Opioid and Gabapentinoid Prescribing in Older Adults with Dementia Before and After the 2016 CDC Opioid Prescribing Guideline.

BACKGROUND

In March 2016, the Centers for Disease Control and Prevention (CDC) issued guidelines advising against opioid use for most chronic pain because of their associated risks. Evaluating how this guideline affected subsequent opioid and non-opioid analgesic prescribing in older adults with dementia is critical, as this population is at heightened risk for both pain undertreatment and adverse medication effects.

OBJECTIVE

To evaluate whether the 2016 CDC opioid prescribing guideline was associated with changes in opioid and gabapentinoid prescribing in older adults with dementia.

DESIGN

Interrupted time series analysis of a longitudinal cohort from 2010 to 2022.

PARTICIPANTS

Community-dwelling older adults (≥ 65 years) with dementia enrolled in the Medicare Current Beneficiary Survey (MCBS), a nationally representative survey linked to Medicare claims.

MAIN MEASURES: Quarterly prescribing rates of opioids (typical opioids, tramadol, buprenorphine) and gabapentinoids (gabapentin, pregabalin) before and after CDC guideline release. Interrupted time series models estimated level (immediate) and trend (slope) changes associated with the guideline.

KEY

RESULTS

We identified 3246 older adults with dementia (median age [IQR] 80.7 [73.8-86.2] years; 61.4% female). Typical opioid prescribing declined by 26.5% over the study period, but the guideline was not associated with this decline (trend change: 0.09 [95% CI -0.1, 0.3] percentage points [ppts]/quarter; level change -1.5 [95% CI -4.1, 1.0] ppt). The guideline was associated with the 27.1% decrease in tramadol prescribing (trend change: -0.2 ppts/quarter [95% CI, -0.3, -0.1]; level change: -1.8 [95% CI, -3.1, -0.6] ppts). Gabapentinoid prescribing increased from 9.5% to 11.5%, with no change in trend (0.0 ppts/quarter [95% CI, -0.01 to 0.02]) after the guideline release. Buprenorphine prescribing remained near zero.

CONCLUSIONS

We identified analgesic selection shifts rather than uniform opioid reductions following the CDC guideline release, but the impact of these shifts on symptom control remains unknown. More nuanced, evidence-based analgesic prescribing guidance is needed for older adults with dementia.