME) all stayed flat or continued to decline for nearly every drug and insurance combination examined.

In other words, more prescriptions were going out, but existing patients were not being given larger or longer courses. The study authors describe this as a pattern of “wider distribution” of opioid prescribing across a larger group of patients, rather than more intensive treatment for those already receiving opioids.

The tramadol exception

One exception stood out. Among Medicaid patients, tramadol was the only drug where both total dispensing and prescriptions per person rose together, by around 7% and 12% a year. Tramadol is a lower potency, Schedule IV opioid, and the authors suggest it may be seen by prescribers or insurers as a more acceptable option than stronger, more tightly regulated drugs. They also flag that tramadol carries its own risks, including complex interactions with other medicines and a tendency to build up in patients with kidney problems, a complication that is common in sickle cell disease.

Why opioids matter so much in sickle cell care

Sickle cell disease causes red blood cells to become misshapen, which can block blood flow and trigger episodes of severe pain known as vaso-occlusive crises. Opioids remain a central part of managing that pain, both during acute episodes and for some patients living with chronic pain day to day. Roughly 100,000 people in the US live with the condition, and it disproportionately affects Black communities.

What might be driving the rebound

The researchers were not able to pin down exactly why prescribing patterns shifted after 2020. The period overlaps with several developments at once, including updated pain management guidance from the American Society of Hematology in 2020, ongoing disruption from the COVID-19 pandemic, and ongoing changes to state and federal opioid policy. Because these factors overlap in time, the study cannot say which one, or which combination, drove the rebound in dispensing.

Limits of the data

The authors also note some limits to the data. The MarketScan databases used in the study do not record which US state a patient lives in, which matters given how much opioid policy and sickle cell care varies from state to state. Even so, with data from nearly 50,000 patients over 13 years, the study is among the largest of its kind to look closely at prescribing patterns for individual opioid drugs, rather than lumping them all together.

Looking ahead

The findings arrive at a moment when sickle cell care is changing rapidly, with new gene therapies and other disease modifying treatments becoming available. The authors argue that as these options expand, it will be just as important to ensure patients can access the full range of pain management tools they need, opioid and non opioid alike, without falling back into the access problems that followed the opioid guidelines of the past decade.

Source: jamanetwork