Generic Options for Pain Management Coming Soon
Treatment of pain, especially chronic pain, is a frustrating and difficult part of primary care. Opioid therapy is problematic for many reasons, not the least of which is that there is just not much evidence that it is effective for long term pain control. The epidemic of opioid diversion, addiction and abuse has been all over the press in the last couple of years. One of the problems in trying to treat pain without opiods is the high cost of several branded non-opioid alternatives. The good news is that three medications that play a small but important role in pain management, Cymbalta (duloxetine), Celebrex (celicoxib), and Lyrica (pregabalin) will lose their patents in the next two years.
Cymbalta, a Serotonin-Norepinephrine receptor inhibitor (SNRI) used occasionally for the treatment of depression is more often used to treat neuropathic pain in patients with diabetic, post-herpetic (after shingles), chemotherapy induced, or idiopathic peripheral neuropathy. It more recently received an FDA approval for the treatment of chronic pain, especially low back pain. It seems to work in both depressed and non-clinically depressed patients. A major problem with use of Cymbalta is that it is expensive and either not covered or at a very high tier copay by insurance. This will change since the Eli Lilly patent on Cymbalta is set to expire in Dec. 2013. By mid 2014 we can expect generic competition for duloxetine, and I expect its use to go way up as it becomes affordable. We will need to watch for the uncommon hepatic toxicity of this drug, but it will be good to have another affordable option.
Celebrex (celecoxib) is another medication that for some patients is a good option for pain treatment. Celebrex is the only remaining COX-2 anti-inflammatory drug left on the market after Vioxx and Bextra were removed for their cardiac risk side effects. Although little proof exists showing that Celebrex causes less gastrointestinal bleeding or works better than currently available generic NSAIDS like ibuprofen or naproxen, I certainly see some patients who don’t tolerate other NSAIDS and find Celebrex very effective for pain of osteoarthritis. The patent for Celebrex expires in May 2014, so by the end of 2104 we should expect generic competition for this drug too.
Lyrica (pregabalin) is yet one more drug used to treat pain, especially pain from fibromyalgia and neuropathy that is set to lose its patent in 2013. The indication for Lyrica that loses its patent is seizure therapy, but it is sure to gain market share off label for other indications too. Lyrica has some advantages over gabapentin, the most common alternative generic available. Hopefully generic pregabalin will be affordable. Generic gabapentin remains moderately expensive.
Maybe as these three drugs to treat pain become more affordably available we will have more success treating pain with non-opioid drugs.