Nonopioid Options to Manage Chronic Pain in Veterans | ACR Convergence
Chronic pain is more prevalent—and more severe—in veterans compared with the general US population.
According to the CDC, approximately 50 million US adults are living with chronic pain. This condition is more prevalent—and more severe—in veterans compared with the general US population.1,2 A 2017 report published by the National Institutes of Health found that 65.5% of surveyed veterans reported having pain 3 months prior to the survey period, with 9.1% classifying that pain as severe.3
Chronic pain is more prevalent—and more severe—in veterans compared with the general US population. | Image credit: Ahmed - stock.adobe.com
Due to the high prevalence of pain, this patient population is at an increased risk for opioid use disorder and opioid overdoses, and identifying nonopioid pain management alternatives is crucial.
At ACR Convergence 2024, 2 studies evaluated mortality in veteran cohorts using nonopioid therapies to manage chronic musculoskeletal pain.
Mortality With Cyclobenzaprine or Baclofen
Among veterans with chronic musculoskeletal conditions who were new users of either cyclobenzaprine or baclofen, no statistically significant differences in either out-of-hospital or all-cause mortality were noted, according to researchers.4
Cyclobenzaprine is a centrally-acting muscle relaxant approved for short-term treatment of muscle spasms associated with acute musculoskeletal pain—"despite limited effectiveness,” researchers noted. It is structurally similar to tricyclic antidepressants and is associated with concerns of tricyclic-like effects of QRS prolongation leading to life-threatening tachycardia and increased mortality. Baclofen, a muscle relaxant used to treat pain and spasticity associated with certain diseases, is an active comparator.
In a retrospective cohort study, researchers used data from the Veterans Health Administration (VHA) from 2015 to 2021. The patient population included new users of cyclobenzaprine or baclofen aged 18 to 89 years with medical codes indicative of a diagnosis of musculoskeletal pain. The primary and secondary study outcomes were out-of-hospital and all-cause mortality, respectively.
READ MORE: Pharmacists Champion Nonopioid Pain Management Strategies
A total of 517,051 patients using cyclobenzaprine and 120,832 patients using baclofen were included in the study (median age, 55 years; 86.1% men; 65.6% white). The most common indications for medication use were back pain and arthralgia, and the most common comorbidities included hypertension, ischemic heart disease, and atrial fibrillation or flutter.
A total of 1906 out-of-hospital deaths and 2040 all-cause deaths were identified: 1302 and 1393 in the cyclobenzaprine group, respectively, and 604 and 647 in the baclofen group, respectively. The incidence rate of out-of-hospital mortality in the cyclobenzaprine group was 10.26 per 1000 person-years, vs 13.18 in the baclofen group (HR, 0.81; 95% CI, 0.74-0.89; aHR, 0.96; 95% CI, 0.74-0.89).
Similarly, the rates of all-cause mortality were 10.96 and 14.10 per 1000 person years in the cyclobenzaprine and baclofen groups, respectively (HR, 0.81; 95% CI, 0.74-0.89; aHR, 0.95; 95% CI, 0.86-1.05).
Mortality With Pregabalin or Duloxetine
As with the first study, investigators for the second study found no statistically significant differences in all-cause mortality among veterans who used pregabalin or duloxetine for musculoskeletal pain.5
This retrospective cohort study used VHA data from 2014 to 2022, identifying veterans with chronic, noncancer musculoskeletal pain who were new users of pregabalin, an antiepileptic therapy with risks of adverse events that include depression and congestive heart failure, or comparator duloxetine, a selective serotonin and norepinephrine reuptake inhibitor.
The cohort included a total of 26,700 patients who used pregabalin and 152,862 patients who used duloxetine (83.1% men, 69.7% white; median age, 56 years). During the study period, 2017 deaths were identified, with rates of all-cause mortality of 17.43 and 13.7 per 1000 person years for pregabalin and duloxetine, respectively (HR, 1.29; 95% CI, 1.14-1.45). After adjusting for covariates, the difference in all-cause mortality rates became statistically nonsignificant (HR, 1.09; 95% CI, 0.95-1.25).
READ MORE: Nonopioid Pain Management Resource Center
References
VA research on pain management. US Department of Veterans Affairs. Accessed November 20, 2024. https://www.research.va.gov/topics/pain.cfm
Dahlhamer J, Lucas J, Zelaya C, et al. Prevalence of chronic pain and high-impact chronic pain among adults — United States, 2016. MMWR Morb Mortal Wkly Rep. 2018;67(36):1001-1006. Doi:10.15585/mmwr.mm6736a2
Pain: US military and veterans. National Center for Complementary and Integrative Health. Updated November 20, 2024. Accessed November 20, 2024. https://www.nccih.nih.gov/health/pain/veterans
Intriago M, Nepal P, Daneil LL, et al. Mortality in US veterans with musculoskeletal conditions using cyclobenzaprine or baclofen. Presented at: ACR Convergence 2024; November 14-19, 2024; Washington, DC. Abstract 1215.
Campbell S, Daniel LL, Dickson AL, et al. All-cause mortality in patients with chronic musculoskeletal pain using pregabalin or duloxetine: A retrospective cohort study in US veterans. Presented at: ACR Convergence 2024; November 14-19, 2024; Washington, DC. Abstract 1214.
