The association between severity of depression and prescription opioid misuse among chronic pain patients with and without anxiety: A cross-sectional study

Conceptualizing problematic use of medicinal Cannabis: Development and preliminary validation of a brief screening questionnaire

The use of Medicinal Cannabis (MC) for treating chronic pain is increasing, globally, yet the definition of problematic MC use remains unclear. Defining problematic use of cannabis in medical and non-medical contexts may be fundamentally different since individuals prescribed MC often experience physical dependence, which do not necessarily imply pathology. We aimed to conceptualize problematic use of MC and develop a brief questionnaire for identifying and quantifying problematic MC use. Content validation used a broad definition of problematic substance use, adapting and compiling an initial list of 36 items from various sources: (a) screening tools for assessing problematic prescription opioid medication use; (b) screening tools for problematic recreational cannabis use and (c) qualitative interviews with MC patients. 390 American self-identified chronic pain patients holding a MC card rated each item from the initial list on a 5-point frequency scale and filled out questionnaires assessing various clinical outcomes. Following initial item titration, a multi-group measurement invariance comparison strategy, using two external indicators: alcohol-related problems and depression, resulted a final eight-item list that met fit quality in a baseline model, presented excellent internal consistency reliability (α = 0.929), and significantly correlated with anxiety and low quality of life. Items in the final list related predominantly to negative consequences of MC use. Problematic use of MC is characterized by negative physiological, social, emotional and functional consequences. The final eight-item list was named the Medicinal Cannabis Negative Consequences Scale (MCNCS), emerging as a brief measure for problematic MC use and demonstrating preliminary reliability and validity, which could aid clinicians and researchers.

Prevalence of Opioid Use Disorder and Opioid Overdose Rates Among People With Mental Illness

OBJECTIVE

The authors examined the prevalence and correlates of co-occurring opioid use disorder and opioid overdose among individuals receiving psychiatric services.

METHODS

This was a cross-sectional study of adults with continuous enrollment in New York State Medicaid who received at least one psychiatric service in 2020 (N=523,885). Logistic regression models were used to examine the correlates of both opioid use disorder and overdose.

RESULTS

In the study sample, the prevalence rate of opioid use disorder was 8.1%; within this group, 7.7% experienced an opioid overdose in the study year. Opioid use disorder rates were lower among younger (18-24 years; 2.0%) and older (≥65 years; 3.1%) adults and higher among men (11.1%) and among those residing in rural areas (9.9%). Compared with Whites (9.4%), opioid use disorder rates were lower for Asian Americans (2.0%, adjusted odds ratio [AOR]=0.22) and Blacks (6.8%, AOR=0.76) and higher for American Indians (13.2%, AOR=1.43) and Hispanics (9.6%, AOR=1.29). Individuals with any substance use (24.9%, AOR=5.20), posttraumatic stress (15.7%, AOR=2.34), bipolar (14.9%, AOR=2.29), or anxiety (11.3%, AOR=2.18) disorders were more likely to have co-occurring opioid use disorder; those with conduct (4.5%, AOR=0.51), adjustment (7.4%, AOR=0.88), or schizophrenia spectrum (7.4%, AOR=0.87) disorders were less likely to have opioid use disorder. Those with suicidality (23.9%, AOR=3.83) or economic instability (23.7%, AOR=3.35) had higher odds of having opioid use disorder. Overdose odds were higher among individuals with suicidality (34.0%, AOR=6.82) and economic instability (16.0%, AOR=2.57).

CONCLUSIONS

These findings underscore the importance of providing opioid use disorder screening and treatment for patients receiving psychiatric services.

Modulation of Comorbid Chronic Neuropathic Pain and Anxiety-Like Behaviors by Glutamatergic Neurons in the Ventrolateral Periaqueductal Gray and the Analgesic and Anxiolytic Effects of Electroacupuncture

Comorbid chronic neuropathic pain and anxiety is a common disease that represents a major clinical challenge. The underlying mechanisms of chronic neuropathic pain and anxiety are not entirely understood, which limits the exploration of effective treatment methods. Glutamatergic neurons in the ventrolateral periaqueductal gray (vlPAG) have been implicated in regulating pain, but the potential roles of the vlPAG in neuropathic pain-induced anxiety have not been investigated. Herein, whole-cell recording and immunofluorescence showed that the excitability of CamkIIα neurons in the vlPAG (vlPAGCamkIIα+ neurons) was decreased in mice with spared nerve injury (SNI), while electroacupuncture (EA) activated these neurons. We also showed that chemogenetic inhibition of vlPAGCamkIIα+ neurons resulted in allodynia and anxiety-like behaviors in naive mice. Furthermore, chemogenetic activation of vlPAGCamkIIα+ neurons reduced anxiety-like behaviors and allodynia in mice with SNI, and EA had a similar effect in alleviating these symptoms. Nevertheless, EA combined with chemogenetic activation failed to further relieve allodynia and anxiety-like behaviors. Artificial inhibition of vlPAGCamkIIα+ neurons abolished the analgesic and anxiolytic effects of EA. Overall, our study reveals a novel mechanism of neuropathic pain-induced anxiety and shows that EA may relieve comorbid chronic neuropathic pain and anxiety by activating vlPAGCamkIIα+ neurons.

Review of Opioid Abuse-Deterrent Formulations: Impact and Barriers to Access

The misuse and abuse of opioid analgesics continue to pose a serious public health concern, but for some patients, opioids remain an important analgesic option. Extended-release (ER) opioid formulations are effective for treating chronic pain and are supported by multiple 12-week efficacy studies. ER opioids often contain a high opioid content, and similar to immediate-release (IR) formulations, are subject to abuse, misuse, and diversion. Unintentional misuse may also occur when ER formulations are manipulated for medicinal administration, such as crushing a dose for easier oral intake. As part of a multipronged strategy designed to fight the opioid epidemic, abuse-deterrent formulations (ADFs) were developed to deter misuse, abuse, and diversion of opioids by making manipulation more difficult and nonoral routes of administration less rewarding. Although ADF opioids have been shown to decrease rates of abuse and diversion, they are not equally effective in terms of deterring manipulation for abuse or misuse. Xtampza ER utilizes DETERx technology, which allows it to retain ER characteristics when chewed or crushed, making it the only ER opioid without a boxed warning against these types of manipulation. OxyContin was also developed as an ADF but uses RESISTEC technology, making the tablet hard to crush and viscous in aqueous solutions. ADF utilization has been hampered by patient access issues, including high prices due to lack of insurance coverage. Postmarket real-world studies demonstrate lower rates of abuse, misuse, and diversion for ADF ER opioids compared with non-ADF formulations. However, similar studies comparing abuse-related effectiveness and health care costs for ADF opioids are warranted if clinicians are expected to utilize these potentially safer opioid formulations. These studies would support further education surrounding the benefits and utilization of ADFs and manipulation potential of different ADFs.

Understanding the effects of nutrition and mental health conditions for patients with opioid use disorder (OUD)

BACKGROUND

The ravaging effects of the opioid epidemic have affected our communities locally and nationally and are multifaceted in their cause and treatment. It is imperative to locate multiple modalities of treatment options and care for patients with opioid use disorder (OUD) including developing healthy nutrition habits and addressing mental health concerns. Understanding patient perceptions of their personal nutrition habits and mental health status is imperative to providing holistic care in the OUD patient population.

METHODS

An anonymous 31-question Likert-scale and multiple-choice survey was administered to patients with an International Classification of Disease (ICD-10) code in their electronic medical record of OUD (N = 124). χ2 and Fisher's exact test where appropriate were performed to determine the demographics of survey participants who acknowledged history of OUD compared to those who did not acknowledge a history of OUD. Log-binomial models were used to generate adjusted prevalence ratios.

RESULTS

Of the 117 patients identified using ICD-10 codes from their medical records as having OUD, only 63 patients acknowledged having a history of OUD, while 54 patients did not. A univariate analysis showed differences in marital status for patients with a self-identified history of OUD. They were also more likely to not be married (divorced or single) (p < 0.01). Patients also tended to be younger than 50 years of age (p < 0.01) and non-White (p < 0.01). There were no differences seen for patients with a history of OUD in the categories of employment (p = 0.31) status or sex (p = 0.51). Patients who acknowledged a history of OUD were significantly more likely to understand the relationship between a healthy diet and reducing the intensity of opioid cravings (p = 0.01) and more likely to consider using nutrition to help combat opioid cravings (p = 0.01). There were no significant differences in overall health or the use of supplements as a part of opioid use treatment. Significant differences were found between those acknowledging a history of OUD having higher rates of depression (p = 0.02) and anxiety (p = 0.02) treatment, despite there not being differences in condition rates for these two conditions (depression, p = 0.08; anxiety, p = 0.27) between the groups. Patients with patient-confirmed OUD were more likely to receive medication treatment (p = 0.03) than those without this acknowledgment.

DISCUSSION

A similar disease burden of anxiety and depression existed for patients acknowledging OUD as opposed to patients denying OUD. However, significant differences existed between these groups in medication treatment, with those acknowledging OUD having higher rates of being treated for both depression and anxiety. Understanding a patient's mental health condition(s) can be impactful for the treatment of OUD. Multifaceted treatment options should include addressing nutritional deficiencies that impact cravings and long-term healing for patients.

CONCLUSION

Nutrition and mental health are key parts of a multifaceted treatment modality for patients dealing with OUD. Assisting patients in treatment for depression and anxiety as well as nutrition can change the trajectory of a patient's opioid use recovery.

Beyond the brink: Unraveling the opioid crisis and its profound impacts

This paper examines the long-standing and severe public health crisis, the opioid epidemic in the United States, which has been worsening since the mid-1990s. In contrast to previous research, it investigates the broader impacts of this epidemic, particularly on family members and healthcare systems. Using a comprehensive dataset spanning from 1998 to 2010, the study analyzes opioid use at the three-digit ZIP code level, utilizing data from the Drug Enforcement Agency (DEA) and individual-level data from the Health and Retirement Study (HRS) in a two-way fixed effect model. The findings reveal significant negative effects on family caregivers, notably adult children, due to the opioid epidemic. Additionally, opioid exposure is associated with increased healthcare utilization, including home health care and hospital use. This research contributes to a deeper understanding of the multifaceted consequences of the opioid epidemic.

Opioids for acute and chronic pain when receiving psychiatric medications

BACKGROUND

People with mental health disorders (MHD) like depression and anxiety are more likely to experience substance use disorders (SUDs) than those without MHD. This study assesses opioid prescription patterns for acute or chronic pain management in patients receiving medication for depression and/or anxiety.

METHODS AND FINDINGS

Cross-sectional data trend analysis of 24.5 million adult medical claims was conducted using medical and pharmacy data (2012-2019) for adults aged 21-64 from the IBM Watson MarketScan Medicaid Multi-State Database. Information on sex, age, race, provider type, acute or chronic pain, and prescriptions for opioids and antidepressant and/or antianxiety medication from outpatient encounters were analyzed. For those receiving opioid prescriptions within 14 days of a pain diagnosis, ICD-10-CM codes were used to categorize diagnoses as chronic pain (back pain, neck pain, joint pain, and headache); or acute pain (dental-, ENT-, and orthopedic-related pain). Nearly 8 million adults had at least one prescription for antidepressant or antianxiety medications (MHD), with 2.5 million of those (32%) also diagnosed with an acute or chronic pain condition (pain + MHD). Among the pain + MHD group, 34% (0.85 million) received an opioid prescription within 14 days of diagnosis. Individuals with chronic pain diagnoses received a higher proportion of opioid prescriptions than those with acute pain. Among individuals with pain + MHD, the majority were aged 50-64 (35%), female (72%), and non-Hispanic white (65.1%). Nearly half (48.2%) of the opioid prescriptions given to adults with an MHD were provided by physicians. Compared to other physician types, Health Care Providers (HCPs) in emergency departments were 50% more likely to prescribe an opioid for dental pain to those with an MHD, whereas dentists were only half as likely to prescribe an opioid for dental pain management. Although overall opioid prescriptions for pain management declined from 2012 to 2019, adults with an MHD received opioids for pain management at nearly twice the level as adults without an MHD.

CONCLUSIONS

Although HCPs have reduced opioids for acute or chronic pain to patients at high-risk for SUD, for example, those with MHD, the use of opioids for pain management has remained at consistently higher levels for this SUD high-risk group, suggesting the need to revisit pain management guidelines for those receiving antidepressant or antianxiety drugs.

The Prevalence of Comorbidities and Substance Use Disorder

Substance use disorders (SUDs) are complex illnesses and may occur in individuals with other physical and mental illnesses. Common comorbidities for SUDs include mental health illness and/or chronic pain. Nurses face additional risk factors for the development of SUD and comorbid illnesses. The relationships among these comorbidities and SUD are multifaceted, requiring understanding of the individual disease processes and how they may impact the manifestations of one another, as well as response to treatment considerations. Understanding the prevalence of these comorbidities and potential relationships is crucial to prevention, management, and treatment outcomes.

To be aware, or to accept, that is the question: Differential roles of awareness of automaticity and pain acceptance in opioid misuse

BACKGROUND

Individuals with chronic low back pain (CLBP) are commonly prescribed long-term opioid therapy (LTOT) for analgesia, placing this population at increased risk for opioid misuse and opioid use disorder. Acceptance of aversive experiences (e.g., chronic pain) and awareness of automatic thoughts and behaviors (i.e., automaticity) are two facets of dispositional mindfulness that may serve as protective mechanisms against opioid misuse risk. Therefore, the aim of the current study was to examine the differential contributions of these constructs to opioid misuse risk among adults with CLBP receiving LTOT.

METHODS

Data were obtained from a sample of 770 adults with opioid-treated CLBP. Bivariate correlations and hierarchical linear regression analyses were used to determine whether chronic pain acceptance and awareness of automatic thoughts and behaviors explained a statistically significant portion of variance in opioid misuse risk after accounting for the effects of other relevant confounders.

RESULTS

Hierarchical regression results revealed that chronic pain acceptance and awareness of automatic thoughts and behaviors contributed a significant portion in the variance of opioid misuse risk. Awareness of automatic thoughts and behaviors was negatively associated with opioid misuse risk, such that individuals with lower levels of awareness of automaticity were at higher risk of opioid misuse. By contrast, pain acceptance was not associated with opioid misuse.

CONCLUSIONS

Findings suggest that awareness of automaticity may buffer against opioid misuse risk. Interventions designed to strengthen awareness of automaticity (e.g., mindfulness-based interventions) might be especially efficacious among this population.

Opioid Use Patterns in a Statewide Adult Medicaid Population Undergoing Elective Lumbar Spine Surgery

STUDY DESIGN

Retrospective administrative database review.

OBJECTIVE

Analyze patterns of opioid use in patients undergoing lumbar surgery and determine associated risk factors in a Medicaid population.

SUMMARY OF BACKGROUND DATA

Opioid use in patients undergoing surgery for degenerative lumbar spine conditions is prevalent and impacts outcomes. There is limited information defining the scope of this problem in Medicaid patients.

MATERIALS AND METHODS

Longitudinal cohort study of adult South Carolina (SC) Medicaid patients undergoing lumbar surgery from 2014 to 2017. All patients had continuous SC Medicaid coverage for 15 consecutive months, including six months before and nine months following surgery. The primary outcome was a longitudinal assessment of postoperative opioid use to determine trajectories and group-based membership using latent modeling. Univariate and multivariable modeling was conducted to assess risk factors for group-based trajectory modeling and chronic opioid use (COU).

RESULTS

A total of 1455 surgeries met inclusion criteria. Group-based trajectory model demonstrated patients fit into five groups; very low use (23.4%), rapid wean following surgery (18.8%), increasing use following surgery (12.9%), slow wean following surgery (12.6%) and sustained high use (32.2%). Variables predicting membership in high opioid use included preoperative opioid use, younger age, longer length of stay, concomitant medications, and readmissions. More than three quarter of patients were deemed COUs (76.4%). On bivariate analysis, patients with degenerative disk disease were more likely to be COUs (24.8% vs. 18.6%; P =0.0168), more likely to take opioids before surgery (88.5% vs. 61.9%; P <0.001) and received higher amounts of opioids during the 30 days following surgery (mean morphine milligram equivalents 59.6 vs. 25.1; P <0.001).

CONCLUSIONS

Most SC Medicaid patients undergoing lumbar elective lumbar spine surgery were using opioids preoperatively and continued long-term use postoperatively at a higher rate than previously reported databases. Preoperative and perioperative intake, degenerative disk disease, multiple prescribers, depression, and concomitant medications were significant risk factors.

Depression in Chinese men with methamphetamine dependence: Prevalence, correlates and relationship with alexithymia

BACKGROUND

The comorbidity between substance use disorder and major depressive disorder is a typical dual diagnosis in the field of substance addiction. However, the prevalence and correlates of depression in methamphetamine addicts and whether it is associated with drug craving and alexithymia have been rarely reported in the Chinese population.

METHODS

We recruited 585 methamphetamine-dependent males from a drug rehabilitation center in China and 203 healthy controls. Demographic and drug use data were collected. Depression was assessed using the Mini International Neuropsychiatric Interview (M.I.N·I.). Methamphetamine cravings and alexithymia were assessed using the Desire for Drugs Questionnaire (DDQ) and the Toronto Alexithymia Scale (TAS).

RESULTS

The prevalence rate of depression in methamphetamine-dependent men was 16.58 % (97/585). The scores of DDQ desire and intention, DDQ negative reinforcement, total DDQ, difficulty identifying feelings (DIF), difficulty describing feelings (DDF), and total TAS score of depressed patients were higher than those of non-depressed patients. However, only DDQ negative reinforcement score, DIF, DDF, and total TAS score remained significant after Bonferroni correction. Additionally, logistic regression analysis found that age, DIF score, and DDQ negative reinforcement score were significant factors contributing to depression in methamphetamine-dependent men.

CONCLUSION

Our findings suggest that the prevalence of depression is significantly higher in methamphetamine-dependent men than in the healthy Chinese population. Furthermore, age, components of alexithymia and drug craving are risk factors for depression in methamphetamine addicts.

The association between chiropractic integration in an Ontario community health centre and continued prescription opioid use for chronic non-cancer spinal pain: a sequential explanatory mixed methods study

BACKGROUND

Emerging evidence suggests that access to chiropractic care may reduce the likelihood of initiating an opioid prescription for spinal pain; however, the impact of chiropractic care for patients already prescribed opioids is uncertain. We undertook a sequential explanatory mixed methods study to evaluate the association between initiating chiropractic care and continued opioid use among adult patients attending an Ontario community health centre (CHC) and receiving opioid therapy for chronic non-cancer spinal pain.

METHODS

We conducted a retrospective cohort study of 210 patient records between January 1, 2014 and December 31, 2020. We used generalized estimating equations, adjusted for patient demographics, co-morbidities, visit frequency, and calendar year, to evaluate the association between receipt versus non-receipt of chiropractic services and continued opioid use (e.g., unique opioid fills, number of refills, and dosages) up to one year following the index chiropractic visit. We also completed follow-up interviews with 14 patients and nine general practitioners from the CHC and integrated these data with our quantitative findings.

RESULTS

Over 12-month follow-up, there were lower rates of opioid fills (incidence rate ratio [IRR] = 0.66; 95% confidence interval [CI], 0.52-0.83) and refills (IRR = 0.27; 95% CI, 0.17-0.42) among chiropractic recipients (n = 49) versus non-recipients (n = 161). Although patients who did and did not receive chiropractic care began the study with the same dose of opioids, recipients were less likely to be prescribed higher-dose opioids (i.e., ≥ 50 mg morphine equivalents daily) compared to non-recipients at three months (odds ratio [OR] = 0.14; 95% CI, 0.04-0.47), six months (OR = 0.14; 95% CI, 0.05-0.40), nine months (OR = 0.19; 95% CI, 0.07-0.57), and 12 months (OR = 0.22; 95% CI, 0.08-0.62). Interviews suggested that patient self-efficacy, limited effectiveness of opioids for chronic pain, stigma regarding use of opioids, and access to chiropractic treatment were important influencing factors.

CONCLUSION

We found that continued prescription opioid use among patients with chronic non-cancer spinal pain who received chiropractic care was lower than in patients who did not receive chiropractic care. Four themes emerged in our qualitative interviews to help provide a richer understanding of this association. Randomized controlled trials are needed to establish the effect of chiropractic care on opioid use for chronic spinal pain.

Reward drive moderates the effect of depression-related cognitive mechanisms on risk of prescription opioid misuse among patients with chronic non-cancer pain

Depression, a prognostic factor for prescription opioid misuse commonly occurs in people with chronic non-cancer pain (CNCP). However, the mechanisms linking depression and prescription opioid misuse remain unclear. This study examined the potential mediating role of pain catastrophizing in the association between depressive symptoms and prescription opioid misuse risk, and impulsivity traits as possible moderators of these relationships. Individuals (N = 198; 77% women) with CNCP using prescription opioids participated in a cross-sectional online survey with validated measures of depression, pain catastrophizing, rash impulsiveness, reward drive, anxiety, pain severity and prescription opioid misuse. Meditation analyses with percentile-based bootstrapping examined pathways to prescription opioid use, controlling for age, sex, pain severity, and anxiety symptoms. Partial moderated mediation of the indirect effect of depressive symptoms on prescription opioid misuse risk through pain catastrophizing by rash impulsiveness and reward drive were estimated. Pain catastrophizing mediated depressive symptoms and prescription opioid misuse risk. Indirect effects were stronger when moderate to high levels of reward drive were included in the model. Findings suggest the risk of prescription opioid misuse in those experiencing depressive symptoms and pain catastrophizing is particularly higher for those higher in reward drive. Treatments targeting these mechanisms may reduce opioid misuse risk. PERSPECTIVE: This article identifies reward drive as a potentially important factor increasing the effects of depression-related cognitive mechanisms on risk of prescription opioid misuse in those with CNCP. These findings could assist in personalizing clinical CNCP management to reduce the risks associated with opioid misuse.

Association of Chiropractic Care With Receiving an Opioid Prescription for Noncancer Spinal Pain Within a Canadian Community Health Center: A Mixed Methods Analysis

OBJECTIVE

The purpose of this study was to examine the association between receipt of chiropractic services and initiating a prescription for opioids among adult patients with noncancer spinal pain in a Canadian community health center.

METHODS

In this sequential explanatory mixed methods analysis, we conducted a retrospective study of 945 patient records (January 2014 to December 2020) and completed interviews with 14 patients and 9 general practitioners. We used Cox proportional hazards regression analyses, adjusted for patient demographics, comorbidities, visit frequency, and calendar year to evaluate the association between receipt of chiropractic care and time to first opioid prescription up to 1 year after presentation. Qualitative data were analyzed thematically and integrated with our quantitative findings.

RESULTS

There were 24% of patients (227 of 945) with noncancer spinal pain who received a prescription for opioids. The risk of initiating a prescription for opioids at 1 year after presentation was 52% lower in chiropractic recipients vs nonrecipients (hazard ratio [HR], 0.48; 99% confidence interval [CI], 0.29-0.77) and 71% lower in patients who received chiropractic services within 30 days of their index visit (HR, 0.29; 99% CI, 0.13-0.68). Patients whose index visit date was in a more recent calendar year were also less likely to receive opioids (HR, 0.86; 99% CI, 0.76-0.97). Interviews suggested that self-efficacy, access to chiropractic services, opioid stigma, and treatment impact were influencing factors.

CONCLUSION

Patients with noncancer spinal pain who received chiropractic care were less likely to obtain a prescription for opioids than patients who did not receive chiropractic care.

Generalized Anxiety Disorder 7-Item (GAD-7) Scores in Medically Authorized Cannabis Patients-Ontario and Alberta, Canada

OBJECTIVES

Despite increasing rates of legalization of medical cannabis worldwide, the current evidence available on its effect on mental health outcomes including anxiety is of mixed results. This study assesses the effect of medical cannabis on generalized anxiety disorder 7-item (GAD-7) scores in adult patients between 2014 and 2019 in Ontario and Alberta, Canada.

METHODS

An observational cohort study of adults authorized to use medical cannabis. The GAD-7 was administered at the time of the first visit to the clinic and subsequently over the follow-up time period of up to 3.2 years. Overall changes in GAD-7 scores were computed (mean change) and categorized as: no change (<1 point); improvement; or worsening-over time.

RESULTS

A total of 37,303 patients had initial GAD-7 scores recorded and 5,075 (13.6%) patients had subsequent GAD-7 follow-up scores. The average age was 54.2 years (SD 15.7 years), 46.0% were male, and 45.6% noted anxiety symptoms at the baseline. Average GAD-7 scores were 9.11 (SD 6.6) at the baseline and after an average of 282 days of follow-up (SD 264) the average final GAD-7 score recorded was 9.04 (SD 6.6): mean change -0.23 (95% CI, -0.28 to -0.17, t[5,074]: -8.19, p-value <0.001). A total of 4,607 patients (90.8%) had no change in GAD-7 score from their initial to final follow-up, 188 (3.7%) had a clinically significant decrease, and 64 (1.3%) noted a clinically significant increase in their GAD-7 scores.

CONCLUSIONS

Overall, there was a statistically significant decrease in GAD-7 scores over time (in particular, in the 6-12-month period). However, this change did not meet the threshold to be considered clinically significant. Thus, we did not detect clinical improvements or detriment in GAD-7 scores in medically authorized cannabis patients. However, future well-controlled clinical trials are needed to fully examine risks or benefits associated with using medical cannabis to treat anxiety conditions.

Stress reveals a specific behavioral phenotype for opioid abuse susceptibility

Susceptibility to stress has long been considered important for the development of substance use disorders. Nonetheless, behavioral and physiological responses to stress are highly variable, making it difficult to identify the individuals who are most likely to abuse drugs. In the present study, we employed a comprehensive battery of tests for negative valence behaviors and nociception to identify individuals predisposed to opioid seeking following oral opioid self-administration. Furthermore, we examined how this profile was affected by a history of stress. We observed that mice receiving foot shock stress failed to exhibit a preference for sucrose, showed increased immobility in the forced swim task, and exhibited mechanical hypersensitivity when compared to controls. When considering these behaviors in light of future fentanyl-seeking responses, we observed that heightened mechanical sensitivity corresponded to higher opioid preference in mice with a history of stress, but not controls. Moreover, we were surprised to discover that paradoxically high sucrose preferences predicted fentanyl preference in shock mice, while signs of anhedonia predicted fentanyl preference in controls. Taken together, these results indicate that stress can act as a physiological modulator, shifting profiles of opioid abuse susceptibility depending on an individual's history.

Opioid Use Disorder Among Clients of Community Mental Health Clinics: Prevalence, Characteristics, and Treatment Willingness

OBJECTIVE

The authors examined the prevalence of co-occurring opioid use disorder and willingness to engage in treatment among clients of eight Los Angeles County Department of Mental Health outpatient clinics.

METHODS

Adults presenting for an appointment over a 2-week period were invited to complete a voluntary, anonymous health survey. Clients who indicated opioid use in the past year were offered a longer survey assessing probable opioid use disorder. Willingness to take medication and receive treatment also was assessed.

RESULTS

In total, 3,090 clients completed screening. Among these, 8% had a probable prescription (Rx) opioid use disorder and 2% a probable heroin use disorder. Of the clients with probable Rx opioid use or heroin use disorder, 49% and 25% were female, respectively. Among those with probable Rx opioid use disorder, 43% were Black, 33% were Hispanic, and 12% were White, and among those with probable heroin use disorder, 24% were Black, 22% were Hispanic, and 39% were White. Seventy-eight percent of those with Rx opioid use disorder had never received any treatment, and 82% had never taken a medication for this disorder; 39% of those with heroin use disorder had never received any treatment, and 39% had never received a medication. The strongest predictor of willingness to take a medication was believing that it would help stop opioid use (buprenorphine, β=13.54, p=0.003, and naltrexone long-acting injection, β=15.83, p<0.001).

CONCLUSIONS

These findings highlight the need to identify people with opioid use disorder and to educate clients in mental health settings about medications for these disorders.

Associations between elevated depressive symptoms and substance use, prescription opioid misuse, overdose history, pain, and general health among community pharmacy patients prescribed opioids

Background: Individuals with pain prescribed opioids experience high rates of comorbid depression. The aim of this study was to characterize pain, substance use, and health status as a function of depressive symptom level in individuals filling an opioid prescription at a community pharmacy. Methods: Participants (N = 1268) filling an opioid prescription enrolled in a study validating a prescription drug monitoring metric completed an online survey assessing sociodemographics, depressive symptoms, substance use, prescription opioid misuse, overdose history, general health, and pain severity and interference. Results: Approximately one-fifth (19.3%) had a positive depression screen result. In covariate-adjusted logistic regression analyses, individuals with a positive depression screen result were more likely to have moderate/high substance use risk scores for prescription opioids (adjusted odds ratio [AOR] = 2.06; 95% confidence interval [CI], 1.51-2.79); street opioids (AOR = 7.18; 95% CI, 2.57-20.01); cannabis (AOR = 2.00; 95% CI, 1.34-3.00); cocaine (AOR = 3.46; 95% CI, 1.46-8.22); tobacco (AOR = 1.59; 95% CI, 1.18-2.15); methamphetamine (AOR = 7.59; 95% CI, 2.58-22.35); prescription stimulants (AOR = 2.95; 95% CI, 1.59-5.49); and sedatives (AOR = 3.41; 95% CI, 2.43-4.79). Individuals with a positive depression screen were more likely to misuse prescription opioids (AOR = 3.46; 95% CI, 2.33-5.15), experience a prior overdose (AOR = 2.69; 95% CI, 1.76-4.11), report poorer general health (AOR = 0.25, 95% CI, 0.18-0.35), and report moderate/severe pain severity (AOR = 4.36, 95% CI, 2.80-6.77) and interference (AOR = 6.47, 95% CI, 4.08-10.26). Conclusions: Individuals prescribed opioids with heightened depression were more likely to report other substance use, prescription opioid misuse, prior overdose, greater pain, and poorer health.

Association of chiropractic integration in an Ontario community health centre with prescription opioid use for chronic non-cancer pain: a mixed methods study protocol

INTRODUCTION

Emerging evidence from a number of primary care centres suggests that integration of chiropractic services into chronic pain management is associated with improved clinical outcomes and high patient satisfaction as well as with reductions in physician visits, specialist referrals use of advanced imaging and prescribing of analgesics. However, formal assessments of the integration of chiropractic services into primary care settings are sparse, and the impact of such integration on prescription opioid use in chronic pain management remains uncertain. To help address this knowledge gap, we will conduct a mixed methods health service evaluation of an integrated chiropractic back pain programme in an urban community health centre in Ontario, Canada. This centre provides services to vulnerable populations with high unemployment rates, multiple comorbidities and musculoskeletal disorders that are commonly managed with prescription opioids.

METHODS AND ANALYSIS

We will use a sequential explanatory mixed methods design, which consists of a quantitative phase followed by a qualitative phase. In the quantitative phase, we will conduct a retrospective chart review and evaluate whether receipt of chiropractic services is associated with reduced opioid use among patients already prescribed opioid therapy for chronic pain. We will measure opioid prescriptions (ie, opioid fills, number of refills and dosages) by reviewing electronic medical records of recipients and non-recipients of chiropractic services between 1 January 2014 and 31 December 2020 and use multivariable regression analysis to examine the association. In the qualitative phase, we will conduct in-depth, one-on-one interviews of patients and their general practitioners to explore perceptions of chiropractic integration and its impact on opioid use.

ETHICS AND DISSEMINATION

This study was approved by the Hamilton Integrated Research Ethics Board at McMaster University (approval number 2021-10930). The results will be disseminated via peer-reviewed publications, conference presentations and in-person or webinar presentations to community members and healthcare professionals.

A Retrospective Study of Psychotropic Drug Use and Prescription Opioid Initiation Among Older Adults

Individuals with mental health problems may be more vulnerable to using prescription opioids than their counterparts. Therefore, the main objective of this study was to assess the initiation of prescription opioids in older adults who used psychotropic drugs compared with those who did not. The authors used a retrospective cohort design and included a sample of older adults enrolled in Pennsylvania's Pharmaceutical Assistance Contract for the Elderly program who did not use prescription opioids in 2013. Using pharmacy claims, patients who used anxiolytics/sedatives/hypnotics (n = 13,512) or antidepressants (n = 17,492) between October and December 2013 were identified and compared with those who did not use anxiolytics/sedatives/hypnotics (n = 114,091) or antidepressants (n = 110,111) during that period, to determine the incidence of prescription opioid use in 2014. Chi-square tests and multivariate logistic regressions were performed for analyses. Compared with patients who did not use anxiolytics/sedatives/hypnotics, those who used were more likely to initiate prescription opioids (15.0% versus 22.0%, P < .0001). Similarly, compared with patients who did not use antidepressants, those who used were more likely to initiate prescription opioids (14.7% versus 21.9%, P < .0001). Multivariate logistic regression indicated that the odds of prescription opioid initiation increased with anxiolytic/sedative/hypnotic use by 44% (AOR = 1.44; P < .0001) and antidepressant use by 48% (AOR = 1.48; P < .0001) among older adults after adjusting for potential confounding variables. Results showed that prescription opioid initiation is associated with prior anxiolytic/sedative/hypnotic or antidepressant use among older adults. Patients with mental health problems should also be queried about pain experiences for effective treatment.

The Relationship between Higher Chronic Opioid Therapy Dose and Specific Personality Traits in Individuals with Chronic Pain

Objective

To evaluate the relationship between opioid use and specific personality traits among individuals with chronic pain stratified by morphine equivalent doses (MEQ).

Design

Observational cohort study. Setting. Chronic pain outpatient clinic in Canada (2017-2019). Patients. Participants were included if they (1) were at least 18 years old, (2) had been diagnosed with chronic pain (pain >3 months), and (3) were able to read and write in English. Interventions. None. Main Outcome Measures. Completion of the following outcome measures: Acceptance and Action Questionnaire, Anxiety Sensitivity Index, Brief-Coping with Problems Experience 28-item, Brief Pain Inventory Short Form, CAGE-AID substance misuse screening tool, EuroQol-5D, Generalized Anxiety Disorder 7-item, and Patient Health Questionnaire 9-item. One-way analysis of variance compared outcomes between MEQ groups.

Results

215 individuals (64.2% female) were included with a mean age of 52.7 ± 11.7 years and time since pain onset of 14.1 ± 10.2 years (range 1-45). There were no significant differences between MEQ groups with respect to sociodemographic and clinical health variables except for gender and employment status and time since pain onset. After controlling for gender, time since pain onset, and average pain severity, patients with MEQ 90+ mg had significantly higher scores for experiential avoidance and anxiety sensitivity in addition to increased pain interference, greater depressive and anxiety symptoms, more dysfunctional coping, and poorer QoL than those with MEQ 1-89 mg or MEQ 0 mg.

Conclusions

Compared to individuals using no or lower-dose opioids to treat chronic pain, those using high-dose opioids had higher scores on two maladaptive personality traits (i.e., anxiety sensitivity and experiential avoidance) which was associated with poorer mood, greater pain interference, lower quality of life, and dysfunctional coping. These maladaptive personality traits may help to explain how individuals with chronic pain utilize higher doses of opioid analgesics.

Gaps in evidence for the use of medically authorized cannabis: Ontario and Alberta, Canada

BACKGROUND

With legal access to medical cannabis in Canada since 2001, there is a need to fully characterize its use at both the individual and population levels. We draw on data from Canada's largest cohort study of medical cannabis to identify the primary reasons for medical cannabis authorization in Canada from 2014 to 2019 in two major provinces: Alberta (AB) and Ontario (ON), and review the extent that evidence supports each indication.

METHODS

Self-reported baseline assessments were collected from adult patients in ON (n = 61,835) and AB (n = 3410) who were authorized medical cannabis. At baseline, sociodemographic, primary medical information, and validated clinical questionnaires were completed by patients as part of an individual assessment. Patients' reasons for seeking medical cannabis were compared to published reviews and guidelines to assess the level of evidence supporting medical cannabis use for each condition.

RESULTS

Medical cannabis use in both AB and ON was similar in both demographic and reason for authorization. The most common reasons for medical cannabis authorization were: (1) pain (AB = 77%, ON = 76%) primarily due to chronic musculoskeletal, arthritic, and neuropathic pain, (2) mental health concerns (AB = 32.9%, ON = 38.7%) due to anxiety and depression, and (3) sleep problems (AB = 28%, ON = 25%). More than 50 other conditions were identified as reasons for obtaining authorization.

CONCLUSION

In both AB and ON, the majority of reasons for medical cannabis authorization are not substantiated by clinical evidence to fully support its efficacy for long-term use. Ongoing epidemiological studies on medical cannabis on these treatments are warranted to fully outline its treatment benefits or risks.

The phenomics and genetics of addictive and affective comorbidity in opioid use disorder

Opioid use disorder (OUD) creates significant public health and economic burdens worldwide. Therefore, understanding the risk factors that lead to the development of OUD is fundamental to reducing both its prevalence and its impact. Significant sources of OUD risk include co-occurring lifetime and current diagnoses of both psychiatric disorders, primarily mood disorders, and other substance use disorders, and unique and shared genetic factors. Although there appears to be pleiotropy between OUD and both mood and substance use disorders, this aspect of OUD risk is poorly understood. In this review, we describe the prevalence and clinical significance of addictive and affective comorbidities as risk factors for OUD development as a basis for rational opioid prescribing and OUD treatment and to improve efforts to prevent the disorder. We also review the genetic variants that have been associated with OUD and other addictive and affective disorders to highlight targets for future study and risk assessment protocols.

Pain Acceptance Creates an Emotional Context That Protects against the Misuse of Prescription Opioids: A Study in a Sample of Patients with Chronic Noncancer Pain

There is solid evidence of an association between several psychological flexibility processes, particularly pain acceptance, and adaptation to chronic pain. However, there are relatively few studies on the relationship between pain acceptance and opioid misuse in chronic pain patients. Thus, the aim of the present study was to test a hypothetical model in which pain acceptance would regulate pain sensations and pain-related thoughts and emotions, which would be related to opioid misuse. The sample comprised 140 chronic pain patients attending two hospitals. All patients were receiving pharmacological treatment, including opioid analgesics. Structural equation modelling analyses showed a significant association between higher pain acceptance and lower pain intensity and catastrophizing, and lower levels of anxiety and depression. Only higher anxiety and depression were significantly associated with increased opioid misuse. The results suggest that levels of anxiety, depression, and pain acceptance must be assessed before opioids are prescribed. Pain acceptance implies a relationship with internal events that protects against anxiety and depression and thus against opioid misuse. Acceptance and Commitment Therapy appears to be particularly appropriate for these patients.

Is the rise in illicit opioids affecting labor supply and disability claiming rates?

This paper examines how the recent transition of the opioid crisis from prescription opioids to more prevalent misuse of illicit opioids, such as heroin and fentanyl, altered labor supply behavior and disability insurance claiming rates. We exploit differential geographic exposure to the reformulation of OxyContin, the largest reduction in access to abusable prescription opioids to date, to study the effects of substitution to illicit markets. We observe meaningful reductions in labor supply measured in terms of employment-to-population ratios, hours worked, and earnings in states more exposed to reformulation relative to those less exposed. We also find evidence of increases in disability applications and beneficiaries.

Prevalence of Problematic Use of Opioids in Patients with Chronic Noncancer Pain: A Systematic Review with Meta-analysis

BACKGROUND AND OBJECTIVE

Opioid prescription for chronic noncancer pain is associated with problematic use. We aimed to review and summarize the evidence on the prevalence of problematic use of opioids in adults with chronic noncancer pain and investigate whether the prevalence rates were changing over time.

DATABASES AND DATA TREATMENT

A systematic review of the literature was undertaken following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. We systematically searched the literature in the electronic databases MEDLINE, SCOPUS, and Web of Science and studies with adult participants with chronic noncancer pain using opioids with indication of one or more of the following terms about problematic opioid use: abuse, misuse, addiction, dependence, problematic use, and aberrant behavior/use were eligible for data extraction. Meta-analysis was performed to estimate the pooled prevalence rates using a random-effects model, and subanalysis was conducted.

RESULTS

Our search identified a total of 784 potentially relevant studies. After a thorough evaluation, 19 papers, mostly from the United States, were included in our qualitative and quantitative synthesis. The majority of the data came from speciality pain clinics. The estimated prevalence of problematic use of opioids in adults with chronic noncancer pain was 36.3% (95% confidence interval: 27.4 to 45.2%; I²  = 99.64%). Problematic opioid use was mostly identified using the questionnaire method. Thirteen studies (68%) presented a low risk of bias.

CONCLUSIONS

Our study presents an alarming estimate regarding the prevalence of problematic use of opioids among patients with noncancer pain. These results deserve special attention from health care professionals and health authorities.

Lack of Premeditation Predicts Aberrant Behaviors Related to Prescription Opioids in Patients with Chronic Pain: A Cross-Sectional Study

OBJECTIVE

In light of the opioid epidemic, there is a need to identify factors that predict aberrant opioid behaviors including misuse and abuse. Impulsivity has been extensively studied in addiction literature, but not in the context of opioid misuse. Hence, this study aimed to identify which of the impulsivity facets (negative urgency, positive urgency, sensation seeking, lack of perseverance, and lack of premeditation) would predict current aberrant opioid-related behaviors in patients with chronic pain.

METHODS

Data were collected through an online survey from patients with chronic pain who visited a tertiary pain clinic. Patients were predominately female (74%), middle aged (M = 55 years), and White/Caucasian (84%). Upon consent, they completed a series of surveys including UPPS-P Impulsive Behavior Scale, the Current Opioid misuse Measure, Pain Catastrophizing Scale, PROMIS-anxiety, depression, and physical function, and a 0-10 numerical pain rating scale. Ordinal regression analyses were conducted to test study hypotheses.

RESULTS

Contrary to expectations, only lack of premeditation predicted higher odds of aberrant opioid-related behaviors in the past 30 days, after controlling for known covariates, and explained 26% of variance. Interestingly, lack of premeditation together with pain catastrophizing as a covariate explained 56% of the variance in aberrant opioid-related behaviors.

DISCUSSION

The current study is the first to identify a potential role of lack of premeditation as an impulsivity facet predicting aberrant opioid-related behaviors among patients with chronic pain.

Opioid Pain Medication Prescription for Chronic Pain in Primary Care Centers: The Roles of Pain Acceptance, Pain Intensity, Depressive Symptoms, Pain Catastrophizing, Sex, and Age

Background: Psychological factors of patients may influence physicians’ decisions on prescribing opioid analgesics. However, few studies have sought to identify these factors. The present study had a double objective: (1) To identify the individual factors that differentiate patients who had been prescribed opioids for the management of chronic back pain from those who had not been prescribed opioids and (2) to determine which factors make significant and independent contributions to the prediction of opioid prescribing. Methods: A total of 675 patients from four primary care centers were included in the sample. Variables included sex, age, pain intensity, depressive symptoms, pain catastrophizing, and pain acceptance. Results: Although no differences were found between men and women, participants with chronic noncancer pain who were prescribed opioids were older, reported higher levels of pain intensity and depressive symptoms, and reported lower levels of pain-acceptance. An independent association was found between pain intensity and depressive symptoms and opioid prescribing. Conclusions: The findings suggest that patient factors influence physicians’ decisions on prescribing opioids. It may be useful for primary care physicians to be aware of the potential of these factors to bias their treatment decisions.

Depression level, not pain severity, is associated with smoked medical marijuana dosage among chronic pain patients

BACKGROUND

The use of medical marijuana (MM) for the treatment of chronic pain is rapidly growing in the United States and Europe; however there is concern regarding the specificity of its therapeutic effects and the motivation underlying its use. While research indicates that among chronic pain prescribed opioids, depression has been associated with increased opioid dosage (regardless of pain levels), the extent to which depression and pain each contribute to MM dose among chronic pain patients is yet unknown.

METHODS

This cross-sectional study included 209 chronic pain patients prescribed smoked MM, in flower or other plant form, with no concurrent opioid treatment. Ordinal regression analyses were performed in order to explore the unique contribution of mean pain level (1-10 scale), depression severity (measured by the Patient Health Questionnaire (PHQ-9)) and anxiety severity (measured by the Generalized Anxiety Disorder scale (GAD-7)) to doses of MM, while taking into account additional sociodemographic and clinical factors.

RESULTS

Individuals with mild depression and those with moderate to severe depression were at significantly increased odds for using higher doses of MM in grams per month(Adjusted Odds Ratio(AOR) = 2.06,95% Confidence Interval(CI) = 1.05-4.01, and AOR = 5.95,95% CI = 1.97-17.98, respectively) compared to those without depression. In addition, individuals with mild depression were at significantly increased odds for smoking more MM joints daily(AOR = 2.07, 95% CI = 1.01-4.23) compared to individuals without depression. Mean levels of pain or anxiety severity were not significantly associated with either dose measures.

CONCLUSIONS

Depression and MM dose are highly correlated and should be concurrently addressed during chronic pain treatment.

The Nucleus Accumbens: A Common Target in the Comorbidity of Depression and Addiction

The comorbidity of depression and addiction has become a serious public health issue, and the relationship between these two disorders and their potential mechanisms has attracted extensive attention. Numerous studies have suggested that depression and addiction share common mechanisms and anatomical pathways. The nucleus accumbens (NAc) has long been considered a key brain region for regulating many behaviors, especially those related to depression and addiction. In this review article, we focus on the association between addiction and depression, highlighting the potential mediating role of the NAc in this comorbidity via the regulation of changes in the neural circuits and molecular signaling. To clarify the mechanisms underlying this association, we summarize evidence from overlapping reward neurocircuitry, the resemblance of cellular and molecular mechanisms, and common treatments. Understanding the interplay between these disorders should help guide clinical comorbidity prevention and the search for a new target for comorbidity treatment.

Effect of Acupuncture on Chronic Pain with Depression: A Systematic Review

Background

Numerous studies suggested that chronic pain and depression were closely related and widespread in the population. When patients have symptoms of chronic pain and depression, the corresponding treatment will become difficult. Acupuncture, a unique therapeutic method of traditional Chinese medicine, has been reported to potentially serve as an alternative treatment for patients with comorbid chronic pain and depression by many research studies.

Methods

A comprehensive search was conducted through the online database, including the Cochrane Library, PubMed, EMBASE, SinoMed, CNKI, and Wanfang database. Trials were RCTs published in the English or Chinese language, recruiting participants with chronic pain and depression comorbidity. The primary outcomes were the Visual Analogue Scale (VAS) and Hamilton Depression Scale (HAMD). Statistical analyses were conducted using Review Manager 5.3. Each trail was quality appraised with the five-point Jadad Score.

Results

7 eligible RCTs involving 535 patients were included. Better therapeutic effect and safety could be observed in the experimental group compared with the control group. There was a significant decrease in the VAS (mean difference (MD) = −0.68 (−1.24, −0.12), P=0.02) and HAMD (MD = −2.18 (−3.09, −1.26), P < 0.00001) scores and the incidence of adverse events between two groups.

Conclusion

In the treatment of chronic pain with depression, acupuncture could not only get better clinical efficacy, but also have higher security compared with medicine therapy, which can be used in patients with poorer response to the conventional medication or suffering from serious side effects.

Changes in patient health questionnaire (PHQ-9) scores in adults with medical authorization for cannabis

Background

Legal access to medical cannabis is increasing world-wide. Despite this, there is a lack of evidence surrounding its efficacy on mental health outcomes, particularly, on depression. This study assesses the effect of medical cannabis on Patient Health Questionnaire (PHQ-9) scores in adult patients between 2014 and 2019 in Ontario and Alberta, Canada.

Methods

An observational cohort study of medically authorized cannabis patients in Ontario and Alberta. Overall change in PHQ-9 scores from baseline to follow-up were evaluated (mean change) over a time period of up to 3.2 years.

Results

37,338 patients from the cohort had an initial PHQ-9 score recorded with 5103 (13.7%) patients having follow-up PHQ-9 scores. The average age was 54 yrs. (SD 15.7), 46% male, 50% noted depression at baseline. The average PHQ-9 score at baseline was 10.5 (SD 6.9), following a median follow-up time of 196 days (IQR: 77–451) the average final PHQ-9 score was 10.3 (SD 6.8) with a mean change of − 0.20 (95% CI: − 0.26, − 0.14, p-value < 0.0001). Overall, 4855 (95.1%) had no clinically significant change in their PHQ-9 score following medical cannabis use while 172 (3.4%) reported improvement and 76 (1.5%) reported worsening of their depression symptoms.

Conclusions

Although the majority showed no clinically important changes in PHQ-9 scores, a number of patients showed improvement or deteriorations in PHQ-9 scores. Future studies should focus on the parallel use of screening questionnaires to control for PHQ-9 sensitivity and to explore potential factors that may have attributed to the improvement in scores pre- and post- 3-6 month time period.

Optimal Pain Control after Outpatient Surgery for Cutaneous Malignancies

Postoperative pain managed with opioids has contributed to the opioid crisis through over-prescribing practices. We assessed opioid-prescribing habits and their use by patients undergoing surgery for cutaneous malignancies. An Institutional Review Board–approved retrospective analysis was conducted for patients who underwent skin cancer resection between January 2018 and June 2018. Data were collected from the electronic medical record, and opioid-related data were collected from patient interviews and state registries. There were 120 study participants (42 females and 78 males) with a median age of 67 years (range, 21–94 years). All received preincision local anesthetic: 64 had liposomal bupivacaine (LB) (53%) and 56 had non-LB bupivacaine (47%). Most participants (n = 88) used 0 opioids (73%), including 43 LB-anesthetic (67%) and 45 non–LB-anesthetic (80%). No significance was seen between those with a diagnosis of chronic pain, narcotic tolerance, an area of resection, and nodal sampling groups in opioid use. Four patients (3%) requested a refill. Of 105 prescriptions written for opioids, 99 had leftover opioids for an over-prescribing rate of 94 per cent. This study suggests pain after skin cancer surgery is manageable with very limited opioid requirements. Our results support prescribing no more than five opioid tablets for postoperative pain control in patients undergoing resection for skin malignancies.

Association between psychotropic drug use and prescription opioid use among older adults

This study investigated the association between psychotropic drug use and prescription opioid use/high dosage opioid use among older adults. A sample of 203,750 older adults enrolled in Pennsylvania's Pharmaceutical Assistance Contract for the Elderly (PACE) program during 2017 was evaluated for prescription opioid and psychotropic drug usage. High dosage opioid use was defined as using >90 morphine milligram equivalents (MME)/day for ≥90 consecutive days. Overall, 20.7% of enrollees filled opioid prescriptions, of which 1.4% used them at high dosages. Multivariate logistic regression indicated that the odds of prescription opioid use increased with anxiolytic/sedative/hypnotic use and antidepressant use. Moreover, high dosage opioid use was significantly associated with anxiolytic/sedative/hypnotic use, antidepressant use and other factors including being younger, male, white, and married but living separately, and having multiple opioid prescribers. Clinicians should carefully evaluate opioid use among older patients using anxiolytics or antidepressants to minimize risks for adverse consequences of opioids.

Negative Affect-Related Factors Have the Strongest Association with Prescription Opioid Misuse in a Cross-Sectional Cohort of Patients with Chronic Pain

OBJECTIVE

Increased opioid prescription to relieve pain among patients with chronic pain is associated with increased risk for misuse, potentially leading to substance use disorders and overdose death. We aimed to characterize the relative importance and identify the most significant of several potential risk factors for the severity of self-reported prescribed opioid misuse behaviors.

METHODS

A sample of 1,193 patients (mean age ± SD = 50.72 ± 14.97 years, 64.04% female) with various chronic pain conditions completed a multidimensional registry assessing four pain severity measures and 14 physical, mental, and social health status factors using the National Institutes of Health's Patient-Reported Outcomes Measurement Information System (PROMIS). A validated PROMIS measure of medication misuse was completed by 692 patients who endorsed currently taking opioid medication. Patients taking opioid medications were compared across all measures with those who do not take opioid medications. Subsequently, a data-driven regression analysis was used to determine which measures best explained variability in severity of misuse. We hypothesized that negative affect-related factors, namely anxiety, anger, and/or depression, would be key predictors of misuse severity due to their crucial role in chronic pain and substance use disorders.

RESULTS

Patients taking opioid medications had significantly greater impairment across most measures. Above and beyond demographic variables, the only and most significant predictors of prescribed opioid misuse severity were as follows: anxiety (β = 0.15, P = 0.01), anger (β = 0.13, P = 0.02), Pain Intensity-worst (β = 0.09, P = 0.02), and depression (β = 0.13, P = 0.04).

CONCLUSIONS

Findings suggest that anxiety, anger, and depression are key factors associated with prescribed opioid misuse tendencies in patients with chronic pain and that they are potential targets for therapeutic intervention.

Association between severity of depressive symptoms and chronic knee pain in Korean adults aged over 50 years: a cross-sectional study using nationally representative data

OBJECTIVES

To identify the association between the presence and severity of depressive symptoms and those of chronic knee pain.

DESIGN

A retrospective cross-sectional study.

PARTICIPANTS

We used data from the sixth Korea National Health and Nutrition Examination Survey (KNHANES VI-2) performed in 2014. Overall, 7550 patients were included in the KNHANES VI-2.

OUTCOME MEASURES

Participants were asked whether they had chronic knee pain, and each answer was either 'yes' or 'no'. Patient Health Questionnaire-9 (PHQ-9) was used as a screening tool for depressive symptoms, and PHQ-9 scores of 10 or higher was classified as the depressed group. In total, 527 patients reported that they had pain in their knee, of whom 91 also had depressive symptoms.

RESULTS

The prevalence of chronic knee pain in the Korean population aged over 50 years was 19.8%. Multiple logistic regression was conducted after adjustment for sex, age, smoking, alcohol drinking, education level, household income, physical activity, sleep duration and comorbidity. The analysis revealed a significant association between depressive symptoms and chronic knee pain (adjusted OR=2.333, p<0.001). In contrast, the severity of depressive symptoms was linearly correlated with the intensity of chronic knee pain (p for trend <0.001). In participants with no chronic knee pain (Numerical Rating Scale; NRS=0) or mild chronic knee pain (NRS=1-4), the prevalence of moderate and severe depressive symptoms was 3.4% and 0.6%, respectively. However, in those with severe chronic knee pain (NRS=8-10), there was a higher prevalence of moderate and severe depressive symptoms (10.1% and 5.8%, respectively) (p<0.001).

CONCLUSIONS

A strong association was observed between the presence and severity of depressive symptoms and the presence of chronic knee pain. The association became stronger with higher levels of depressive symptoms, indicating a positive correlation between depressive symptoms severity and chronic knee pain.

Examining the association between bullying victimization and prescription drug misuse among adolescents in the United States

BACKGROUND

Although studies have examined the association between bullying victimization and adolescent substance behaviors, there is a dearth of research investigating the association between bullying victimization and prescription drug misuse. The objective of this study was to examine the cross-sectional association between bullying victimization and prescription drug misuse among adolescents.

METHODS

Data for this study came from the 2017 Youth Risk Behavior Survey. A sample of 9974 adolescents aged 14-18 years (50.1% female) were analyzed using binary logistic regression with prescription drug misuse as the outcome variable and bullying victimization as the main explanatory variable.

RESULTS

Of the 9,974 adolescents, 13.1% misused prescription drugs. One in ten adolescents were victims of both school bullying and cyberbullying, 5.1% were victims of only cyberbullying, 9% were victims of only school bullying, and 75.8% experienced neither school bullying nor cyberbullying victimization. In the binary logistic regression model, adolescents who experienced both school bullying and cyberbullying victimization had 1.66 times higher odds of misusing prescription drugs (AOR = 1.66, p < .001, 95% CI = 1.34-2.06) and adolescents who experienced only school bullying victimization had 1.30 times higher odds of misusing prescription drugs (AOR = 1.30, p < .05, 95% CI = 1.02-1.64). Being lesbian, gay, or bisexual; feeling sad or hopeless; cigarette smoking; binge drinking; cannabis use; and illicit drug use were statistically significantly associated with prescription drug misuse.

CONCLUSIONS

Understanding the association between bullying victimization and prescription drug misuse could contribute to early identification of adolescents who may misuse prescription drugs.

Observational retrospective study of the association of initial healthcare provider for new-onset low back pain with early and long-term opioid use

OBJECTIVE

This study examined the association of initial provider treatment with early and long-term opioid use in a national sample of patients with new-onset low back pain (LBP).

DESIGN

A retrospective cohort study of patients with new-onset LBP from 2008 to 2013.

SETTING

The study evaluated outpatient and inpatient claims from patient visits, pharmacy claims and inpatient and outpatient procedures with initial providers seen for new-onset LBP.

PARTICIPANTS

216 504 individuals aged 18 years or older across the USA who were diagnosed with new-onset LBP and were opioid-naïve were included. Participants had commercial or Medicare Advantage insurance.

EXPOSURES

The primary independent variable is type of initial healthcare provider including physicians and conservative therapists (physical therapists, chiropractors, acupuncturists).

MAIN OUTCOME MEASURES

Short-term opioid use (within 30 days of the index visit) following new LBP visit and long-term opioid use (starting within 60 days of the index date and either 120 or more days' supply of opioids over 12 months, or 90 days or more supply of opioids and 10 or more opioid prescriptions over 12 months).

RESULTS

Short-term use of opioids was 22%. Patients who received initial treatment from chiropractors or physical therapists had decreased odds of short-term and long-term opioid use compared with those who received initial treatment from primary care physicians (PCPs) (adjusted OR (AOR) (95% CI) 0.10 (0.09 to 0.10) and 0.15 (0.13 to 0.17), respectively). Compared with PCP visits, initial chiropractic and physical therapy also were associated with decreased odds of long-term opioid use in a propensity score matched sample (AOR (95% CI) 0.21 (0.16 to 0.27) and 0.29 (0.12 to 0.69), respectively).

CONCLUSIONS

Initial visits to chiropractors or physical therapists is associated with substantially decreased early and long-term use of opioids. Incentivising use of conservative therapists may be a strategy to reduce risks of early and long-term opioid use.

Iatrogenic opioid use disorder, chronic pain and psychiatric comorbidity: A systematic review

OBJECTIVE

A systematic review of the literature on the risks of developing iatrogenic opioid use disorders in chronic pain patients with psychiatric comorbidity.

METHODS

We conducted literature searches on Pubmed with key subjects: "chronic pain", "psychiatry", "opioids" and "opioid use disorder" and for original, English written articles published from 2000 until the first of September 2017. Final selection of the articles for review was made in a consensus between three reviewers.

RESULTS

Longitudinal studies showed a significant association between psychiatric comorbidity, especially depression and anxiety disorders and the development of problematic opioid use, more severe opioid craving and poor opioid treatment outcome (analgesia and side effects) in chronic pain patients. Cross-sectional studies showed a similar association between psychiatric disorders and problematic opioid use, where studies in specialized pain settings showed a higher prevalence of psychiatric disorders, compared to non-specialized settings.

CONCLUSIONS

This systematic review showed a significant association between psychiatric comorbidity, especially depression and anxiety disorders and the development of problematic opioid use in chronic pain patients. We therefore recommend psychiatric screening in chronic pain management. Chronic pain patients with comorbid psychiatric disorders need a multidisciplinary approach and monitoring opioid use is warranted in these patients.

Members of the same pharmacological family are not alike: Different opioids, different consequences, hope for the opioid crisis?

Pain management is the specialized medical practice of modulating pain perception and thus easing the suffering and improving the life quality of individuals suffering from painful conditions. Since this requires the modulation of the activity of endogenous systems involved in pain perception, and given the large role that the opioidergic system plays in pain perception, opioids are currently the most effective pain treatment available and are likely to remain relevant for the foreseeable future. This contributes to the rise in opioid use, misuse, and overdose death, which is currently characterized by public health officials in the United States as an epidemic. Historically, the majority of preclinical rodent studies were focused on morphine. This has resulted in our understanding of opioids in general being highly biased by our knowledge of morphine specifically. However, recent in vitro studies suggest that direct extrapolation of research findings from morphine to other opioids is likely to be flawed. Notably, these studies suggest that different opioid analgesics (opioid agonists) engage different downstream signaling effects within the cell, despite binding to and activating the same receptors. This recognition implies that, in contrast to the historical status quo, different opioids cannot be made equivalent by merely dose adjustment. Notably, even at equianalgesic doses, different opioids could result in different beneficial and risk outcomes. In order to foster further translational research regarding drug-specific differences among opioids, here we review basic research elucidating differences among opioids in pharmacokinetics, pharmacodynamics, their capacity for second messenger pathway activation, and their interactions with the immune system and the dopamine D2 receptors.

Mechanisms and Clinical Features of Co-occurring Opioid and Nicotine Use

Purpose of review

To review the literature addressing shared pathophysiological and clinical features of opioid and nicotine use to inform etiology and treatment, and highlight areas for future research.

Recent findings

Opioid and nicotine use co-occur at an alarmingly high rate, and this may be driven in part by interactions between the opioid and cholinergic systems underlying drug reward and the transition to dependence. Pain, among other shared risk factors, is strongly implicated in both opioid and nicotine use and appears to play an important role in their co-occurrence. Additionally, there are important sex/gender considerations that require further study. Regarding treatment, smoking cessation can improve treatment outcomes in opioid use disorder, and pharmacological approaches that target the opioid and cholinergic systems may be effective for treating both classes of substance use disorders.

Summary

Understanding overlapping etiological and pathophysiological mechanisms of opioid and nicotine use can aid in understanding their co-occurrence and guiding their treatment.