Predictors of opioid misuse in patients with chronic pain: a prospective cohort study

Co-morbid pain and opioid addiction: long term effect of opioid maintenance on acute pain

INTRODUCTION

Medication assisted treatment for opioid dependence alters the pain experience. This study will evaluate changes pain sensitivity and tolerance with opioid treatments; and duration of this effect after treatment cessation.

METHOD

120 Individuals with chronic pain were recruited in 4 groups (N = 30): 1-methadone for opioid addiction; 2-buprenorphine for opioid addiction; 3-history of opioid maintenance treatment for opioid addiction but with prolonged abstinence (M = 121 weeks; SD = 23.3); and 4-opioid naïve controls. Participants completed a psychological assessment and a cold water task including, time to first pain (sensitivity) and time to stopping the pain task (tolerance). Data analysis used survival analyses.

RESULTS

A Kaplan-Meier-Cox survival analysis showed group differences for both pain sensitivity (log rank = 15.50; p < .001) and tolerance (log rank = 20.11; p < .001). Current or historical use of opioid maintenance resulted in differing pain sensitivity compared to opioid naïve (p's < .01). However, tolerance to pain was better among those with a history of opioid maintenance compared to active methadone patients (p < .05), with the highest tolerance found among opioid naïve control group participants (p's < .001). Correlations within the prolonged abstinent group indicated pain tolerance was significantly improved as length of opioid abstinence increased (R = .37; p < .05); but duration of abstinence did not alter sensitivity (ns).

CONCLUSION

Among individuals with a history of prolonged opioid maintenance, there appears to be long-term differences in pain sensitivity that do not resolve with discontinuation of opioid maintenance. Although pain sensitivity does not change, pain tolerance does improve after opioid maintenance cessation. Implications for treating co-morbid opioid addiction and pain (acute and chronic) are discussed.

Comparison of the risks of shopping behavior and opioid abuse between tapentadol and oxycodone and association of shopping behavior and opioid abuse

OBJECTIVES

This study compared the risks of opioid shopping behavior and opioid abuse between tapentadol immediate release and oxycodone immediate release and, to validate the definition of shopping, examined the association between opioid shopping and opioid abuse further.

MATERIALS AND METHODS

This retrospective cohort study using linked dispensing and diagnosis databases followed opioid-naive patients for development of shopping behavior and/or opioid abuse during 1 year after initial exposure to tapentadol or oxycodone. Shopping was defined by having overlapping opioid prescriptions from >1 prescriber filled at ≥3 pharmacies; abuse by having International Classification of Diseases, 9th revision diagnoses reflecting opioid abuse, addiction, or dependence. To determine their association, we cross-tabulated shopping and opioid abuse and calculated odds ratios. Risks of developing each outcome were estimated using logistic regression.

RESULTS

Among 277,401 participants initiating opioid use with tapentadol (39,524) or oxycodone (237,877), 0.6% developed shopping behavior, 0.75% developed abuse. Higher proportions of patients in the oxycodone group developed shopping behavior and abuse than in the tapentadol group (shopping: adjusted odds ratio [95% confidence interval], 0.45 [0.36-0.55]; abuse: 0.44 [0.37-0.54]). Shopping behavior and abuse were associated; of those with shopping behavior, 6.5% had abuse. Age (18 to 64 y), sex (male), prior benzodiazepine use, paying cash, and history (mood disorders, abuse of nonopioid medications, and back pain) were risk factors for developing either outcome.

DISCUSSION

Shopping behavior and abuse measure complementary, but associated, constructs, which further validates the current definition of shopping. The risk of developing either is lower among patients who initiate opioid use with tapentadol than those who initiate opioid use with oxycodone.

A long-term, open-label safety study of single-entity hydrocodone bitartrate extended release for the treatment of moderate to severe chronic pain

Objective

To evaluate the long-term safety, tolerability, and effectiveness of single-entity extended-release hydrocodone in opioid-experienced subjects with moderate to severe chronic pain not receiving adequate pain relief or experiencing intolerable side effects from their current opioid.

Methods

This multicenter, open-label study started with a conversion/titration phase (≤6 weeks) where subjects (n=638) were converted to individualized doses (range 20–300 mg) of extended-release hydrocodone dosed every 12 hours, followed by a 48-week maintenance phase (n=424). The primary objective (safety and tolerability) and the secondary objective (long-term efficacy as measured by change in average pain score; 0= no pain, 10= worst imaginable pain) were monitored throughout the study.

Results

Subjects were treated for a range of chronic pain etiologies, including osteoarthritis, low back pain, and neuropathic and musculoskeletal conditions. The mean hydrocodone equivalent dose at screening was 68.9±62.2 mg/day and increased to 139.5±81.7 mg/day at the start of the maintenance phase. Unlimited dose adjustments were permitted at the investigator’s discretion during the maintenance phase, reflecting typical clinical practice. No unexpected safety issues were reported. Common adverse events during the conversion/titration and maintenance phases, respectively, were constipation (11.3% and 12.5%), nausea (10.7% and 9.9%), vomiting (4.1% and 9.7%), and somnolence (7.7% and 4.2%). Four deaths occurred during the study; all were considered unrelated to treatment. One subject died 13 months after the study ended. From the start to end of the conversion/titration phase, 84% of subjects had a clinically meaningful improvement in average pain score (≥30% improvement), and the mean average pain scores remained stable through the maintenance phase.

Conclusion

This single-entity, extended-release formulation of hydrocodone was generally safe, well tolerated, and effective in reducing chronic pain for 48 weeks. This formulation provides a new option for patients experiencing chronic pain, especially those who are taking immediate-release hydrocodone and have concerns about liver toxicity due to acetaminophen.

Opioid misuse behaviors in adolescents and young adults in a hematology/oncology setting

OBJECTIVE

To describe the occurrence and psychosocial correlates of aberrant opioid-associated behavior (AOB) in adolescent and young adult (AYA) hematology and oncology patients prescribed opioid therapy.

METHODS

Structured retrospective chart reviews were conducted for AYA patients (N = 398) accepted for active treatment at a large pediatric hematology/oncology institution over a 17-month period. Opioid therapy was documented in the records of 94 out of the 398 patients. The records of those 94 patients were further reviewed to identify documented AOB and documented correlates of AOB.

RESULTS

Of the 94 patients prescribed opioid therapy, 11.7% exhibited AOB. At least one psychosocial risk factor was identified in 90.9% of patients with AOB. Concurrent use of multiple opioids was significantly associated with AOB (p = .003).

CONCLUSIONS

Hematology/oncology AYA patients may exhibit AOB despite a legitimate clinical indication for opioid therapy. Clinicians should consider young patients' psychosocial risk factors when using opioid therapy.

Risk assessment of opioid misuse in italian patients with chronic noncancer pain

Objective. Opioid therapy in patients with chronic noncancer pain must be preceded by evaluation of the risk of opioid misuse. The aim of this study was to evaluate the predictive validity of the Italian translation of the Pain Medication Questionnaire (PMQ) and of the Diagnosis Intractability Risk and Efficacy Score (DIRE) in chronic pain patients. Design. 75 chronic noncancer pain patients treated with opioids were enrolled and followed longitudinally. Risk of opioid misuse was evaluated through PMQ, DIRE, and the physician's clinical evaluation. Pain experience and psychological characteristics were assessed through specific self-report instruments. At follow-ups, pain intensity, aberrant drug behaviors, and presence of the prescribed opioid and of illegal substances in urine were also checked. Results. PMQ demonstrated good internal consistency (Cronbach's α = 0.77) and test-retest reliability (r = 0.86). Significant correlations were found between higher PMQ scores and the number of aberrant drug behaviors detected at 2-, 4-, and 6-month follow-ups (P < 0.01). Also the DIRE demonstrated good predictive validity. Conclusions. The results obtained with specific tools are more reliable than the clinician's evaluation alone in predicting the risk of opioid misuse; regular monitoring and psychological intervention will contribute to improving compliance and outcome of long-term opioid use.

Prescription medication misuse among HIV-infected individuals taking antiretroviral therapy

HIV has become a highly treatable disease due to advances in antiretroviral therapy (ART). Additionally, HIV-infected individuals often take opiates, barbiturates, and benzodiazepines to treat co-occurring conditions, including pain and symptoms of HIV. We sought to examine prescription medication misuse by surveying 295 HIV-infected patients receiving ART. Participants answered questions about their demographics, alcohol and other drug use, psychiatric diagnoses, ART adherence and side effects, and quality of life. Eleven percent of our sample acknowledged prescription medication misuse. In regression analysis, prescription medication misusers were more likely to report any drinking to intoxication (OR=4.31, 95% CI: 1.35-13.76, p=0.013), reported greater severity of ART side effects (OR=1.05, 95% CI: 1.01-1.10, p=0.041), and demonstrated poorer cognitive functioning (OR=0.97, 95% CI: 0.94-0.99, p=0.048) compared to those who did not misuse prescription medications. Special care should be taken by medical providers before prescribing medications that may be abused or diverted. Patients should also be screened for aberrant use, even if not prescribed. ART side effects, cognitive deficits, and alcohol abuse may serve as risk factors or indicators of prescription medication misuse, and should be monitored.

Opioid analgesic misuse is associated with incomplete antiretroviral adherence in a cohort of HIV-infected indigent adults in San Francisco

There is little or no data examining the association between either pain or the use or misuse of opioid analgesic with adherence to antiretroviral medications (ARVs) among HIV-infected adults. We interviewed a community-based cohort of HIV-infected indigent adults prescribed antiretroviral medications (ARVs) quarterly to examine the association between (1) pain, (2) receipt of opioid analgesics, and (3) opioid analgesic misuse with self-reported ARV adherence. Of 281 participants, most (82.5 %) reported severe or moderate pain, half (52.4 %) received a prescription for opioids, and one quarter (24.6 %) misused opioid analgesics. Most (71.9 %) reported >90 % ARV adherence. In a GEE model, neither pain (unadjusted OR 1.14, CI 0.90–1.45) nor prescription of opioid analgesics (unadjusted OR 1.11, CI 0.84–1.49) were significantly associated with ARV adherence. Misuse of opioid analgesics was associated with incomplete adherence (AOR 1.42, CI 1.09–1.86). Individuals who misuse opioid analgesics, like those who use illicit substances, may have difficulty adhering to medication regimens.

Everybody's Doing It: Initiation to Prescription Drug Misuse

In this article, we present findings from a qualitative National Institute on Drug Abuse-funded study of nonmedical prescription drug users in the San Francisco Bay Area. We interviewed young adults between the ages of 18 and 25 years, who used prescription drugs nonmedically at least 12 times in the 6 months prior to the interview. Employing Aker's Social Learning Theory and Zinberg's Drug, Set, and Setting, we explore the factors that contributed to participants' choices to begin using prescription drugs nonmedically. Social Learning Theory provides the framework for understanding how deviant behaviors are learned and imitated, while set and setting emphasizes the psychological and social contexts of initiation and the ways in which the set and setting of the initiating user were influenced by exposure, motivation, access, and setting. Together, social learning, and set and setting allow us to understand the interaction of individual and social factors contributing to nonmedical prescription drug use initiation.

Improving opioid prescription practices and reducing patient risk in the primary care setting

Chronic pain is complex, and the patient suffering from chronic pain frequently experiences concomitant medical and psychiatric disorders, including mood and anxiety disorders, and in some cases substance use disorders. Ideally these patients would be referred to an interdisciplinary pain program staffed by pain medicine, behavioral health, and addiction specialists. In practice, the majority of patients with chronic pain are managed in the primary care setting. The primary care clinician typically has limited time, training, or access to resources to effectively and efficiently evaluate, treat, and monitor these patients, particularly when there is the added potential liability of prescribing opioids. This paper reviews the role of opioids in managing chronic noncancer pain, including efficacy and risk for misuse, abuse, and addiction, and discusses several models employing novel technologies and health delivery systems for risk assessment, intervention, and monitoring of patients receiving opioids in a primary care setting.

Abuse liability measures for use in analgesic clinical trials in patients with pain: IMMPACT recommendations

Assessing and mitigating the abuse liability (AL) of analgesics is an urgent clinical and societal problem. Analgesics have traditionally been assessed in randomized clinical trials (RCTs) designed to demonstrate analgesic efficacy relative to placebo or an active comparator. In these trials, rigorous, prospectively designed assessment for AL is generally not performed. The Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) convened a consensus meeting to review the available evidence and discuss methods for improving the assessment of the AL of analgesics in clinical trials in patients with pain. Recommendations for improved assessment include: (1) performing trials that include individuals with diverse risks of abuse; (2) improving the assessment of AL in clinical trials (eg, training study personnel in the principles of abuse and addiction behaviors, designing the trial to assess AL outcomes as primary or secondary outcome measures depending on the trial objectives); (3) performing standardized assessment of outcomes, including targeted observations by study personnel and using structured adverse events query forms that ask all subjects specifically for certain symptoms (such as euphoria and craving); and (4) collecting detailed information about events of potential concern (eg, unexpected urine drug testing results, loss of study medication, and dropping out of the trial). The authors also propose a research agenda for improving the assessment of AL in future trials.

Epidemiology of emergency department visits for opioid overdose: a population-based study

OBJECTIVES

To evaluate the rate of emergency department (ED) visits for opioid overdose and to examine whether frequent ED visits for opioid overdose are associated with more hospitalizations, near-fatal events, and health care spending.

PATIENTS AND METHODS

Retrospective cohort study of adults with at least 1 ED visit for opioid overdose between January 1, 2010, and December 31, 2011, derived from population-based data of State Emergency Department Databases and State Inpatient Databases for 2 large and diverse states: California and Florida. Main outcome measures were hospitalizations for opioid overdose, near-fatal events (overdose involving mechanical ventilation), and hospital charges during the year after the first ED visit.

RESULTS

The analytic cohort comprised 19,831 unique patients with 21,609 ED visits for opioid overdose. During a 1-year period, 7% (95% CI, 7%-7%; n=1389 patients) of the patients had frequent (2 or more) ED visits, accounting for 15% (95% CI, 14%-15%; n=3167) of all opioid overdose ED visits. Middle age, male sex, public insurance, lower household income, and comorbidities (such as chronic pulmonary disease and neurological diseases) were associated with frequent ED visits (all P<.01). Overall, 53% (95% CI, 52%-54%; n=11,412) of the ED visits for opioid overdose resulted in hospitalizations; patients with frequent ED visits for opioid overdose had a higher likelihood of hospitalization (adjusted odds ratio, 3.98; 95% CI, 3.38-4.69). In addition, 10.0% (95% CI, 10%-10%; n=2161) of the ED visits led to near-fatal events; patients with frequent ED visits had a higher likelihood of a near-fatal event (adjusted odds ratio, 2.27; 95% CI, 1.96-2.66). Total charges in Florida were $208 million (95% CI, $200-$219 million).

CONCLUSION

In this population-based cohort, we found that frequent ED visits for opioid overdose were associated with a higher likelihood of future hospitalizations and near-fatal events.

[Chronic non-cancer-related pain. Long-term treatment with rapid-release and short-acting opioids in the context of misuse and dependency]

Annually published data show a continual increase in the volume of opioid prescriptions in Germany, thus indicating an intensification of opioid therapy. The majority of opioids are prescribed to treat chronic non-cancer-related pain. On the basis of current guidelines, as well as in terms of the lack of data regarding long-term use of opioids and their effectiveness beyond a period of 3 months, this development must be viewed critically. With reference to four case reports, we discuss and evaluate opioid therapy in relation to medication misuse and the development of drug dependency. Particular emphasis is placed on the administration of rapid-release and short-acting opioid preparations, which we consider to be particularly problematic.

Prescription opioid misuse among ED patients discharged with opioids

STUDY OBJECTIVES

The purposes of this study were to determine the prevalence of prescription opioid misuse in a cohort of discharged emergency department (ED) patients who received prescription opioids and to examine factors predictive of misuse.

METHODS

This prospective observational study enrolled a sample of ED patients aged 18 to 55 years who were discharged with a prescription opioid. Participants completed surveys at baseline in the ED, then 3 and 30 days later. Follow-up surveys contained questions about opioid use and misuse, including screening questions from the National Epidemiologic Survey on Alcohol and Related Conditions. Patients were categorized as misusers if they (1) self-escalated their dose, (2) obtained additional prescription opioids without a prescription, or (3) used for a reason besides pain.

RESULTS

Of the 85 patients who completed follow-ups, 36 (42%) reported misuse at either 3 or 30 days. There was no difference in demographic variables, pain scores, analgesic treatment, or discharge diagnoses between misusers and nonmisusers. Self-escalation of dose was the most common category of misuse (33/36; 92%). Taking prescription opioids without a doctor's prescription was reported by 39% (14/36), and taking pain medications for a reason other than pain was reported by 36% (13/36). The presence of disability, chronic pain, preexisting prescription opioid use, oxycodone use, and past 12-month risk of substance abuse were associated with misuse.

CONCLUSIONS

Prescription opioid misuse was prevalent among this cohort of ED patients. A heterogeneous mixture of behaviors was captured. Future research should focus on the etiologies of misuse with directed screening and interventions to decrease misuse.

The effect of cognitive load and patient race on physicians' decisions to prescribe opioids for chronic low back pain: a randomized trial

OBJECTIVE

To test the hypothesis that racial biases in opioid prescribing would be more likely under high levels of cognitive load, defined as the amount of mental activity imposed on working memory, which may come from environmental factors such as stressful conditions, chaotic workplace, staffing insufficiency, and competing demands, one's own psychological or physiological state, as well as from demands inherent in the task at hand.

DESIGN

Two (patient race: White vs Black) by two (cognitive load: low vs high) between-subjects factorial design.

SETTING AND PARTICIPANTS

Ninety-eight primary care physicians from the Veterans Affairs Healthcare System.

METHODS

Web-based experimental study. Physicians were randomly assigned to read vignettes about either a Black or White patient, under low vs high cognitive load, and to indicate their likelihood of prescribing opioids. High cognitive load was induced by having physicians perform a concurrent task under time pressure.

RESULTS

There was a three-way interaction between patient race, cognitive load, and physician gender on prescribing decisions (P = 0.034). Hypotheses were partially confirmed. Male physicians were less likely to prescribe opioids for Black than White patients under high cognitive load (12.5% vs 30.0%) and were more likely to prescribe opioids for Black than White patients under low cognitive load (30.8% vs 10.5%). By contrast, female physicians were more likely to prescribe opioids for Black than White patients in both conditions, with greater racial differences under high (39.1% vs 15.8%) vs low cognitive load (28.6% vs 21.7%).

CONCLUSIONS

Physician gender affected the way in which patient race and cognitive load influenced decisions to prescribe opioids for chronic pain. Future research is needed to further explore the potential effects of physician gender on racial biases in pain treatment, and the effects of physician cognitive load on pain treatment.

Pain, pain catastrophizing, and past legal charges related to drugs

Using a self-report survey methodology in a cross-sectional consecutive primary care sample (N = 238), we examined pain at 3 time points (today, past month, past year), pain catastrophizing using the Pain Catastrophizing Scale, and history of legal charges for 5 drug-related crimes as defined by the Federal Bureau of Investigation. Among the subsample of 185 participants with histories of being prescribed analgesics, 33 reported a history of legal charges for drug-related crimes. Analyses of variance among this subsample confirmed statistically significant relationships between the current level of pain and history of legal charges for drug-related crimes, as well as level of pain catastrophizing and history of legal charges for drug-related crimes.

The association between negative affect and prescription opioid misuse in patients with chronic pain: the mediating role of opioid craving

Over the past decade, considerable research has accumulated showing that chronic pain patients experiencing high levels of negative affect (NA) are at increased risk for prescription opioid misuse. The primary objective of the present study was to examine the factors that underlie the association between NA and prescription opioid misuse among patients with chronic pain. In this study, 82 patients with chronic musculoskeletal pain being prescribed opioid medication completed the Current Opioid Misuse Measure, a well-validated self-report questionnaire designed to assess prescription opioid misuse. Patients were also asked to complete self-report measures of pain intensity, NA, and opioid craving. A bootstrapped multiple mediation analysis was used to examine the mediating role of patients' pain intensity and opioid craving in the association between NA and prescription opioid misuse. Consistent with previous research, we found a significant association between NA and prescription opioid misuse. Interestingly, results revealed that opioid craving, but not pain intensity, mediated the association between NA and opioid misuse. The Discussion addresses the potential psychological and neurobiological factors that might contribute to the interrelationships among NA, opioid craving, and prescription opioid misuse in patients with pain. The clinical implications of our findings are also discussed.

PERSPECTIVE

Our study provides new insights into the factors that underlie the association between negative affect and prescription opioid misuse in patients with chronic pain. Our findings could have important clinical implications, particularly for patients being prescribed opioid medication, and for reducing rates of opioid misuse in patients with pain.

Treating pain in sickle cell disease with opioids: clinical advances, ethical pitfalls

This article explores the ethical principles of prescribing in Sickle Cell Disease. The first two sections of the article provide detailed scientific justification for the last section of the manuscript, which explores and discusses the ethical principles.

The missing 'P' in pain management: how the current opioid epidemic highlights the need for psychiatric services in chronic pain care

OBJECTIVE

The prevalence of opioid therapy for chronic noncancer pain has increased dramatically in recent years, with a parallel increase in opioid abuse, misuse and deaths from accidental overdose. We review epidemiological and clinical data that point to the important roles psychiatric disorders have in the use and abuse of opioids in patients with chronic pain.

METHOD

We conducted literature searches on the PubMed with the key phrases "chronic pain" and "opioid therapy" and selected those articles on the epidemiology of comorbidity between chronic pain and psychiatric disorders, the trends in long-term opioid therapy and the clinical trials that involved using opioid therapy for chronic pain or for mental health disorders. We then thoroughly reviewed the bibliography of all relevant articles to identify additional papers to be included in the present review.

RESULTS

Chronic pain is highly comorbid with common psychiatric disorders. Patients with mental health and substance abuse disorders are more likely to receive long-term opioid therapy for chronic pain and more likely to have adverse outcomes from this therapy. Although opioids may exert brief antidepressant and anxiolytic effects in some patients with depression or anxiety, there is scant evidence for long-term benefit from opioid treatment of psychiatric disorders.

CONCLUSIONS

Opioids may be used in current clinical practice as the de facto and only psychiatric treatment for patients with chronic pain, despite little evidence for sustained benefit. The opioid epidemic thus reflects a serious unmet need for better recognition and treatment of common mental health problems in patients with chronic pain. Psychiatry is the missing P in chronic pain care.

Management of chronic pain with chronic opioid therapy in patients with substance use disorders

Substance use disorders (SUDs), whether active or in remission, are often encountered in patients with chronic nonmalignant pain. Clinicians are challenged when managing chronic pain while facing substance abuse issues during the course of chronic opioid therapy (COT). Further, the interrelated behavioral symptomatology of addiction and chronic pain suggests that if one disorder is untreated, effective treatment of the other in not possible. Incomplete understanding of the overlapping presentations of the two disorders, coupled with insufficient management of both conditions, leads to undertreated pain and premature discharge of SUD patients from pain treatment. In order to achieve pain relief and optimal functionality, both conditions need to be carefully managed. This paper reviews the prevalence of SUDs in chronic pain patents; the overlapping presentation of the two disorders; risk factors and stratification for addiction; identification of addiction in the chronic pain population; and suggestions for treating patients with COT, with an emphasis on relapse prevention. With appropriate assessment and treatment, COT for chronic pain patients with a history of SUD can be successful, leading to improved functionality and quality of life.

Organizational performance impacting patient satisfaction in Ontario hospitals: a multilevel analysis

BACKGROUND

Patient satisfaction in health care constitutes an important component of organizational performance in the hospital setting. Satisfaction measures have been developed and used to evaluate and improve hospital performance, quality of care and physician practice. In order to direct improvement strategies, it is necessary to evaluate both individual and organizational factors that can impact patients' perception of care. The study aims were to determine the dimensions of patient satisfaction, and to analyze the individual and organizational determinants of satisfaction dimensions in hospitals.

METHODS

We used patient and hospital survey data as well as administrative data collected for a 2008 public hospital report in Ontario, Canada. We evaluated the clustering of patient survey items with exploratory factor analysis and derived plausible dimensions of satisfaction. A two-level multivariate model was fitted to analyze the determinants of satisfaction.

RESULTS

We found eight satisfaction factors, with acceptable to good level of loadings and good reliability. More than 95% of variation in patient satisfaction scores was attributable to patient-level variation, with less than 5% attributable to hospital-level variation. The hierarchical models explain 5 to 17% of variation at the patient level and up to 52% of variation between hospitals. Individual patient characteristics had the strongest association with all dimensions of satisfaction. Few organizational performance indicators are associated with patient satisfaction and significant determinants differ according to the satisfaction dimension.

CONCLUSIONS

The research findings highlight the importance of adjusting for both patient-level and organization-level characteristics when evaluating patient satisfaction. Better understanding and measurement of organization-level activities and processes associated with patient satisfaction could contribute to improved satisfaction ratings and care quality.

"Nonmedical" prescription opioid use in North America: a call for priority action

Nearly four years after the United States Congress heralded a "decade of pain control and research", chronic pain remains a mounting public health concern worldwide. The escalating prevalence of chronic pain in recent years has been paralleled by a rise in prescription opioid availability, misuse, and associated human and social costs. However, national monitoring surveys in the U.S. and Canada currently fail to differentiate between prescription opioid misuse for the purposes of euphoria versus pain or withdrawal management. Furthermore, there is a lack of evidence-based guidelines for pain management among high-risk individuals, and a glaring lack of education for practitioners in the areas of pain and addiction medicine. Herein we propose multiple avenues for intervention and research in order to mitigate the individual, social and structural problems related to undertreated pain and prescription opioid misuse.

Pain management in older adults

BACKGROUND

Chronic pain is prevalent among older adults but is underrecognized and undertreated. The approach to pain assessment and management in older adults requires an understanding of the physiology of aging, validated assessment tools, and common pain presentations among older adults.

OBJECTIVE

To identify the overall principles of pain management in older adults with a specific focus on common painful conditions and approaches to pharmacologic treatment.

METHODS

We searched PubMed for common pain presentations in older adults with heart failure, end-stage renal disease, dementia, frailty, and cancer. We also reviewed guidelines for pain management. Our review encompassed 2 guidelines, 10 original studies, and 22 review articles published from 2000 to the present. This review does not discuss nonpharmacologic treatments of pain.

RESULTS

Clinical guidelines support the use of opioids in persistent nonmalignant pain. Opioids should be used in patients with moderate or severe pain or pain not otherwise controlled but with careful attention to potential toxic effects and half-life. In addition, clinical practice guidelines recommend use of oral nonsteroidal anti-inflammatory drugs with extreme caution and for defined, limited periods.

CONCLUSION

An understanding of the basics of pain pathophysiology, assessment, pharmacologic management, and a familiarity with common pain presentations will allow clinicians to effectively manage pain for older adults.

Treating pain in addicted patients: recommendations from an expert panel

Clinicians may face pragmatic, ethical, and legal issues when treating addicted patients. Equal pressures exist for clinicians to always address the health care needs of these patients in addition to their addiction. Although controversial, mainly because of the lack of evidence regarding their long-term efficacy, the use of opioids for the treatment of chronic pain management is widespread. Their use for pain management in the addicted population can present even more challenges, especially when evaluating the likelihood of drug-seeking behavior. As the misuse and abuse of opioids continues to burgeon, clinicians must be particularly vigilant when prescribing chronic opioid therapy. The purpose of this article is to summarize recommendations from a recent meeting of experts convened to recommend how primary care physicians should approach treatment of chronic pain for addicted patients when an addiction specialist is not available for a referral. As there is a significant gap in guidelines and recommendations in this specific area of care, this article serves to create a foundation for expanding chronic pain guidelines in the area of treating the addicted population. This summary is designed to be a practical how-to guide for primary care physicians, discussing risk assessment, patient stratification, and recommended therapeutic approaches.

Catastrophic thinking and increased risk for prescription opioid misuse in patients with chronic pain

BACKGROUND

As a consequence of the substantial rise in the prescription of opioids for the treatment of chronic noncancer pain, greater attention has been paid to the factors that may be associated with an increased risk for prescription opioid misuse. Recently, a growing number of studies have shown that patients with high levels of catastrophizing are at increased risk for prescription opioid misuse.

OBJECTIVE

The primary objective of this study was to examine the variables that might underlie the association between catastrophizing and risk for prescription opioid misuse in patients with chronic pain.

METHODS

Patients with chronic musculoskeletal pain (n=115) were asked to complete the SOAPP-R, a validated self-report questionnaire designed to identify patients at risk for prescription opioid misuse. Patients were also asked to complete self-report measures of pain intensity, catastrophizing, anxiety, and depression.

RESULTS

Consistent with previous research, we found that catastrophizing was associated with an increased risk for prescription opioid misuse. Results also revealed that the association between catastrophizing and risk for opioid misuse was partially mediated by patients' levels of anxiety. Follow-up analyses, however, indicated that catastrophizing remained a significant 'unique' predictor of risk for opioid misuse even when controlling for patients' levels of pain severity, anxiety and depressive symptoms.

DISCUSSION

Discussion addresses the factors that might place patients with high levels of catastrophizing at increased risk for prescription opioid misuse. The implications of our findings for the management of patients considered for opioid therapy are also discussed.

Risk factors for incident nonmedical prescription opioid use and abuse and dependence: results from a longitudinal nationally representative sample

BACKGROUND

There has been a significant increase in opioid prescriptions and the prevalence of opioid nonmedical use. Nonmedical use may lead to opioid abuse/dependence, a serious public health concern. The aim of this paper was to determine the mental and physical health predictors of incident nonmedical prescription opioid use (NMPOU) and abuse/dependence, and the impact of comorbidity in a longitudinal, nationally representative sample.

METHODS

Data come from Waves 1 and 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (N=34,653; ≥20 years old). Mental disorders were assessed using the Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV edition. Physical conditions were based on self-reports of physician-diagnoses. Multiple logistic regression models examined the associations between mental and physical health predictors at Wave 1 and their association to incident NMPOU and abuse/dependence disorders at Wave 2.

RESULTS

After adjusting for sociodemographics, Axis I and II mental disorders and physical conditions, the presence of mental disorders (i.e., mood, personality disorders and substance use disorders), physical conditions (i.e., increasing number of physical conditions, any physical condition, arteriosclerosis or hypertension, cardiovascular disease and arthritis) and sociodemographic factors (i.e., sex and marital status) at Wave 1 positively predicted incident abuse/dependence at Wave 2. Comorbid disorders increased the risk of NMPOU and abuse/dependence.

CONCLUSION

These results suggest the importance of mental and physical comorbidity as a risk for NMPOU and abuse/dependence, emphasizing the need for careful screening practices when prescribing opioids.

The downward spiral of chronic pain, prescription opioid misuse, and addiction: cognitive, affective, and neuropsychopharmacologic pathways

Prescription opioid misuse and addiction among chronic pain patients are emerging public health concerns of considerable significance. Estimates suggest that more than 10% of chronic pain patients misuse opioid analgesics, and the number of fatalities related to nonmedical or inappropriate use of prescription opioids is climbing. Because the prevalence and adverse consequences of this threat are increasing, there is a pressing need for research that identifies the biobehavioral risk chain linking chronic pain, opioid analgesia, and addictive behaviors. To that end, the current manuscript draws upon current neuropsychopharmacologic research to provide a conceptual framework of the downward spiral leading to prescription opioid misuse and addiction among chronic pain patients receiving opioid analgesic pharmacotherapy. Addictive use of opioids is described as the outcome of a cycle initiated by chronic pain and negative affect and reinforced by opioidergic-dopamingeric interactions, leading to attentional hypervigilance for pain and drug cues, dysfunctional connectivity between self-referential and cognitive control networks in the brain, and allostatic dysregulation of stress and reward circuitry. Implications for clinical practice are discussed; multimodal, mindfulness-oriented treatment is introduced as a potentially effective approach to disrupting the downward spiral and facilitating recovery from chronic pain and opioid addiction.

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.

Unintentional prescription opioid-related overdose deaths: description of decedents by next of kin or best contact, Utah, 2008-2009

BACKGROUND

Little is known about the characteristics that may predispose an individual to being at risk for fatal overdose from prescription opioids.

OBJECTIVE

To identify characteristics related to unintentional prescription opioid overdose deaths in Utah.

DESIGN

Interviews were conducted (October 2008-October 2009) with a relative or friend most knowledgeable about the decedent's life.

SUBJECTS

Analyses involved 254 decedents aged 18 or older, where cause of death included overdose on at least one prescription opioid.

KEY RESULTS

Decedents were more likely to be middle-aged, Caucasian, non-Hispanic/Latino, less educated, not married, or reside in rural areas than the general adult population in Utah. In the year prior to death, 87.4 % were prescribed prescription pain medication. Reported potential misuse prescription pain medication in the year prior to their death was high (e.g., taken more often than prescribed [52.9 %], obtained from more than one doctor during the previous year [31.6 %], and used for reasons other than treating pain [29.8 %, almost half of which "to get high"]). Compared with the general population, decedents were more likely to experience financial problems, unemployment, physical disability, mental illness (primarily depression), and to smoke cigarettes, drink alcohol, and use illicit drugs. The primary source of prescription pain medication was from a healthcare provider (91.8 %), but other sources (not mutually exclusive) included: for free from a friend or relative (24 %); from someone without their knowledge (18.2 %); purchase from a friend, relative, or acquaintance (16.4 %); and purchase from a dealer (not a pharmacy) (11.6 %).

CONCLUSIONS

The large majority of decedents were prescribed opioids for management of chronic pain and many exhibited behaviors indicative of prescribed medication misuse. Financial problems, unemployment, physical disability, depression, and substance use (including illegal drugs) were also common.

Trajectories of health care service utilization and differences in patient characteristics among adults with specific chronic pain: analysis of health plan member claims

Introduction

The lack of consistency surrounding the diagnosis of chronic non-cancer pain, treatment approaches, and patient management suggests the need for further research to better characterize the chronic non-cancer pain population.

Objective

The purpose of this study was to identify distinct trajectories of health care service utilization of chronic non-cancer pain patients and describe the characteristic differences between trajectory groups.

Patients and methods

This study utilized the MarketScan claims databases. A total of 71,392 patients diagnosed with either low back pain or osteoarthritis between 2006 and 2009 served as the study sample. Each subject’s claims data were divided into three time periods around an initial diagnosis date: pre-period, post-Year 1, and post-Year 2. Subjects were categorized as either high (H) or low (L) cost at each post period, resulting in the creation of four trajectory groups based on the post-Year 1 and 2 cost pattern: H-H, H-L, L-H, and L-L. Multivariate statistical tests were used to predict and discriminate between trajectory group memberships.

Results

The H-H, L-H, and H-L groups each utilized significantly greater pre-period high-cost venue services, post-Year 1 outpatient services, and post-Year 1 opioids compared to the L-L group (P < 0.001). Additionally, the H-H and L-H groups displayed elevated Charlson comorbidity index scores compared with the L-L group (P < 0.001), with each showing increased odds of having both opioid dependence and cardiovascular disease diagnoses (P < 0.01).

Conclusion

This study identified patient characteristics among chronic pain patients that discriminated between different levels of post-index high-cost venue service utilization and trajectories of change in the same. With implications for managed care program implementation and resource management, this study highlights results from a developed algorithm that employed a variety of accessible data elements to effectively discriminate between patients based on their pattern of high-cost venue service utilization over time.

Risk for prescription opioid misuse among patients with a history of substance use disorder

BACKGROUND

History of substance use disorder (SUD) is associated with risk for prescription opioid misuse in chronic pain patients; however, little data are available regarding risk for prescription opioid misuse within the subgroup of patients with SUD histories.

METHODS

Participants with chronic pain, histories of SUD, and current opioid prescriptions were recruited from a single VA Medical Center. Participants (n=80) completed measures of risk for prescription opioid misuse, pain severity, pain-related interference, pain catastrophizing, attitudes about managing pain, emotional functioning, and substance abuse.

RESULTS

Participants were divided into three groups based on risk for prescription opioid misuse, as assessed by the Pain Medication Questionnaire (PMQ). Participants in the High-PMQ group reported more pain severity, interference, catastrophizing, depressive symptoms, and lowest self-efficacy for managing pain, relative to the Low-PMQ group; the High-PMQ group and Moderate-PMQ group differed on measures of pain severity, catastrophizing, and psychiatric symptoms (all p-values <0.05). The High-PMQ group had the highest rates of current SUD (32% versus 20% and 0, p=0.009). A regression analysis evaluated factors associated with PMQ scores: pain catastrophizing was the only variable significantly associated with risk for prescription opioid misuse.

CONCLUSIONS

Among patients with SUD histories, those with higher risk for prescription opioid misuse reported more pain and impairment, symptoms of depression, and were more likely to have current SUD, relative to patients with lower risk for prescription opioid misuse. In adjusted analyses, pain catastrophizing was significantly associated with risk for prescription opioid misuse, but current SUD status was not a significant predictor.

Is religious coping related to better quality of life following acute myocardial infarction?

Although few studies have examined the extent to which religiousness is related to better well-being following acute myocardial infarction (AMI), studies from the broader literature suggest that positive religious coping may be helpful while more negative forms of religious coping may be related to poorer well-being. To assess the relationship between positive and negative religious coping and depressive symptoms in patients with AMI, we collected data twice over a 1-month period from 56 patients hospitalized with a first AMI. Controlling for demographic variables and social support, both positive and negative religious coping were independently related to higher levels of depressive symptoms both in hospital and at a one-month follow-up. Further, even when controlling for baseline depressive symptoms, religious coping predicted higher subsequent depressive symptoms. These results suggest that religious coping appears to be maladaptive in dealing with acute MI, perhaps because this type of recovery requires more active forms of coping.

Aberrant drug-related behaviors: unsystematic documentation does not identify prescription drug use disorder

OBJECTIVE

No evidence-based methods exist to identify prescription drug use disorder (PDUD) in primary care (PC) patients prescribed controlled substances. Aberrant drug-related behaviors (ADRBs) are suggested as a proxy. Our objective was to determine whether ADRBs documented in electronic medical records (EMRs) of patients prescribed opioids and benzodiazepines could serve as a proxy for identifying PDUD.

DESIGN

A cross-sectional study of PC patients at an urban, academic medical center.

SUBJECTS

Two hundred sixty-four English-speaking patients (ages 18-60) with chronic pain (≥3 months), receiving ≥1 opioid analgesic or benzodiazepine prescription in the past year, were recruited during outpatient PC visits.

OUTCOME MEASURES

Composite International Diagnostic Interview defined Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnoses of past year PDUD and no disorder. EMRs were reviewed for 15 prespecified ADRBs (e.g., early refill, stolen medications) in the year before and after study entry. Fisher's exact test compared frequencies of each ADRB between participants with and without PDUD.

RESULTS

 Sixty-one participants (23%) met DSM-IV PDUD criteria and 203 (77%) had no disorder; 85% had one or more ADRB documented. Few differences in frequencies of individual behaviors were noted between groups, with only "appearing intoxicated or high" documented more frequently among participants with PDUD (N = 10, 16%) vs no disorder (N = 8, 4%), P = 0.002. The only common ADRB, "emergency visit for pain," did not discriminate between those with and without the disorder (82% PDUD vs 78% no disorder, P = 0.6).

CONCLUSIONS

EMR documentation of ADRBs is common among PC patients prescribed opioids or benzodiazepines, but unsystematic clinician documentation does not identify PDUDs. Evidence-based approaches are needed.

Problematic prescription opioid use in an HIV-infected cohort: the importance of universal toxicology testing

BACKGROUND

Providers treating chronic pain must attempt to relieve suffering, while minimizing problematic prescription opioid use, including addiction and diversion. Previously described risk factors for problematic use include history of substance use, younger age, male sex, psychiatric comorbidity, and lower education level.

METHODS

We examined these risk factors in HIV-infected individuals, using cross-sectional and longitudinal data from the Manhattan HIV Brain Bank. Problematic use was defined as illicit substance use (documented by urine toxicology or structured psychiatric interview), while receiving prescription opioids.

RESULTS

Among 173 participants prescribed opioids, 62% had problematic use, the majority of which was discovered by urine toxicology. Problematic use was associated with past substance use, current psychiatric disorder, and poorer adherence to antiretrovirals. However, when participants without problematic use at baseline were followed longitudinally, these factors were not predictive. Furthermore, the cumulative incidence of problematic use behaviors was no greater than in a similar group of participants who were not prescribed opioids.

CONCLUSIONS

Problematic prescription opioid use is common among HIV-infected individuals and is associated with history of substance use, current psychiatric disorder, and poor adherence to antiretrovirals. However, these factors do not predict future problematic use in those who are not currently using illicit substances, and the prescription of an opioid does not seem to predispose patients toward a future substance use disorder. Rather than attempting to assess risk for problematic prescription opioid use in HIV-infected individuals, we recommend baseline and follow-up urine toxicology.

Individual and county-level factors associated with use of multiple prescribers and multiple pharmacies to obtain opioid prescriptions in California

Use of multiple prescribers and pharmacies is a means by which some individuals misuse opioids. Community characteristics may be important determinants of the likelihood of this phenomenon independent of individual-level factors. This was a retrospective cohort study with individual-level data derived from California's statewide prescription drug monitoring program (PDMP) and county-level socioeconomic status (SES) data derived from the United States Census. Zero-truncated negative binomial (ZTNB) regression was used to model the association of individual factors (age, gender, drug schedule and drug dose type) and county SES factors (ethnicity, adult educational attainment, median household income, and physician availability) with the number of prescribers and the number of pharmacies that an individual used during a single year (2006). The incidence rates of new prescriber use and new pharmacy use for opioid prescriptions declined across increasing age groups. Males had a lower incidence rate of new prescriber use and new pharmacy use than females. The total number of licensed physicians and surgeons in a county was positively, linearly, and independently associated with the number of prescribers and pharmacies that individuals used for prescription opioids. In summary, younger age, female gender, and living in counties with more licensed physicians and surgeons were associated with use of more prescribers and/or more pharmacies for obtaining prescription opioids.

Attentional bias for prescription opioid cues among opioid dependent chronic pain patients

Recurrent use of prescription opioid analgesics by chronic pain patients may result in opioid dependence, which involves implicit neurocognitive operations that organize and impel craving states and compulsive drug taking behavior. Prior studies have identified an attentional bias (AB) towards heroin among heroin dependent individuals. The aim of this study was to determine whether opioid-dependent chronic pain patients exhibit an AB towards prescription opioid-related cues. Opioid-dependent chronic pain patients (n = 32) and a comparison group of non-dependent opioid users with chronic pain (n = 33) completed a dot probe task designed to measure opioid AB. Participants also rated their opioid craving and self-reported arousal associated with opioid-related and neutral images, pain severity, and relief from pain treatments. Repeated-measures ANOVA revealed a significant group (opioid-dependent vs. non-dependent opioid user) × presentation duration (200. vs. 2,000 ms.) interaction, such that opioid-dependent individuals evidenced a significant AB towards opioid cues presented for 200 ms but not for cues presented for 2,000 ms, whereas non-dependent opioid users did not exhibit a significant mean AB at either stimulus duration. Among opioid-dependent individuals, 200 ms opioid AB was significantly associated with opioid craving, while among non-dependent opioid users, 200 ms opioid AB was significantly associated with relief from pain treatments. Furthermore, dependent and non-dependent opioid users experienced opioid cues as significantly more arousing than neutral cues. Opioid dependence among chronic pain patients appears to involve an automatic AB towards opioid-related cues. When coupled with chronic pain, attentional fixation on opioid cues may promote compulsive drug use and addictive behavior.

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.

Denial of prescription opioids among young adults with histories of opioid misuse

OBJECTIVES

An exploratory study was undertaken to examine how being denied prescription opioids to treat pain impacted the drug-using careers of young adults with a history of misuse of prescription drugs.

DESIGN

Ethno-epidemiological methodology utilizing a cross-sectional design, semi-structured interviews, and qualitative/quantitative data analysis. Settings.  Non-clinical participants were recruited from natural settings, such as streets, parks, beaches, and college campuses, in New York City and Los Angeles during 2008 and 2009.

PARTICIPANTS

One hundred fifty participants aged 16 to 25 who had misused a prescription opioid, tranquilizer, or stimulant in the past 90 days. Outcome Measures.  Analyses focused on denial of opioids and associated consequences, including self-medication with prescription opioids and heroin.

RESULTS

Thirty-four participants (22.7%) described being denied prescription opioids for the treatment of a painful condition. Current opioid misuse and current pain problems were higher in this group compared to those who had never been denied prescription opioids. Reasons for denial included being identified as a drug user by a physician, lack of health insurance, and having medication withheld by a parent or authority figure. Approximately half reported self-medicating pain with either illegally obtained prescription opioids or heroin. Self-medication often coincided with initiation of new risk behaviors and more intensive drug use.

CONCLUSION

Being denied prescription opioids was an important moment in the drug using careers of many study participants. Results suggest that effective pain management techniques are needed to prevent high-risk young adults with pain problems from engaging in escalated opioid misuse and risk behaviors.

Primary care providers' views on chronic pain management among high-risk patients in safety net settings

OBJECTIVE

We examined chronic pain management practices and confidence and satisfaction levels in treating chronic pain among primary care providers (PCPs) who cared for high-risk patients in safety net health settings.

DESIGN

We recruited PCPs (N = 61) through their HIV-infected patients who were enrolled in a longitudinal study on pain, use, and misuse of opioid analgesics (Pain Study). We asked PCPs to complete a questionnaire about all of their patients in their practice on the prevalence of chronic pain and illicit substance use, use of opioid analgesics, confidence and satisfaction levels in treating chronic pain, and likelihood of prescribing opioid analgesics in response to clinical vignettes.

RESULTS

All PCPs cared for at least some patients with chronic pain, and the majority prescribed opioid analgesics for its treatment. All PCPs cared for at least some patients who used illicit substances. PCPs reported low confidence and satisfaction levels in treating chronic pain. The majority (73.8%) of PCPs were highly likely to prescribe opioid analgesics to a patient without a history of substance use who had chronic pain. The majority (88.5%) were somewhat to highly likely to prescribe opioid analgesics to a patient with a prior history of substance use but not active use. Most (67.2%) were somewhat to highly likely to prescribe opioids to a patient with active substance use.

CONCLUSION

In order to improve PCPs' confidence and satisfaction in managing chronic pain, further work should explore the root causes of low confidence and satisfaction and also explore possible remedies.

A model to identify patients at risk for prescription opioid abuse, dependence, and misuse

OBJECTIVE

The objective of this study was to use administrative claims data to identify and analyze patient characteristics and behavior associated with diagnosed opioid abuse.

DESIGN

Patients, aged 12-64 years, with at least one prescription opioid claim during 2007-2009 (n = 821,916) were selected from a de-identified administrative claims database of privately insured members (n = 8,316,665). Patients were divided into two mutually exclusive groups: those diagnosed with opioid abuse during 1999-2009 (n = 6,380) and those without a diagnosis for opioid abuse (n = 815,536). A logistic regression model was developed to estimate the association between an opioid abuse diagnosis and patient characteristics, including patient demographics, prescription drug use and filling behavior, comorbidities, medical resource use, and family member characteristics. Sensitivity analyses were conducted on the model's predictive power.

RESULTS

In addition to demographic factors associated with abuse (e.g., male gender), the following were identified as "key characteristics" (i.e., odds ratio [OR] > 2): prior opioid prescriptions (OR = 2.23 for 1-5 prior Rxs; OR = 6.85 for 6+ prior Rxs); at least one prior prescription of buprenorphine (OR = 51.75) or methadone (OR = 2.97); at least one diagnosis of non-opioid drug abuse (OR = 9.89), mental illness (OR = 2.45), or hepatitis (OR = 2.36); and having a family member diagnosed with opioid abuse (OR = 3.01).

CONCLUSIONS

Using medical as well as drug claims data, it is feasible to develop models that could assist payers in identifying patients who exhibit characteristics associated with increased risk for opioid abuse. These models incorporate medical information beyond that available to prescription drug monitoring programs that are reliant on drug claims data and can be an important tool to identify potentially inappropriate opioid use.