Prescription opiate abuse in chronic pain patients: clinical criteria, incidence, and predictors

Long-term opioid treatment of chronic nonmalignant pain: unproven efficacy and neglected safety?

BACKGROUND

For the past 30 years, opioids have been used to treat chronic nonmalignant pain. This study tests the following hypotheses: (1) there is no strong evidence-based foundation for the conclusion that long-term opioid treatment of chronic nonmalignant pain is effective; and (2) the main problem associated with the safety of such treatment - assessment of the risk of addiction - has been neglected.

METHODS

Scientometric analysis of the articles representing clinical research in this area was performed to assess (1) the quality of presented evidence (type of study); and (2) the duration of the treatment phase. The sufficiency of representation of addiction was assessed by counting the number of articles that represent (1) editorials; (2) articles in the top specialty journals; and (3) articles with titles clearly indicating that the addiction-related safety is involved (topic-in-title articles).

RESULTS

Not a single randomized controlled trial with opioid treatment lasting >3 months was found. All studies with a duration of opioid treatment ≥6 months (n = 16) were conducted without a proper control group. Such studies cannot provide the consistent good-quality evidence necessary for a strong clinical recommendation. There were profound differences in the number of addiction articles related specifically to chronic nonmalignant pain patients and to opioid addiction in general. An inadequate number of chronic pain-related publications were observed with all three types of counted articles: editorials, articles in the top specialty journals, and topic-in-title articles.

CONCLUSION

There is no strong evidence-based foundation for the conclusion that long-term opioid treatment of chronic nonmalignant pain is effective. The above identified signs indicating neglect of addiction associated with the opioid treatment of chronic nonmalignant pain were present.

Associations among pain, non-medical prescription opioid use, and drug overdose history

BACKGROUND AND OBJECTIVE

Recently, use of prescription opioids (POs) has increased; non-medical PO (NMPO) use is linked to overdose. NMPO use is common among individuals prescribed opioids for pain, and those in substance use disorder (SUD) treatment with pain could be at increased risk for unintentional overdose due to NMPO use. We examined associations between pain, NMPO use, and overdose among SUD treatment patients.

METHODS

Among 342 patients at a residential SUD treatment center, logistic regression examined the association of overdose with pain, adjusting for substance use, suicide attempts, and demographics.

RESULTS

Pain was positively related to NMPO use. Heroin use, suicide attempts, pain, and NMPO use were positively associated with overdose; but NMPO use attenuated the pain-overdose relationship.

CONCLUSIONS

The relationship between pain and overdose among substance users may be, in part, explained by the association between pain and heavy NMPO use.

Evolution of opioid risk management and review of the classwide REMS for extended-release/long-acting opioids

In 2007, the Food and Drug Administration Amendments Act (FDAAA) afforded the US Food and Drug Administration (FDA) the ability to enforce postmarketing risk management strategies for prescription medicines. Under this policy, certain medications with known or potential risks could be required to have a Risk Evaluation and Mitigation Strategy (REMS), a risk management program designed to ensure that a product's therapeutic benefit outweighs its risks. Prescription opioid analgesics, particularly extended-release (ER)/long-acting (LA) formulations, have undergone scrutiny in recent years due to the serious risks associated with their use, especially when they are prescribed improperly, misused, or abused. In July 2012, the FDA approved a classwide REMS for ER and LA opioids. This ER/LA opioid REMS program is designed to improve prescriber education and patient awareness about safe opioid use to minimize the risks of addiction, unintentional overdose, and death. Because clinicians often encounter patients with moderate-to-severe chronic, noncancer pain who are in need of around-the-clock opioid analgesia, knowledge of the conditions of this classwide REMS may become essential to continue prescribing ER/LA opioids. This article briefly describes the changes in US risk management policies that have shaped today's regulatory environment and provides an overview of the requirements for the classwide ER/LA opioid REMS.

Cross-Validation of a Screener to Predict Opioid Misuse in Chronic Pain Patients (SOAPP-R)

OBJECTIVES

The Screener and Opioid Assessment for Patients with Pain - Revised (SOAPP-R) is a self-report questionnaire designed to predict aberrant medication-related behaviors among persons with chronic pain. This measure was developed to complement current risk assessment practices and to improve a clinician's ability to assess a patient's risk for opioid misuse. The aim of this study was to cross-validate the SOAPP-R with a new sample of chronic, non-cancer pain patients.

METHODS

Three hundred and two participants (N=302) prescribed opioids for pain were recruited from five pain management centers in the U.S. Subjects completed a series of self-report measures and were followed for five months. Patients were rated by their treating physician, had a urine toxicology screen, and were classified on the Aberrant Drug Behavior index.

RESULTS

Seventy-three percent (73.2%) of the subjects (N= 221) were followed and 66 participants repeated the SOAPP-R after one week for test-retest reliability. The reliability and predictive validity, as measured by the area under the curve (AUC), were found to be highly significant (test-retest reliability = .91; coefficient alpha = .86; AUC = .74) and were sufficiently similar to values found with the initial sample. A cut-off score of 18 revealed a sensitivity of .80 and specificity of .52.

CONCLUSIONS

Results of this cross-validation study suggest that the psychometric parameters of the SOAPP-R are not based solely on the unique characteristics of the initial validation sample. The SOAPP-R is found to be a reliable and valid screening tool for risk of aberrant drug-related behavior among chronic pain patients.

Prescription opioid abuse, chronic pain, and primary care: a Co-occurring Disorders Clinic in the chronic disease model

Abuse of opioids has become a public health crisis. The historic separation between the addiction and pain communities and a lack of training in medical education have made treatment difficult to provide, especially in primary care. The Co-occurring Disorders Clinic (COD) was established to treat patients with co-morbid chronic pain and addiction. This retrospective chart review reports results of a quality improvement project using buprenorphine/naloxone to treat co-occurring chronic non-cancer pain (CNCP) and opioid dependence in a primary care setting. Data were collected for 143 patients who were induced with buprenorphine/naloxone (BUP/NLX) between June 2009 and November 2011. Ninety-three patients (65%) continued to be maintained on the medication and seven completed treatment and were no longer taking any opioid (5%). Pain scores showed a modest, but statistically significant improvement on BUP/NLX, which was contrary to our expectations and may be an important factor in treatment retention for this challenging population.

Pharmaceutical treatment patterns for patients with a diagnosis related to chronic pain initiating a slow-release strong opioid treatment in Sweden

Slow-release strong opioids (SRSO) are indicated in patients with severe chronic pain. Side effects, lack of efficacy and risk of dependency limit their use in clinical practice. The aim of this study was to explore prescription patterns of SRSO in Swedish real-world data on patients with a diagnosis related to chronic pain (DRCP). Patient-level data were extracted from the national prescriptions register and a regional register with diagnosis codes. The prescription sequences, switches, co-medications, and strengths over time were analyzed for cancer and noncancer patients. Of 840,000 patients with a DRCP, 16,257 initiated treatment with an SRSO in 2007 to 2008. They were 71 years old on average; 60% were female and 34% had cancer. The most common first prescription was oxycodone (54%) followed by fentanyl (19%), buprenorphine (14%), and morphine (13%). 63% refilled their prescription within 6 months, and 12% switched to another SRSO, most commonly fentanyl. After 3 years, 51% of cancer and 27% of noncancer patients still being in contact with health care remained on any SRSO. Of noncancer patients, 35% had a psychiatric co-medication (SSRI or benzodiazepine). In conclusion, fewer patients remain on SRSO in the long-term in clinical practice than reported in previous clinical trials. Oxycodone is the most common first SRSO prescription and one-third of patients get a prescription indicating psychiatric comorbidity. Our interpretation of these findings are that there is need for better treatment options for these patients, and that more effort is needed to improve treatment guidelines and to ascertain that these guidelines are followed.

Chronic pain and addiction: challenging co-occurring disorders

Chronic pain is commonly treated by prescribing an opioid medication. For those suffering from both chronic pain and substance dependence, barriers to adequate pain management increase. This often causes both disorders to exacerbate one another. Effective treatment may also be hampered by opioid-induced hyperalgesia, tolerance, physical dependence, "chemical coping," and diminished physical and emotional functioning. This article reviews current research trends, potential problems stemming from prescription opioid use, and suggestions for clinical practice.

Medical and psychological risks and consequences of long-term opioid therapy in women

BACKGROUND

Long-term opioid use has increased substantially over the past decade for U.S. women. Women are more likely than men to have a chronic pain condition, to be treated with opioids, and may receive higher doses. Prescribing trends persist despite limited evidence to support the long-term benefit of this pain treatment approach.

PURPOSE

To review the medical and psychological risks and consequences of long-term opioid therapy in women.

METHOD

Scientific literature containing relevant keywords and content were reviewed.

RESULTS AND CONCLUSIONS

Long-term opioid use exposes women to unique risks, including endocrinopathy, reduced fertility, neonatal risks, as well as greater risk for polypharmacy, cardiac risks, poisoning and unintentional overdose, among other risks. Risks for women appear to vary by age and psychosocial factors may be bidirectionally related to opioid use. Gaps in understanding and priorities for future research are highlighted.

Dynamic risk factors in the misuse of opioid analgesics

OBJECTIVE

Identify the risk factors for prescription opioid misuse among patients taking prescription opioids to deal with chronic pain.

METHODS

We examined the literature for a variety of dynamic risk factors associated with opioid misuse among the chronic pain population in order to present a narrative review. Considered were: taking single or multiple opioids, pain intensity, mental health disorders, including a history of preadolescent sexual abuse, personal and familial history of substance abuse, a history of legal problems, being a crime victim, drug-seeking behaviors, drug craving, and age.

RESULTS

A variety of risk factors have been studied in the literature. Risk factors in chronic opioid therapy patients are dynamic in that they can change with disease progression, tolerance, changes in pain quality, mental health, comorbidities, other drug therapies or drug interactions, and changes in the patient's lifestyle.

CONCLUSION

Opioid analgesic therapy must be tailored to carefully monitor all patients in order to minimize misuse and abuse, since the risk is constant and dynamic and therefore every patient is at some degree of risk for opioid misuse.

Chronic Pain in the Outpatient Palliative Care Clinic

Chronic pain is common. Many patients with cancer and other life-limiting illnesses have chronic pain that is related to their disease, and some have comorbid chronic nonmalignant chronic pain. As palliative care continues to move upstream and outpatient palliative care programs develop, palliative care clinicians will be called upon to treat chronic pain. Chronic pain differs from acute pain in the setting of advanced disease and a short prognosis in terms of its etiology, comorbidities—especially psychiatric illness and substance abuse—and management. To successfully care for these patients, palliative care providers will need to learn new clinical competencies. This article will review chronic pain management core competencies for palliative care providers.

The changing landscape of opioid prescribing: long-acting and extended-release opioid class-wide Risk Evaluation and Mitigation Strategy

Prescriptions for opioid analgesics to manage moderate-to-severe chronic noncancer pain have increased markedly over the last decade, as have postmarketing reports of adverse events associated with opioids. As an unintentional consequence of greater prescription opioid utilization, there has been the parallel increase in misuse, abuse, and overdose, which are serious risks associated with all opioid analgesics. In response to these concerns, the Food and Drug Administration announced the requirement for a class-wide Risk Evaluation and Mitigation Strategy (REMS) for long-acting and extended-release (ER) opioid analgesics in April 2011. An understanding of the details of this REMS will be of particular importance to primary care providers. The class-wide REMS is focused on educating health care providers and patients on appropriate prescribing and safe use of ER opioids. Support from primary care will be necessary for the success of this REMS, as these clinicians are the predominant providers of care and the main prescribers of opioid analgesics for patients with chronic pain. Although currently voluntary, future policy will likely dictate that providers undergo mandatory training to continue prescribing medications within this class. This article outlines the elements of the class-wide REMS for ER opioids and clarifies the impact on primary care providers with regard to training, patient education, and clinical practice.

Maladaptive opioid use behaviors and psychiatric illness: what should we do with what we know?

It is well established that opioids are broadly effective for chronic pain. Although there is some agreement that stable, moderate dosing is desirable; longer-term management of patients with chronic pain often confronts clinicians with difficult decisions regarding when to intensify opioid treatment and when to declare failure. Under these circumstances the concern for addiction arises with uncomfortable frequency in specialty settings. An emerging literature has defined a number of plausible markers of risk for aberrant opioid use behaviors in clinical chronic pain populations. Some of these risk factors involve the presence of comorbid psychiatric illnesses, which puts clinicians in the difficult position of deciding whether or not to limit treatment to patients who are more complex. The authors discuss the issues of bad behavioral outcomes in opioid therapy, the implications of this emerging literature for clinicians, and suggest broad areas in which researchers can improve the knowledge base with which clinicians operate.

Aberrant behaviors with prescription opioids and problem drug use history in a community-based cohort of HIV-infected individuals

CONTEXT

The treatment of pain in patients with substance use disorders creates tensions for clinicians between undertreating pain and enabling opioid analgesic misuse.

OBJECTIVES

To characterize prevalence and factors associated with aberrant opioid analgesic behaviors in a cohort of HIV-infected individuals who are at high risk for opioid analgesic misuse.

METHODS

We assessed pain and substance use disorders in a cross-sectional study that enrolled 296 participants from the Research on Access to Care in the Homeless cohort, a community-based sample of indigent HIV-infected adults. We measured aberrant opioid behaviors, defined as major or minor depending on level of risk of harm to patients, using Audio Computer-Assisted Self-Interview technology.

RESULTS

Most participants (91.2%) reported pain in the week before interview, with the majority of these experiencing severe pain (53.7%). More than two-thirds (69.2%) of the participants met criteria for a lifetime history of cocaine, amphetamine, or heroin/opioid use disorder as defined by the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition). More than one-third of the sample (37.4%) had a history of aberrant opioid behavior within 90 days of interview. One-fifth (18.5%) had a history of "major" aberrant behaviors.

CONCLUSION

In this high-risk population, severe pain is common and aberrant opioid behaviors are prevalent but not universal. As recommended by American Pain Society and American Academy of Pain Medicine guidelines, when prescribing opioid analgesics, clinicians must consider variation in the severity of aberrant behaviors, particularly aberrant behaviors that may represent undertreatment of pain.

Validation and usefulness of the Danish version of the Pain Medication Questionnaire in opioid-treated chronic pain patients

BACKGROUND

Addiction is a feared complication of long-term opioid therapy for chronic pain patients. A screening tool to assess the potential risk of addiction may be helpful.

METHODS

The Pain Medication Questionnaire (PMQ) was translated into Danish by a 'forward' and 'backward' translation procedure. Patients with chronic non-cancer pain and cancer pain treated at a tertiary pain center were screened for addiction using Portenoy's criteria and invited to answer the Danish version of the PMQ.

RESULTS

Two hundred nine patients participated in the study. PMQ was able to discriminate between addicted and non-addicted patients. Patients with high PMQ scores indicating a risk of addiction drank more alcohol, smoked more tobacco, used higher doses of morphine, had a higher anxiety and depression score, and had poorer mental health. Using a cut-off score of 22, the PMQ had a sensitivity of 82%, but the specificity at this cut-point was 56%, indicating a risk of false positive cases. Convergent and discriminant validity were confirmed by correlation with opioid doses, alcohol and tobacco use, anxiety and depression scores, and inverse correlation with mental health and social role. Test-retest showed a very strong correlation. Cronbach's alpha for internal consistency was 0.61. Ten components were found to have eigenvalues above 1.0, confirming the multidimensional structure of the questionnaire.

CONCLUSIONS

The PMQ may assist physicians in addiction risk assessment and stratification when treating chronic pain patients with opioids. PMQ is not a diagnostic tool and should only be used as an indicator for possible addiction problems.

Patient characteristics associated with frequent calls to a headache specialty clinic

OBJECTIVE

To identify characteristics of patients who frequently initiate contact with a headache specialty clinic outside of scheduled appointments.

MATERIALS AND METHODS

We scanned records of all telephone calls received during 1 calendar year at an academic headache clinic to identify frequent callers. High-frequency (HF) callers were defined as established patients who initiated calls on ≥20 days during the year. We compared these patients with a cohort of established low-frequency (LF) callers who initiated no telephone calls during the same year. Clinic records were analyzed for demographic characteristics, diagnoses, and medication use. Additionally, we administered a questionnaire to clinic physicians and administrative staff querying their perception of each patient's demands on clinic resources.

RESULTS

High-frequency (n=26) and LF (n=18) callers did not differ significantly in marital status, ethnicity, diagnosis, or age. There was a trend toward female gender among HF callers and toward being outside of a body mass index range of 19 to 30 kg/m2. The groups were similar in their use of triptans and botulinum toxin treatments, but HF callers were more likely to be opioid users (96% vs 11.1%) and more likely to be taking multiple opioids in substantially higher potency, dosage, and quantity (154.4 mg vs 1.4 mg morphine equivalents/day). More than 80% of each group were migraineurs, but HF callers were more likely to have comorbid psychiatric disorders (P<0.05). High-frequency callers were also more likely to be rated by administrative staff and physicians as demanding and time-consuming.

CONCLUSIONS

In this university-based headache specialty clinic, HF callers were more likely to be opioid users on high morphine-equivalent doses. Compared with LF callers, HF callers placed a greater burden on health care resources as perceived by staff and physicians.

Is primary care providers' trust in socially marginalized patients affected by race?

BACKGROUND

Interpersonal trust plays an important role in the clinic visit. Clinician trust in the patient may be especially important when prescribing opioid analgesics because of concerns about misuse. Previous studies have found that non-white patients are perceived negatively by clinicians.

OBJECTIVE

To examine whether clinicians' trust in patients differed by patients' race/ethnicity in a socially marginalized cohort.

DESIGN

Cross-sectional study of patient-clinician dyads.

PARTICIPANTS

169 HIV infected indigent patients recruited from the community and their 61 primary care providers (PCPs.)

MAIN MEASURES

The Physician Trust in Patients Scale (PTPS), a validated scale that measures PCPs' trust in patients.

KEY RESULTS

The mean PTPS score was 43.2 (SD 10.8) out of a possible 60. Reported current illicit drug use and prescription opioid misuse were similar across patients' race or ethnicity. However, both patient illicit drug use and patient non-white race/ethnicity were associated with lower PTPS scores. In a multivariate model, non-white race/ethnicity was independently associated with PTPS scores 6.3 points lower than whites (95% CI: -9.9, -2.7). Current illicit drug use was associated with PTSP scores 5.5 lower than no drug use (95% CI -8.5, -2.5).

CONCLUSION

In a socially marginalized cohort, non-white patients were trusted less than white patients by their PCPs, despite similar rates of illicit drug use and opioid analgesic misuse. The effect was independent of illicit drug use. This finding may reflect unconscious stereotypes by PCPs and may underlie disparities in chronic pain management.

Nonmedical prescription opioid use and mental health and pain comorbidities: a narrative review

OBJECTIVE

In North America, the prevalence of nonmedical prescription opioid use (NMPOU), and morbidity and mortality related to prescription opioid analgesics (POAs) has risen sharply. Epidemiologic studies have suggested a high prevalence of mental health and pain comorbidities in NMPOU samples. Given the potential importance for interventions, a narrative review was conducted on studies reporting data on the co-occurrence of NMPOU with mental health problems and pain symptoms in general, treatment, or special populations.

METHOD

A search of MEDLINE, PubMed, PsycINFO, and Web of Science using defined search terms yielded 74 studies on NMPOU and mental health and (or) pain. Thirty-nine studies published between 1997 and 2009 were included in the review-based on the data they provided on NMPOU and mental health and pain comorbidities.

RESULTS

Our review found strong associations between NMPOU and the comorbidities of interest. Associations between NMPOU and mental health were strongest for depression (OR range 1.2 to 4.3) followed by anxiety disorders (OR range 1.2 to 3.0) in general and treatment populations. The prevalence of pain ranged from 14.5% to 61.5% in general, treatment, and street drug user samples reporting NMPOU.

CONCLUSIONS

The extensive associations observed between NMPOU and mental health and pain comorbidities suggest that effective preventive or treatment interventions for NMPOU must consider and attend to these comorbidities. As POAs are widely available and used in North America, POAs may increasingly be used in nonmedical ways for pain or mental health problems not effectively diagnosed or treated.

Association between urine drug test results and treatment outcome in high-risk chronic pain patients on opioids

OBJECTIVE

: How to best use urine drug test (UDT) results in the management of opioid pharmacotherapy has not been elucidated. The purpose of this study was to describe how the results of UDTs gathered from a group of chronic pain patients in a high-risk monitored opioid pharmacotherapy program apply to treatment outcome.

METHODS

: Retrospective review of the medical records of 335 primary care patients on chronic opioids more than 22 months.

RESULTS

: Patients with a UDT containing unprescribed opioids were more likely to demonstrate resolution of aberrant behavior (P = 0.02) and less likely to be discharged from treatment (P = 0.04). Patients with cocaine, alone or in combination, in the UDT were less likely to resolve aberrant behavior (P = 0.007 and 0.001), and were more likely to be electively or administratively discharged from treatment (P = 0.012 and 0.001).

DISCUSSION

: In this group of high-risk pain patients on chronic opioids, information gained from UDT results can be used to predict treatment outcomes and inform appropriate interventions. Patients on chronic opioids who have a UDT positive for an illicit opioid or unprescribed opioids alone are more likely to respond to monitored opioid pharmacotherapy. Patients with a UDT positive for cocaine, alone or in combination, are less likely to resolve aberrant behavior within the structure of a monitored opioid pharmacotherapy program and are more likely to be discharged electively or administratively from the program without significant transition to addiction treatment. Further studies are needed to investigate which patient responded best to structured opioid pharmacotherapy programs and how to appropriately handle abnormal UDT results to improve the management and engagement in appropriate treatment for this population.

Prevalence and correlates of nonmedical use of prescription opioids in patients seen in a residential drug and alcohol treatment program

Population-based data indicate that rates of nonmedical use of prescription opioids (POs) have increased dramatically over the past decade. However, data are lacking on nonmedical use of POs in individuals seeking treatment for substance use disorders. Patients (N = 351) seeking treatment from a residential drug and alcohol treatment program were assessed for nonmedical use of POs prior to treatment entry. Approximately 68% (65% men and 78% women) of patients reported at least some nonmedical PO use in the 30 days prior to treatment. Our results indicate that nonmedical PO use was more common in those with higher levels of depressive symptoms and pain intensity and in those with lower physical functioning. Treatment programs should consider actively screening participants for nonmedical PO use and consider how nonmedical use of pain medications might influence their treatment planning for patients.

Primary care providers’ judgments of opioid analgesic misuse in a community-based cohort of HIV-infected indigent adults

BACKGROUND

Primary care providers (PCPs) must balance treatment of chronic non-cancer pain with opioid analgesics with concerns about opioid misuse.

OBJECTIVE

We co-enrolled community-based indigent adults and their PCPs to determine PCPs’ accuracy of estimating opioid analgesic misuse and illicit substance use.

DESIGN

Patient-provider dyad study.

PARTICIPANTS

HIV-infected, community-based indigent adults (‘patients’) and their PCPs.

MAIN MEASURES

Using structured interviews, we queried patients on use and misuse of opioid analgesics and illicit substances. PCPs completed patient- and provider-specific questionnaires. We calculated the sensitivity, specificity, and measures of agreement between PCPs’ judgments and patients’ reports of opioid misuse and illicit substance use. We examined factors associated with PCPs’ thinking that their patients had misused opioid analgesics and determined factors associated with patients’ misuse.

KEY RESULTS

We had 105 patient-provider dyads. Of the patients, 21 had misused opioids and 45 had used illicit substances in the past year. The sensitivity of PCPs’ judgments of opioid analgesic misuse was 61.9% and specificity, 53.6% (Kappa score 0.09, p = 0.10). The sensitivity of PCPs’ judgments of illicit substance use was 71.1% and specificity, 66.7% (Kappa score 0.37, p <0.001). PCPs were more likely to think that younger patients (Adjusted odds ratio (AOR) 0.89, 95% CI 0.84-0.97), African American patients (AOR 2.53, 95% CI 1.05-6.07) and those who had used illicit substances in the past year (AOR 3.33, 95% CI 1.35-8.20) had misused opioids. Younger (AOR 0.94, 95% CI 0.86-1.02) and African American (AOR 0.71, 95% CI 0.25-1.97) patients were not more likely to report misuse, whereas persons who had used illicit substances were (AOR 3.01, 95% CI 1.04-8.76).

CONCLUSION

PCPs’ impressions of misuse were discordant with patients’ self-reports of opioid analgesic misuse. PCPs incorrectly used age and race as predictors of misuse in this high-risk cohort.

To what extent does a cohort of new users of weak opioids develop persistent or probable problematic opioid use?

When opioid therapy is initiated for a new pain condition, it may be unknown whether the pain will persist beyond the time of tissue healing. The aim of this study was to determine the prevalence of prescription patterns indicating persistent and/or problematic opioid use in a cohort of opioid-naive patients starting therapy with weak opioids. Data were drawn from the nationwide Norwegian Prescription Database. The study population was all new users of opioids receiving prescriptions of a weak opioid in 2005 for nonmalignant pain. This cohort was followed until December 2008. In order to be classified as having probable problematic opioid use, patients had to meet all of the following criteria: received opioids at least once every year from 2005 to 2008 and in 2008; (1) were dispensed more than 365 defined daily doses (DDDs) of opioids; (2) received opioid prescriptions from more than 3 doctors; and (3) were dispensed more than 100 DDDs of benzodiazepines. There were 245,006 persons who were new users of weak opioids in 2005 (216,902 codeine, 26,326 tramadol, 1778 dextropropoxyphene). There were 17,252 (7% of new users) who received a prescription for opioids at least once each of the 3 following years. Of these subjects, 686 patients were dispensed more than 365 DDDs of opioids in 2008 and are probably persistent users. There were 191 subjects who met our criteria for probable problematic opioid use. In a cohort of new opioid users who started treatment with weak opioids, only 0.3% and 0.08% developed prescription patterns indicating persistent opioid use and problematic opioid use, respectively.

Computerized progress notes for chronic pain patients receiving opioids; the Prescription Opioid Documentation System (PODS)

OBJECTIVE

We herein provide a description of a health information technology tool using computer-assisted survey instruments as a methodology for documentation during long-term opioid therapy.

DESIGN

We report our experience using the Prescription Opioid Documentation and Surveillance (PODS) System, a medical informatics tool that utilizes validated questionnaires to automate the assessment of opioid prescribing for chronic nonmalignant pain.

SETTING AND PATIENTS

Chronic pain patients answered questions that were presented on a computer terminal prior to each appointment in a Department of Veterans Affairs Pain Clinic.

MEASURES

Pain levels, activities of daily living, and screening for common psychological disorders were sought at each visit. Results were tabulated with some information gathered sequentially permitting evaluation of progress. Following a face-to-face interview, the clinician added additional comments to the medical record.

RESULTS

By deploying a systematic series of questions that are recalled by the computer, PODS assures a comprehensive assessment.

CONCLUSIONS

The PODS fulfills medicolegal requirements for documentation and provides a systematic means of determining outcomes. This process facilitates the determination of the appropriate intervals between clinic visits by stratifying patients into high, moderate, and low risk.

Risk factors associated with opioid medication misuse in community-dwelling older adults with chronic pain

OBJECTIVES

The aim of the study was to identify physical, psychological, and social risk factors associated with opioid medication misuse among community-dwelling older adults with chronic pain.

METHODS

Using a cross-sectional research design, a confidential survey was administered at 11 outpatient clinics affiliated with the Baltimore Veterans Affairs Medical Center and the University of Maryland Medical System. A sample of 163 older adults (response rate 80.7%) with chronic pain and receiving opioid medications provided demographic information and responded to survey items. Severity of pain, alcohol problems, physical disability, depressive symptoms, spirituality, social support, and social network were assessed. Descriptive statistics and exploratory regression analyses were employed to determine factors independently associated with misuse.

RESULTS

Higher levels of pain severity and depressive symptoms, and lower physical disability scores were significantly associated with increased risk of opioid medication misuse. Alcohol problems, spirituality, social support, and social network were not associated with opioid medication misuse.

DISCUSSION

High pain intensity scores may indicate undertreatment of pain or may represent a rationalization to justify opioid medication use. Higher levels of depressive symptoms have been noted in the chronic pain population and may contribute to misuse of opioid medications for psychic effects. Less physically disabled persons are more likely to misuse opioid medications or older person receiving multiple medications may wish to avoid potential adverse drug effects. While there was an association between lower levels of disability and higher risk for opioid medication misuse, a causal relationship could not be determined.

Aberrant drug-related behavior observed during clinical studies involving patients taking chronic opioid therapy for persistent pain and fentanyl buccal tablet for breakthrough pain

CONTEXT

Information on aberrant drug-related behaviors in the clinical study setting is limited.

OBJECTIVES

This retrospective analysis was designed to identify the types and frequency of aberrant drug-related behaviors (including misuse and abuse) and associated patient characteristics in opioid-tolerant patients with chronic pain.

METHODS

Data from opioid-tolerant patients participating in clinical studies of fentanyl buccal tablet (FBT) for breakthrough pain (up to 18 months of clinical study case-report forms) were retrospectively reviewed and coded for abuse, overdose, and aberrant behavior. Aberrant behaviors were categorized as those involving FBT (overuse, lost or stolen study drug) and those not involving FBT (patients seeking prescriptions from other sources, not returning for follow-up).

RESULTS

Of the 1,160 patients evaluated, 10 (<1%) patients had an abuse-related event, 18 (<2%) had a positive urine drug screening (nonprescribed drug or illicit substance), and 12 (1%) had an event consistent with opioid overdose; 124 (11%) had aberrant behaviors related to FBT, and 68 (6%) had aberrant behaviors that were not. Aberrant behaviors were more frequent in men (odds ratio [OR]: 1.5; 95% confidence interval [CI]: 1.1, 2.1; P<0.01), in patients 42 years or younger (OR: 2.5; 95% CI: 1.6, 4.0; P<0.01), and in patients 43 years to 49 years (OR: 1.9; 95% CI: 1.2, 3.1; P<0.01).

CONCLUSION

The incidence of drug abuse events and aberrant drug-related behaviors was relatively low, probably because of the implementation of universal precautions and the controlled clinical study setting. Even in this setting, events occurred, highlighting the limits of screening and the need for ongoing monitoring of aberrant behavior.

Factor structure of pain medication questionnaire in community-dwelling older adults with chronic pain

OBJECTIVES

This study was to develop a version of the Pain Medication Questionnaire (PMQ) specific to the elderly chronic pain population and to identify relevant subscales and items for that population. Exploratory factor analysis (EFA) was conducted to assess the factor structure of the PMQ, to eliminate items that are not appropriate for this population, and to improve ease of administration in the elderly population.

METHODS

Data were obtained through a survey administered to older adults with chronic pain who consumed opioid medications in a cross-sectional study at outpatient clinics affiliated with the Baltimore Veterans Affairs Medical Center and the University of Maryland Medical System. EFA was conducted on the PMQ in the geriatric chronic pain population, which was compared with the PMQ studies from the general chronic pain population.

RESULTS

A two-factor solution yielded Factor 1 with four items and Factor 2 with three items; 18 items did not load significantly on either factor, and only seven items loaded significantly on either factor. All of the chosen factor loadings ranged from 0.41 to 0.88.

CONCLUSION

  The findings suggest that, although a small number of the items were identified from the overall scale, they adequately explain two relatively unique factors pertaining to pain management among older adults. This preliminary study suggests that the seven-item PMQ may be useful in assessing opioid medication misuse in community-dwelling older adults with chronic pain. Future studies are needed to confirm the reliability, validity, and factor structure of this modified PMQ in the geriatric population.

Nonmedical use of sedative-hypnotics and opiates among rural and urban women with protective orders

The purpose of this study was to examine the prevalence and risk factors for lifetime nonmedical use of sedative-hypnotics and opiates among a sample of rural and urban women with recent partner violence victimization (n=756). Nearly one third of the sample (32.8%) reported ever using illicit sedative-hypnotics or opiates. Nonmedical use of sedative-hypnotics and opiates was significantly associated with lifetime cumulative exposure to interpersonal victimization, rural Appalachian residency, past-year use of other substances and other substance-related problems, and lifetime unmet health care needs. Findings have implications for substance abuse prevention and treatment and victim advocacy programs.

Cross validation of the current opioid misuse measure to monitor chronic pain patients on opioid therapy

OBJECTIVES

The Current Opioid Misuse Measure (COMM) is a self-report measure of risk for aberrant medication-related behavior among persons with chronic pain who are prescribed opioids for pain. It was developed to complement predictive screeners of opioid misuse potential and improve a clinician's ability to periodically assess a patient's risk for opioid misuse. The aim of this study was to cross-validate the COMM with a sample of chronic noncancer pain patients.

METHODS

Two hundred and twenty-six participants prescribed opioids for pain were recruited from 5 pain management centers in the United States. Participants completed the 17-item COMM and a series of self-report measures. Patients were rated by their treating physician, had a urine toxicology screen, and were classified on the Aberrant Drug Behavior index.

RESULTS

The reliability and predictive validity in this cross validation as measured by the area under the curve (AUC) were found to be highly significant (AUC=0.79) and not significantly different from the AUC obtained in the original validation study (AUC=0.81). Reliability (coefficient α) was 0.83, which is comparable to the 0.86 obtained in the original sample.

DISCUSSION

Results of the cross validation suggest that the psychometric parameters of the COMM are not based solely on unique characteristics of the initial validation sample. The COMM seems to be a reliable and valid screening tool to help detect current aberrant drug-related behavior among chronic pain patients.

Risks for opioid abuse and dependence among recipients of chronic opioid therapy: results from the TROUP study

OBJECTIVE

To estimate the prevalence of and risk factors for opioid abuse/dependence in long-term users of opioids for chronic pain, including risk factors for opioid abuse/dependence that can potentially be modified to decrease the likelihood of opioid abuse/dependence, and non-modifiable risk factors for opioid abuse/dependence that may be useful for risk stratification when considering prescribing opioids.

METHODS

We used claims data from two disparate populations, one national, commercially insured population (HealthCore) and one state-based, publicly insured (Arkansas Medicaid). Among users of chronic opioid therapy, we regressed claims-based diagnoses of opioid abuse/dependence on patient characteristics, including physical health, mental health and substance abuse diagnoses, sociodemographic factors, and pharmacological risk factors.

RESULTS

Among users of chronic opioid therapy, 3% of both the HealthCore and Arkansas Medicaid samples had a claims-based opioid abuse/dependence diagnosis. There was a strong inverse relationship between age and a diagnosis of opioid abuse/dependence. Mental health and substance use disorders were associated with an increased risk of opioid abuse/dependence. Effects of substance use disorders were especially strong, although mental health disorders were more common. Concerning opioid exposure; lower days supply, lower average doses, and use of Schedule III-IV opioids only, were all associated with lower likelihood of a diagnosis of opioid abuse/dependence.

CONCLUSION

Opioid abuse and dependence are diagnosed in a small minority of patients receiving chronic opioid therapy, but this may under-estimate actual misuse. Characteristics of the patients and of the opioid therapy itself are associated with the risk of abuse and dependence.

The prescribed opioids difficulties scale: a patient-centered assessment of problems and concerns

OBJECTIVES

Chronic opioid therapy for chronic noncancer pain has increased dramatically in recent years. Research on associated risks has typically focused on opioid abuse and dependence, and opioid misuse or aberrant drug use behaviors, but these risks have been defined from the providers' perspective. The aim of this article was to develop a psychometrically sound method for assessing difficulties patients attribute to chronic opioid therapy.

METHODS

A cross-sectional, observational study of patients prescribed opioids for chronic noncancer pain was conducted in a large integrated service delivery network in Washington State. Data were obtained from a phone interview and electronic health records including pharmacy data. Exploratory and confirmatory factor analyses were conducted using a split sample design.

RESULTS

The interview response rate was 56.5% and a total of 1144 patients were included in analyses. A 2 factor solution was obtained and replicated with excellent fit statistics. Two correlated factors were identified-opioid control concerns and psychosocial problems-with 50% of the sample reporting difficulties with prescribed opioids: 24% reported elevated psychosocial problems and 36% reported elevated concerns about controlling their use of prescribed opioids.

DISCUSSION

The Prescribed Opioid Difficulties Scale identifies common difficulties that patients ascribe to chronic opioid therapy. This scale may provide both an entry point and a framework for a patient-centered clinical dialog about the pros and cons of use of opioid medicines for managing chronic pain.

Pilot study of a preliminary criterion standard for prescription opioid misuse

Multidisciplinary experts created a behaviorally defined preliminary criterion standard definition of probable prescription opioid misuse (PPOM) that could be rated from material found in administrative, pharmacy, and electronic health record databases. They then derived a scoring system to identify PPOM patients requiring referral to a specialist. Experts next rated cases of misuse and nonmisuse. Rater no. 1 correctly differentiated 37 of 40 cases (92.5%); kappa coefficient was .79 (CI: .57, 1.00). Rater no. 2 correctly identified 39 of 40 cases (97.5%); kappa was .94 (CI: .81, 1.00). Kappa for comparing raters was .73 (CI: .49, .98). This preliminary study demonstrates that multidisciplinary raters can use behaviorally based criteria to identify patients with known PPOM from health plan databases.

Prescription use disorders in older adults

The number of older adults needing substance abuse treatment is projected to rise significantly in the next few decades. This paper will focus on the epidemic of prescription use disorders in older adults. Particular vulnerabilities of older adults to addiction will be considered. Specifically, the prevalence and patterns of use of opioids, stimulants, and benzodiazepines will be explored, including the effects of these substances on morbidity and mortality. Treatment intervention strategies will be briefly discussed, and areas for future research are suggested.

Managing acute and chronic pain in a substance abuse treatment program for the addicted individual early in recovery: a current controversy

Patients early in recovery from addictive disorders are in a tenuous position and when these individuals are stressed from acute or chronic pain they face even more challenges. Physicians are often conflicted by the desire to help the patient achieve pain control and maintain sobriety. While there have been a handful of studies examining patients in either active addiction with pain or with a more remote history of addiction with pain, there have been very few, if any, that look at treating patients during their addiction recovery process who suffer from pain. This article will examine the issue of whether it is ever appropriate to use opioid pain medications on such patients and, if so, what guidelines can be used to maximize the chances of a good outcome while minimizing the chances of causing a recurrence or exacerbation of addiction.

An analysis of heavy utilizers of opioids for chronic noncancer pain in the TROUP study

CONTEXT

Although opioids are increasingly used for chronic noncancer pain (CNCP), we know little about opioid dosing patterns among individuals with CNCP in usual care settings, and how these are changing over time.

OBJECTIVES

To investigate the distribution of mean daily dose and mean days supply among patients with CNCP in two disparate populations, one national and commercially insured population (HealthCore) and one state based and publicly insured (Arkansas Medicaid), for years 2000 and 2005.

METHODS

For individuals with any opioid use, we calculated the distribution of mean daily dose (in milligram morphine equivalents), mean days supply in a year, mean annual dose, and patient characteristics associated with heavy utilizers of opioids.

RESULTS

Between 2000 and 2005, across all percentiles, there was little change in the mean daily opioid dose. In HealthCore, mean days supply increased most rapidly at the top end of the days supply distribution, whereas in Arkansas Medicaid, the greatest increases were near the median of days supply. In HealthCore, the top 5% of users accounted for 70% of total use (measured in milligram morphine equivalents), and the top 5% of Arkansas Medicaid users accounted for 48% of total use. The likelihood of heavy opioid utilization was increased among individuals with multiple pain conditions, and in HealthCore, among those with mental health and substance use disorders.

CONCLUSION

Opioid use is heavily concentrated among a small percent of patients. The characteristics of these high utilizers need to be further established, and the benefits and risks of their treatment evaluated.

Patients with problematic opioid use can be weaned from codeine without pain escalation

BACKGROUND

Brief treatments for chronic non-malignant pain patients with problematic opioid use are warranted. The aims of the present study were to investigate (1) whether it is possible to withdraw codeine use in such patients with a brief cognitive-behavioural therapy (CBT), (2) whether this could be done without pain escalation and reduction in quality of life and (3) to explore the effects of codeine reduction on neurocognitive functioning.

METHODS

Eleven patients using codeine daily corresponding to 40-100 mg morphine were included. Two specifically trained physicians treated the patients with six CBT sessions, tapering codeine gradually within 8 weeks. Codeine use, pain intensity, quality of life and neuropsychological functioning were assessed at pre-treatment to the 3-month follow-up.

RESULTS

Codeine use was significantly reduced from mean 237 mg [standard deviation (SD) 65] pre-treatment to 45 mg (SD 66) post-treatment and to 48 mg (SD 65) at follow-up without significant pain escalation or reductions in quality of life. Moreover, neuropsychological functioning improved significantly on some tests, while others remained unchanged.

CONCLUSION

The promising findings of codeine reduction in this weaning therapy programme for pain patients with problematic opioid use should be further evaluated in a larger randomized control trial comparing this brief CBT with both another brief treatment and attention placebo condition.

Gender differences in risk factors for aberrant prescription opioid use

This is a longitudinal predictive study to examine gender differences in the clinical correlates of risk for opioid misuse among chronic pain patients prescribed opioids for pain. Two hundred seventy-five male and 335 female patients prescribed opioids for chronic noncancer pain were asked to complete a series of baseline questionnaires, including the revised Screener and Opioid Assessment for Pain Patients (SOAPP-R). After 5 months, the subjects were administered a structured prescription drug use interview (Prescription Drug Use Questionnaire; PDUQ) and submitted a urine sample for toxicology assessment. Their treating physicians also completed a substance misuse behavior checklist (Prescription Opioid Therapy Questionnaire; POTQ). At 5-month follow-up, women showed higher scores on the PDUQ (P < .05), whereas men had a higher incidence of physician-rated aberrant drug behavior on the POTQ (P < .05). An item analysis of the SOAPP-R, PDUQ, and POTQ showed that women tended to score higher on items relating to psychological distress, whereas the male patients tended to report having more legal and behavioral problems. These results suggest that risk factors associated with prescription opioid misuse may differ between men and women.

PERSPECTIVE

Understanding gender differences in substance abuse risk among chronic pain patients is important for clinical assessment and treatment. This study suggests that women are at greater risk to misuse opioids because of emotional issues and affective distress, whereas men tend to misuse opioids because of legal and problematic behavioral issues.

Trends in use of opioids for chronic noncancer pain among individuals with mental health and substance use disorders: the TROUP study

OBJECTIVES

Use of prescription opioids for chronic pain is increasing, as is abuse of these medications, though the nature of the link between these trends is unclear. These increases may be most marked in patients with mental health (MH) and substance use disorders (SUDs). We analyzed trends between 2000 and 2005 in opioid prescribing among individuals with noncancer pain conditions (NCPC), with and without MH and SUDs.

METHODS

Secondary data analysis of longitudinal administrative data from 2 dissimilar populations: a national, commercially insured population and Arkansas Medicaid enrollees. We examined these opioid outcomes: (1) rates of any prescription opioid use in the past year, (2) rates of chronic use of prescription opioids (greater than 90 d in the past year), (3) mean days supply of opioids, (4) mean daily opioid dose in morphine equivalents, and (5) percentage of total opioid dose that was Schedule II opioids.

RESULTS

In 2000, among individuals with NCPC, chronic opioid use was more common among those with a MH or SUD than among those without in commercially insured (8% vs. 3%, P<0.001) and Arkansas Medicaid (20% vs. 13%, P<0.001) populations. Between 2000 and 2005, in commercially insured, rates of chronic opioid use increased by 34.9% among individuals with an MH or SUD and 27.8% among individuals without these disorders. In Arkansas Medicaid chronic, opioid use increased by 55.4% among individuals with an MH or SUD and 39.8% among those without.

DISCUSSION

Chronic use of prescription opioids for NCPC is much higher and growing faster in patients with MH and SUDs than in those without these diagnoses. Clinicians should monitor the use of prescription opioids in these vulnerable groups to determine whether opioids are substituting for or interfering with appropriate MH and substance abuse treatment.

High rates of inappropriate drug use in the chronic pain population

Chronic opioid treatment is a highly effective method to treat chronic pain; however, the prevalence of abuse of opioids can make treating patients with these agents difficult for clinicians. The objective of this study was to describe rates of inappropriate utilization, abuse, and diversion in a population of patients who were prescribed chronic opioids, as measured by urine drug testing in the clinical setting. A retrospective analysis was conducted of results from all urine drug tests conducted by Ameritox, Ltd. between January 2006 and January 2009, for patients whose physicians ordered the test in order to screen for noncompliance. Data from 938,586 patient test samples showed that 75% of patients were unlikely to be taking their medications in a manner consistent with their prescribed pain regimen. Thirty-eight percent of patients were found to have no detectable level of their prescribed medication, 29% had a nonprescribed medication present, 27% had a drug level higher than expected, 15% had a drug level lower than expected, and 11% had illicit drugs detected in their urine. Note that all categories add to a total greater than 100% as each category is not mutually exclusive, and a single patient could fall into multiple categories. The high observed rate of noncompliance demonstrates a significant clinical concern and confirms the importance of periodic urine drug screening for the population prescribed long-term opioid therapy.

Opioid use behaviors, mental health and pain--development of a typology of chronic pain patients

BACKGROUND

The intersection of pain, addiction and mental health has not been adequately described. We describe the roles of these three conditions in a chronic pain patient population using opioid analgesics. Aims were to improve our understanding of this population as well as to explore ways of identifying different types of patients.

METHODS

We conducted a retrospective cohort study in a large integrated group medical practice in Washington State with persons using opioids chronically (n=704). Patient classes were derived with latent class analysis using factors representing DSM-IV opioid abuse and dependence, opioid misuse, pain, anxiety and depression. Regression analyses explored the utility of automated and interview data to distinguish the empirically derived patient groups.

RESULTS

Three classes were identified: a Typical group, the substantial majority that had persistent, moderate mental health and pain symptoms; an Addictive Behaviors group with elevated mental health symptoms and opioid problems, but pain similar to the Typical class; and a Pain Dysfunction class with significantly higher pain interference as well as elevated mental health and opioid problems. Prescribed average daily dose of opioids was three times higher for those in the two atypical groups and was strongly associated with class membership after adjusting for other variables.

CONCLUSION

We describe three distinct types of patient classes as well as data elements that could help identify the two atypical types. Further research is needed to confirm these findings and determine the utility of this approach in other clinical settings.

Measurement of opioid problems among chronic pain patients in a general medical population

INTRODUCTION

Chronic opioid therapy for non-malignant pain has greatly expanded, increasing the urgency of identifying those experiencing problems related to prescribed opioids. The Prescription Drug Use Questionnaire (PDUQ), which shares substantial content with subsequently developed instruments, was developed within a pain clinic setting designed to identify problematic opioid use. The utility of the PDUQ and its relationship with the DSM-IV approach needs to be established for patients being treated in general medical settings.

METHODS

Patients (n=704) from a large HMO prescribed opioids chronically were interviewed using the PDUQ and the Composite International Diagnostic Interview (CIDI) DSM-IV opioid abuse and dependence instrument. The internal reliability of the PDUQ was assessed. Factor analytic procedures were utilized to determine the factor structure of the PDUQ alone and in combination with CIDI DSM-IV.

RESULTS

The internal reliability of the PDUQ in this population was poor (Cronbach's coefficient alpha=0.56) compared to the original development study (alpha=0.81). Factor analysis of a reduced set of PDUQ items yielded three factors: addictive behaviors, addictive concerns, and pain treatment problems. Factor analysis combining DSM-IV and PDUQ items indicated abuse and dependence were a single, distinct factor.

CONCLUSIONS

In this study of chronic pain patients on opioids in a general medical population, the PDUQ performed differently than in previously described pain clinic populations. CIDI DSM-IV items were distinct from a reduced set of PDUQ items, suggesting the need to reconsider approaches to the measurement of opioid problems for these patients. The four factors identified deserve further study, as they may signal the need for distinct interventions to improve the care of patients prescribed chronic opioid therapy for pain.

Clinical trials of pancreatic enzyme replacement for painful chronic pancreatitis--a review

Painful chronic pancreatitis is a challenging problem for clinicians and patients. Many patients receive a therapeutic trial of pancreatic enzyme supplementation at some point in the course of their disease, but it is unclear what the expected outcome of such a trial should be and whether or not all patients should receive a trial of pancreatic enzymes. We searched PubMed for all studies of pancreatic enzyme supplementation for painful chronic pancreatitis from 1980 to the present. We also searched the references of identified manuscripts and requested additional information from study authors when necessary. Manuscripts were assessed for study design, bias, pain assessment, and pain management protocol. The results are described in full.