Reduction of opioid and barbiturate use following initiation of rimegepant for migraine in the United States

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OBJECTIVE: The primary objective of this study was to evaluate opioid and barbiturate utilization before and after the first prescription of the calcitonin gene-related peptide receptor antagonist rimegepant in individuals with migraine. BACKGROUND: Although not recommended in migraine treatment guidelines, opioids and barbiturates are often prescribed for the acute treatment of migraine, despite the risks of dependence and harm. Initiating a migraine-specific acute treatment might reduce the use of opioids and barbiturates. METHODS: This retrospective cohort study among adults in the United States with migraine and a first prescription for rimegepant (fill quantity of eight tablets, indicative of acute treatment) was based on administrative claims data from the IQVIA PharMetrics Plus longitudinal health plan database (September 1, 2019, through March 31, 2023). For opioids and butalbital (separately), number of prescription fills and average dispensed amounts (as morphine milligram equivalents [MME] and milligrams [mg], respectively) were assessed in the 180 days preceding (pre-index) and the 180 days following (post-index) rimegepant initiation. Subgroup analyses included individuals using ≥ 1 preventive treatment, and individuals with problematic opioid use (≥ 3 opioid prescriptions and/or MME in the fourth quartile). RESULTS: Among 1928 opioid users, rimegepant initiation was associated with a significant difference in opioid prescription fills (median [interquartile range (IQR)] 2 [1-5] pre-index vs. 1 [0-5] post-index, p < 0.001) and average dispensed MME (25 [17.5-37.5] pre-index vs. 14 [0-30] post-index, p < 0.001), and 740 users (38.4%) discontinued opioids. Among 873 butalbital users, rimegepant initiation was associated with a significant difference in butalbital prescription fills (median [IQR] 2 [1-4] pre-index vs. 1 [0-3] post-index, p < 0.001) and average dispensed mg (200 [100-300] pre-index vs. 25 [0-187.5] post-index, p < 0.001), and 422 users (48.3%) discontinued opioids. Rimegepant initiation was associated with reduction of opioid and butalbital utilization in the subgroups using preventive treatment, and reduction of opioid utilization in the subgroup with problematic opioid use. CONCLUSIONS: Rimegepant initiation was associated with reductions in utilization of opioids and butalbital, including in individuals using preventive treatment for migraine, and with reduction of opioid utilization in individuals with problematic opioid use.

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