Prescription opioids following herpes zoster: An observational study among insured adults, United States, 2007-2021

Kathleen Dooling; Jessica Leung; Michele K. Bohm

doi:10.5055/jom.0845

Authors

Kathleen Dooling, MD, MPH https://orcid.org/0000-0002-7546-9327
Jessica Leung, MPH https://orcid.org/0000-0002-5164-7555
Michele K. Bohm, MPH https://orcid.org/0000-0002-7119-4645

DOI:

https://doi.org/10.5055/jom.0845

Keywords:

herpes zoster, vaccine, antivirals, opioids

Abstract

Background: The opioid overdose epidemic has resulted in hundreds of thousands of overdose deaths in the United States (US). One indication for opioids is herpes zoster (HZ)—a common painful condition with an estimated 1 million cases occurring annually in the US.

Objective: We aimed to characterize prescription opioid claims and trends among patients with HZ who were previously opioid naive.

Design: We used a cohort study involving three insurance claims databases in the US. We included all beneficiaries 18-64 years (commercial and Medicaid) and beneficiaries 65 years and older (Medicare) who were diagnosed with incident HZ during 2007-2021. We determined the proportion of opioid-naive patients with HZ who filled an opioid prescription within 30 days and 180 days following HZ diagnosis. We also examined trends over the study period, proportion receiving moderate, high dosages (50-89 morphine milligram equivalent [MME], and ≥90 MME per day), and long-term receipt.

Results: Among all three insurance databases, 2,595,837 patients had an incident episode of HZ and were opioid naive during the prior 6 months. Within 30 days following HZ, 623,515 (24 percent) filled a prescription for an opioid. The percentage with an opioid claim declined during 2007-2021 for all groups; 65 percent for commercially insured patients, 51 percent for Medicaid-insured patients, and 60 percent for Medicare-insured patients. Approximately 8-15 percent of all beneficiaries received moderate and 2-6 percent received high dosage opioids. Long-term prescription opioid use of at least 6 months was found in 7-12 percent of the patients.

Conclusions: Continuing trends in judicious opioid prescribing as well as use of recommended HZ vaccines may decrease opioid prescriptions for HZ.

Author Biographies

Kathleen Dooling, MD, MPH

Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia

Jessica Leung, MPH

Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia

Michele K. Bohm, MPH

Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia

References

Hope-Simpson RE: Postherpetic neuralgia. J R Coll Gen Pract. 1975; 25: 571-575.

Yawn BP, Saddier P, Wollan PC, et al.: A population-based study of the incidence and complication rates of herpes zoster before zoster vaccine introduction. Mayo Clin Proc. 2007; 82: 1341-1349. DOI: https://doi.org/10.4065/82.11.1341

Harpaz R, Leung JW: The epidemiology of herpes zoster in the United States during the era of varicella and herpes zoster vaccines: Changing patterns among older adults. Clin Infect Dis. 2018; 69: 341-344. DOI: https://doi.org/10.1093/cid/ciy953

Dworkin RH, Johnson RW, Breuer J, et al.: Recommendations for the management of herpes zoster. Clin Infect Dis. 2007; 44(Suppl. 1): S1-26.

Insinga RP, Itzler RF, Pellissier JM, et al.: The incidence of herpes zoster in a United States administrative database. J Gen Intern Med. 2005; 20: 748-753. DOI: https://doi.org/10.1111/j.1525-1497.2005.0150.x

Cohen JL: Clinical practice: Herpes zoster. N Engl J Med. 2013; 369: 255-263. DOI: https://doi.org/10.1056/NEJMcp1302674

Albrecht M: Treatment of herpes zoster in the immunocompetent host. Available at https://www.uptodate.com/contents/treatment-of-herpes-zoster-in-the-immunocompetent-host. Accessed March 14, 2019.

Centers for Disease Control and Prevention: Vital signs: Overdoses of prescription opioid pain relievers—United States, 1999–2008. MMWR. 2011; 60: 1487-1492.

Boudreau D, Von Korff M, Rutter CM, et al.: Trends in long-term opioid therapy for chronic non-cancer pain. Pharmacoepidemiol Drug. 2009; 18: 1166-1175. DOI: https://doi.org/10.1002/pds.1833

Von Korff M, Saunders K, Thomas Ray G, et al.: De facto long-term opioid therapy for noncancer pain. Clin J Pain. 2008; 24: 521-527. DOI: https://doi.org/10.1097/AJP.0b013e318169d03b

Chou R, Hartung D, Turner J, et al.: Opioid treatments for chronic pain. In Comparative Effectiveness Review. Rockville, MD: Agency for Healthcare Research and Quality, 2020. DOI: https://doi.org/10.23970/AHRQEPCCER229

Bohnert AS, Valenstein M, Bair MJ, et al.: Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA. 2011; 305: 1315-1321. DOI: https://doi.org/10.1001/jama.2011.370

Centers for Disease Control and Prevention: Understanding the epidemic. 2018. Available at https://www.cdc.gov/drugoverdose/epidemic/index.html. Accessed March 27, 2023.

Chou R, Fanciullo GJ, Fine PG, et al.: Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009; 10: 113-130.e22. DOI: https://doi.org/10.1016/j.jpain.2008.10.008

US Department of Veterans Affairs, US Department of Defense: VA/DoD Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain. Washington, DC: US Department of Veterans Affairs, US Department of Defense, 2010.

Dowell D, Ragan KR, Jones CM, et al.: CDC clinical practice guideline for prescribing opioids for pain—United States, 2022. MMWR Recomm Rep. 2022; 71(No. RR-3): 1-95. DOI: https://doi.org/10.15585/mmwr.rr7103a1

Guy GP, Jr, Zhang K, Bohm MK, et al.: Vital signs: Changes in opioid prescribing in the United States, 2006-2015. MMWR Morb Mortal Wkly Rep. 2017; 66: 697-704. DOI: https://doi.org/10.15585/mmwr.mm6626a4

Centers for Disease Control and Prevention: US opioid dispensing rate maps. Available at https://www.cdc.gov/drugoverdose/rxrate-maps/index.html. Accessed March 27, 2023.

Poirrier JE, DeMartino JK, Nagar S, et al.: Burden of opioid use for pain management among adult herpes zoster patients in the US and the potential impact of vaccination. Hum Vaccin Immunother. 2020; 18: 2040328. DOI: https://doi.org/10.1080/21645515.2022.2040328

Hansen L, IBM Watson Health: White paper: IBM MarketScan research databases for life sciences and researchers. Available at https://marketscan.truvenhealth.com/marketscanuniversity/publications/2018%20Watson%20Health%20LS%20MarketScan%20for%20LS%20researchers%20tech%20WP%204.pdf. Accessed April 16, 2023.

Centers for Medicare and Medicaid Services: Research data assistance center: ResDac. Available at https://www.resdac.org. Accessed February 27, 2023.

Centers for Disease Control and Prevention: CDC file of national drug codes for opioid analgesics, and linked oral morphine milligram equivalent conversion factors, 2020 version. Atlanta, GA: Centers for Disease Control and Prevention, 2021. Available at https://www.cdc.gov/drugoverdose/resources/data.html. Accessed December 2, 2022.

Mikosz CA, Zhang K, Haegerich T, et al.: Indication-specific opioid prescribing for US patients with Medicaid or private insurance, 2017. JAMA Netw Open. 2020; 3: E204514. DOI: https://doi.org/10.1001/jamanetworkopen.2020.4514

Harpaz R, Ortega-Sanchez IR, Seward JF: Prevention of herpes zoster. MMWR Morb Mortal Wkly Rep. 2008; 57: 1-30.

Dooling KL, Guo A, Patel M, et al.: Recommendations of the advisory committee on immunization practices for use of herpes zoster vaccines. MMWR Morb Mortal Wkly Rep. 2018; 67: 103-108. DOI: https://doi.org/10.15585/mmwr.mm6703a5

Oxman MN, Levin MJ, Johnson GR, et al.: A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults. N Engl J Med. 2005; 352: 2271-2284. DOI: https://doi.org/10.1056/NEJMoa051016

Cunningham AL, Lal H, Kovac M, et al.: Efficacy of the herpes zoster subunit vaccine in adults 70 years of age or older. N Engl J Med. 2016; 375: 1019-1032. DOI: https://doi.org/10.1056/NEJMoa1603800

Lal H, Cunningham AL, Godeaux O, et al.: Efficacy of an adjuvanted herpes zoster subunit vaccine in older adults. N Engl J Med. 2015; 372: 2087-2096. DOI: https://doi.org/10.1056/NEJMoa1501184

Lu P, Hung M, Srivastav A, et al.: Surveillance of vaccination coverage among adult populations—United States, 2018. MMWR Surveill Summ. 2021; 70(No. SS-3): 1-26. DOI: https://doi.org/10.15585/mmwr.ss7003a1

Dworkin RH, Barbano RL, Tyring SK, et al.: A randomized, placebo-controlled trial of oxycodone and of gabapentin for acute pain in herpes zoster. Pain. 2009; 142: 209-217. DOI: https://doi.org/10.1016/j.pain.2008.12.022

Edlund MJ, Martin BC, Russo JE, et al.: The role of opioid prescription in incident opioid abuse and dependence among individuals with chronic noncancer pain: The role of opioid prescription. Clin J Pain. 2014; 30: 557-564. DOI: https://doi.org/10.1097/AJP.0000000000000021

Shah A, Hayes CJ, Martin BC: Characteristics of initial prescription episodes and likelihood of long-term opioid use—United States, 2006-2015. MMWR Morb Mortal Wkly Rep. 2017; 66: 265-269. DOI: https://doi.org/10.15585/mmwr.mm6610a1

Gomes T, Mamdani MM, Dhalla IA, et al.: Opioid dose and drug-related mortality in patients with nonmalignant pain. Arch Intern Med. 2011; 171(7): 686-691. DOI: https://doi.org/10.1001/archinternmed.2011.117

Mullooly JP, Riedlinger K, Chun C, et al.: Incidence of herpes zoster, 1997–2002. Epidemiol Infect. 2005; 133: 245-253. DOI: https://doi.org/10.1017/S095026880400281X

Yawn BP, Wollan PC, Kurland MJ, et al.: Herpes zoster recurrences more frequent than previously reported. Mayo Clin Proc. 2011; 86: 88-93. DOI: https://doi.org/10.4065/mcp.2010.0618