Prevalence of Substance Use and Psychiatric Disorders in a Highly Select Chronic Pain Population

Plasma Lysophosphatidic Acid Concentrations in Sex Differences and Psychiatric Comorbidity in Patients with Cocaine Use Disorder

We have recently reported sex differences in the plasma concentrations of lysophosphatidic acid (LPA) and alterations in LPA species in patients with alcohol and cocaine use disorders. Preclinical evidence suggests a main role of lysophosphatidic acid (LPA) signaling in anxiogenic responses and drug addiction. To further explore the potential role of the LPA signaling system in sex differences and psychiatric comorbidity in cocaine use disorder (CUD), we conducted a cross-sectional study with 88 patients diagnosed with CUD in outpatient treatment and 60 healthy controls. Plasma concentrations of total LPA and LPA species (16:0, 18:0, 18:1, 18:2 and 20:4) were quantified and correlated with cortisol and tryptophan metabolites [tryptophan (TRP), serotonin (5-HT), kynurenine (KYN), quinolinic acid (QUIN) and kynurenic acid (KYNA)]. We found sexual dimorphism for the total LPA and most LPA species in the control and CUD groups. The total LPA and LPA species were not altered in CUD patients compared to the controls. There was a significant correlation between 18:2 LPA and age at CUD diagnosis (years) in the total sample, but total LPA, 16:0 LPA and 18:2 LPA correlated with age at onset of CUD in male patients. Women with CUD had more comorbid anxiety and eating disorders, whereas men had more cannabis use disorders. Total LPA, 18:0 LPA and 20:4 LPA were significantly decreased in CUD patients with anxiety disorders. Both 20:4 LPA and total LPA were significantly higher in women without anxiety disorders compared to men with and without anxiety disorders. Total LPA and 16:0 LPA were significantly decreased in CUD patients with childhood ADHD. Both 18:1 LPA and 20:4 LPA were significantly augmented in CUD patients with personality disorders. KYNA significantly correlated with total LPA, 16:0 LPA and 18:2 LPA species, while TRP correlated with the 18:1 LPA species. Our results demonstrate that LPA signaling is affected by sex and psychiatric comorbidity in CUD patients, playing an essential role in mediating their anxiety symptoms.

Tramadol and Codeine Stacking/Boosting Dose Exposure Induced Neurotoxic Behaviors, Oxidative Stress, Mitochondrial Dysfunction, and Neurotoxic Genes in Adolescent Mice

In spite of the increasing epidemic of pharmaceutical opioids (codeine and tramadol) misuse and abuse among the adolescents, little is known about the neurotoxic consequences of the widespread practice of tramadol and codeine abuse involving increasing multiple doses across days, referred to as stacking and boosting. Hence, in this study, we replicated stacking and boosting doses of tramadol, codeine alone, or in combination on spontaneous motor activity and cognitive function in adolescent mice and adduced a plausible mechanism of possible neurotoxicity. Ninety-six adolescent mice were randomly distributed into 4 groups (n = 24 per group) and treated thrice daily for 9 days with vehicle, tramadol (20, 40, or 80 mg/kg), codeine (40, 80, or 160 mg/kg), or their combinations. Exposure of mice to tramadol induced hyperactivity and stereotypic behavior while codeine exposure caused hypoactivity and nootropic effect but tramadol-codeine cocktail led to marked reduction in spontaneous motor activity and cognitive function. In addition, tramadol, codeine, and their cocktail caused marked induction of nitroso-oxidative stress and inhibition of mitochondrial complex I activity in the prefrontal cortex (PFC) and midbrain (MB). Real-time PCR expression profiling of genes encoding neurotoxicity (RT) showed that tramadol exposure upregulate 57 and downregulate 16 neurotoxic genes, codeine upregulate 45 and downregulate 25 neurotoxic genes while tramadol-codeine cocktail upregulate 52 and downregulate 20 neurotoxic genes in the PFC. Findings from this study demonstrate that the exposure of adolescents mice to multiple and increasing doses of tramadol, codeine, or their cocktail lead to spontaneous motor coordination deficits indicative of neurotoxicity through induction of oxidative stress, inhibition of mitochondrial complex I activity and upregulation of neurotoxicity encoding genes in mice.

Hip Fracture Risk After Treatment with Tramadol or Codeine: An Observational Study

INTRODUCTION

Hip fractures among older people are a major public health issue, which can impact quality of life and increase mortality within the year after they occur. A recent observational study found an increased risk of hip fracture in subjects who were new users of tramadol compared with codeine. These drugs have somewhat different indications. Tramadol is indicated for moderate to severe pain and can be used for an extended period; codeine is indicated for mild to moderate pain and cough suppression.

OBJECTIVE

In this observational study, we compared the risk of hip fracture in new users of tramadol or codeine, using multiple databases and analytical methods.

METHODS

Using data from the Clinical Practice Research Datalink and three US claims databases, we compared the risk of hip fracture after exposure to tramadol or codeine in subjects aged 50-89 years. To ensure comparability, large-scale propensity scores were used to adjust for confounding.

RESULTS

We observed a calibrated hazard ratio of 1.10 (95% calibrated confidence interval 0.99-1.21) in the Clinical Practice Research Datalink database, and a pooled estimate across the US databases yielded a calibrated hazard ratio of 1.06 (95% calibrated confidence interval 0.97-1.16).

CONCLUSIONS

Our results did not demonstrate a statistically significant difference between subjects treated for pain with tramadol compared with codeine for the outcome of hip fracture risk.

Design of CLARO (Collaboration Leading to Addiction Treatment and Recovery from other Stresses): A randomized trial of collaborative care for opioid use disorder and co-occurring depression and/or posttraumatic stress disorder

INTRODUCTION

Opioid use disorder (OUD) co-occurring with depression and/or posttraumatic stress disorder (PTSD) is common and, if untreated, may lead to devastating consequences. Despite the availability of evidence-based treatments for these disorders, receipt of treatment is low. Even when treatment is provided, quality is variable. Primary care is an important and underutilized setting for treating co-occurring disorders (COD) because OUD, depression and PTSD are frequently co-morbid with medical conditions and most people visit a primary care provider at least once a year. With rising rates of OUD and opioid-related fatalities, this is a critical treatment and quality gap in a vulnerable and stigmatized population.

METHODS

CLARO (Collaboration Leading to Addiction Treatment and Recovery from Other Stresses) is a multi-site, randomized pragmatic trial of collaborative care (CC) for co-occurring disorders in 13 rural and urban primary care clinics in New Mexico to improve care for patients with OUD and co-occurring depression and/or PTSD. CC, a service delivery approach that uses multi-faceted interventions, has not been tested with COD. We will enroll and randomize 900 patients to either CC adapted for COD (CC-COD) or enhanced usual care (EUC) and will collect patient data at baseline, 3-, and 6-month follow-up. Our primary outcomes are medications for OUD (MOUD) access, MOUD continuity of care, depression symptoms, and PTSD symptoms.

DISCUSSION

Although CC is effective for improving outcomes in primary care among patients with mental health conditions, it has not been tested for COD. This article describes the CLARO CC-COD intervention and clinical trial.

Excessive alcohol use and drug overdose deaths, New Mexico, 2015-2016

BACKGROUND

Excessive alcohol use is an important component of a person's risk for drug overdose death. But alcohol's contribution to overdose death risk has not been well quantified. We aimed to quantify the role of excessive alcohol use, particularly as defined by a blood alcohol concentration (BAC) ≥0.08 g/dL, in drug overdose deaths in New Mexico (NM).

METHODS

The study was conducted in 2018. We abstracted death records (scene investigation, toxicology, pathology) for all drug overdose deaths in NM during 2015-2016, information on BAC, other indications of alcohol, risk factors, comorbidities, and drug type and linked this information with demographic characteristics on death certificates. A Poisson regression model was used to determine independent associations between decedents' characteristics and alcohol involvement among drug overdose decedents.

RESULTS

Approximately 18 % (n = 170) of the 946 drug overdose decedents in this study had a BAC ≥ 0.08 g/dL. After adjustment, drug overdose decedents who were American Indian/Alaska Native or had a history of alcohol use disorder were more likely to have had a BAC ≥ 0.08 g/dL at the time of death. However, decedents who had methamphetamine involved in their death or who had a history of diabetes, mental illness, or chronic pain were less likely to have a BAC ≥ 0.08 g/dL at the time of death.

CONCLUSIONS

Nearly 1 in 5 overdose decedents had a BAC ≥ 0.08 g/dL at the time of death, suggesting that evidence-based alcohol prevention strategies (e.g., increasing alcohol taxes, regulating alcohol outlet density) could reduce the risk of drug overdose death.

Opioids Use and Abuse: Prescription Practice, Attitude, and Beliefs among Doctors of Karachi

Background

Opioid analgesics, also known as narcotics, are medicinal drugs used primarily for the management of pain secondary to any type of cancer, severe injury or surgery. Due to the ease of availability, opioids are commonly abused. In 2015, reported deaths exceeded 33,000 Americans from opioid overdose. A survey in 2013 revealed nearly 1.6 million Pakistanis abusing prescription opioids for non-medical needs. Although commonly prescribed by primary care physicians, most of them are diffident to stand by all the recommended strategies to reduce the incidence of opioid abuse.

Methods

A cross-sectional study was conducted during the period of August through October 2018. A sample size of 365 was determined using a 95% confidence interval at a degree of precision of 5%. A 22-item questionnaire was given to doctors with at least two years practicing experience either from a private or a public healthcare setup. Doctors who had never prescribed opioids were excluded from the study. Out of the eligible participants, 15 refused to take part in the survey, and the co-operation rate was recorded as 95.8%. Collected data were analyzed using statistical package for social science (SPSS) version 22 for Windows. Frequencies, percentages, mean, standard deviation, and chi-square were used to explore the variables. The statistical significance level was considered at p < 0.5.

Results

Opioids were reported to be used mainly for treating acute pain (40.5%), chronic pain (24.7%) and both acute and chronic (34.8%). A minority of doctors (29%) screened their patients for opioid addiction. A significant association (p = 0.000) between the frequency of opioid prescription and prior screening for depression was determined. Surprisingly, only 23.2% clinicians frequently screened their patients for depression before prescribing opioids. The rate of counselling regarding drug tapering was found to be 71.6%. A majority, i.e., 88%, of the respondents anticipated the misuse of opioids they prescribe whereas 74% also held a belief that patients self-medicate their untreated pain. Participants reported addiction (54%) as the most common reason for abuse followed by the role of pharmaceutical companies (43%) and pharmacies (41%). About 80.2% clinicians believed that patients addicted to opioids could get well and return to their daily routine.

Conclusion

The rising opioid epidemic is a major concern for doctors prescribing opioids. Adaptation of medical school curricula and appropriate training can equip doctors for better management of patients requiring opioids. This includes the screening of patients using standard risk assessment tools for opioid abuse leading to a more controlled opioid prescription practice. Dissemination of these tools will boost doctors' confidence and may help in reducing morbidity and mortality from opioid abuse.

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.

Ten-year prevalence of mental disorders in patients presenting with chronic pain in secondary care: A register linkage cohort study

BACKGROUND

Prevalence rates of mental disorders in patients with chronic pain vary and may be overestimated when assessed by screening instruments only. Objectives were to estimate the 10-year prevalence of different mental disorders diagnosed by psychiatrists in patients with chronic pain compared with the Danish general population.

METHODS

Patients (n = 7197) consulted in the interdisciplinary Pain Clinic South at Odense University Hospital, Denmark, from 2005 to 2015 were included. Data from the Pain Clinic were linked to the Danish National Patient Register-Psychiatry and the Danish Civil Registration System. Age and gender standardized prevalence ratios (SPR) were calculated.

RESULTS

In all, 17.8% of patients with chronic pain had been diagnosed with a mental disorder. The most frequent diagnoses were adjustment disorders (subcategory of anxiety disorders) (8.9%), depression (6.1%), personality disorders (3.8%), and substance abuse disorders (3.5%). Women and men with chronic pain had higher rates of anxiety disorders (SPR 3.1; 95% CI 2.9-3.4) and depression (SPR 2.5; 95% CI 2.3-2.8), whereas men had higher rates of substance abuse disorders (SPR 1.6; 95% CI 1.3-1.9) than found for the general population.

CONCLUSIONS

Although depression and anxiety were noted more frequently among patients with chronic pain than the general population, prevalence rates were lower than previously reported. The most frequent diagnoses were adjustment disorders.

SIGNIFICANCE

Prevalence rates of anxiety and depression diagnosed by psychiatrists in patients with chronic pain were found to be lower than previous findings using screening instruments. Adjustment disorders were the most frequent disorders diagnosed, as this study is the first to investigate.

Prevalence of Posttraumatic Stress Disorder in Persons with Chronic Pain: A Meta-analysis

OBJECTIVE

To summarize evidence for the prevalence of posttraumatic stress disorder (PTSD) among persons with chronic pain (CP).

METHODS

We searched databases for studies published between January 1995 and December 2016, reporting the prevalence of PTSD in persons with CP. Two reviewers independently extracted data and assessed the risk of bias. We calculated the pooled prevalence using a random-effects model and performed subgroup analyses according to pain location, the population and assessment method.

RESULTS

Twenty-one studies were included and the PTSD prevalence varied from 0-57%, with a pooled mean prevalence of 9.7%, 95% CI (5.2-17.1). In subgroup analysis, the PTSD prevalence was 20.5%, 95% CI (9.5-39.0) among persons with chronic widespread pain, 11.2%, 95% CI (5.7-22.8) among persons with headache, and 0.3%, 95% CI (0.0-2.4) among persons with back pain. The prevalence in clinical populations was 11.7%, 95% CI (6.0-21.5) and in non-clinical populations 5.1%, 95% CI (0.01-17.2). In studies of self-reported PTSD symptoms, PTSD prevalence was 20.4%, 95% CI (10.6-35.5), and in studies where structured clinical interviews had been used to assess PTSD its prevalence was 4.5%, 95% (CI 2.1-9.3). The risk of bias was medium for most studies and the heterogeneity was high (I2 = 98.6).

CONCLUSION

PTSD is overall more prevalent in clinical cohorts of persons with CP and particularly in those with widespread pain, but may not always be more prevalent in non-clinical samples of persons with CP, compared to the general population. There is a large heterogeneity in prevalence across studies. Future research should identify sources of heterogeneity and the mechanisms underlying the comorbidity of the two conditions.

Depression in patients with chronic pain attending a specialised pain treatment centre: prevalence and impact on health care costs

This cross-sectional study aimed to determine the prevalence and impact of depression on health care costs in patients with complex chronic pain. The sample included 1204 patients attending a tertiary pain management service for people with chronic disabling pain, unresponsive to medical treatment. As part of routine care, patients completed a web-based questionnaire assessing mental and physical health, functioning, and service use in the preceding 3 months. Depression was assessed using the 9-item Patient Health Questionnaire. Self-report health care utilisation was measured across 4 domains: general practitioner contacts, contacts with secondary/tertiary care doctors, accident and emergency department visits, and days hospitalised. The participation rate was 89%. Seven hundred and thirty-two patients (60.8%; 95% CI 58.0-63.6) met criteria for probable depression, and 407 (33.8%) met the threshold for severe depression. Patients with depression were more likely to be unable to work because of ill health and reported greater work absence, greater pain-related interference with functioning, lower pain acceptance, and more generalised pain. Mean total health care costs per 3-month period were £731 (95% CI £646-£817) for patients with depression, compared with £448 (95% CI £366-£530) for patients without depression. A positive association between severe depression and total health care costs persisted after controlling for key demographic, functional, and clinical covariates using multiple linear regression models. These findings reveal the extent, severity, and impact of depression in patients with chronic pain and make evident a need for action. Effective treatment of depression may improve patient health and functioning and reduce the burden of chronic pain on health care services.

Psychological Considerations in the Assessment and Treatment of Pain in Neurorehabilitation and Psychological Factors Predictive of Therapeutic Response: Evidence and Recommendations from the Italian Consensus Conference on Pain in Neurorehabilitation

Background: In order to provide effective care to patients suffering from chronic pain secondary to neurological diseases, health professionals must appraise the role of the psychosocial factors in the genesis and maintenance of this condition whilst considering how emotions and cognitions influence the course of treatment. Furthermore, it is important not only to recognize the psychological reactions to pain that are common to the various conditions, but also to evaluate how these syndromes differ with regards to the psychological factors that may be involved. As an extensive evaluation of these factors is still lacking, the Italian Consensus Conference on Pain in Neurorehabilitation (ICCPN) aimed to collate the evidence available across these topics.

Objectives: To determine the psychological factors which are associated with or predictive of pain secondary to neurological conditions and to assess the influence of these aspects on the outcome of neurorehabilitation.

Methods: Two reviews were performed. In the first, a PUBMED search of the studies assessing the association between psychological factors and pain or the predictive value of these aspects with respect to chronic pain was conducted. The included papers were then rated with regards to their methodological quality and recommendations were made accordingly. In the second study, the same methodology was used to collect the available evidence on the predictive role of psychological factors on the therapeutic response to pain treatments in the setting of neurorehabilitation.

Results: The first literature search identified 1170 results and the final database included 189 articles. Factors such as depression, anxiety, pain catastrophizing, coping strategies, and cognitive functions were found to be associated with pain across the various conditions. However, there are differences between chronic musculoskeletal pain, migraine, neuropathy, and conditions associated with complex disability with regards to the psychological aspects that are involved. The second PUBMED search yielded 252 studies, which were all evaluated. Anxiety, depression, pain catastrophizing, coping strategies, and pain beliefs were found to be associated to different degrees with the outcomes of multidisciplinary programs, surgery, physical therapies, and psychological interventions. Finally, sense of presence was found to be related to the effectiveness of virtual reality as a distraction tool.

Conclusions: Several psychological factors are associated with pain secondary to neurological conditions and should be acknowledged and addressed in order to effectively treat this condition. These factors also predict the therapeutic response to the neurorehabilitative interventions.

A Systematic Review of Personality Disorders and Health Outcomes

Personality disorders have been associated with a wide swath of adverse health outcomes and correspondingly high costs to healthcare systems. To date, however, there has not been a systematic review of the literature on health conditions among individuals with personality disorders. The primary aim of this article is to review research documenting the associations between personality disorders and health conditions. A systematic review of the literature revealed 78 unique empirical English-language peer-reviewed articles examining the association of personality disorders and health outcomes over the past 15 years. Specifically, we reviewed research examining the association of personality disorders with sleep disturbance, obesity, pain conditions, and other chronic health conditions. In addition, we evaluated research on candidate mechanisms underlying health problems in personality disorders and potential treatments for such disorders. Results underscore numerous deleterious health outcomes associated with PD features and PD diagnoses, and suggest potential biological and behavioural factors that may account for these relations. Guidelines for future research in this area are discussed.

Pseudoaddiction: Fact or Fiction? An Investigation of the Medical Literature

Tremendous growth in opioid prescribing over two decades in the USA has correlated with proportional increases in diversion, addiction, and overdose deaths. Pseudoaddiction, a concept coined in 1989, has frequently been cited to indicate that under-treatment of pain, rather than addiction, is the more pressing and authentic clinical problem in opioid-seeking patients. This investigative review searched Medline articles containing the term "pseudoaddiction" to determine its footprint in the literature with a focus on how it has been characterized and empirically validated. By 2014, pseudoaddiction was discussed in 224 articles. Only 18 of these articles contributed to or questioned pseudoaddiction from an anecdotal or theoretical standpoint, and none empirically tested or confirmed its existence. Twelve of these articles, including all four that acknowledged pharmaceutical funding, were proponents of pseudoaddiction. These papers described pseudoaddiction as an iatrogenic disease resulting from withholding opioids for pain that can be diagnosed, prevented, and treated with more aggressive opioid treatment. In contrast, six articles, none with pharmaceutical support, questioned pseudoaddiction as a clinical construct. Empirical evidence supporting pseudoaddiction as a diagnosis distinct from addiction has not emerged. Nevertheless, the term has been accepted and proliferated in the literature as a justification for opioid therapy for non-terminal pain in patients who may appear to be addicted but should not, from the perspective of pseudoaddiction, be diagnosed with addiction. Future studies should examine whether acceptance of pseudoaddiction has complicated accurate pain assessment and treatment, and whether it has contributed to or reflected medical-cultural shifts that produced the iatrogenic opioid addiction epidemic.

Prescription opioid epidemic and infant outcomes

BACKGROUND AND OBJECTIVES

Although opioid pain relievers are commonly prescribed in pregnancy, their association with neonatal outcomes is poorly described. Our objectives were to identify neonatal complications associated with antenatal opioid pain reliever exposure and to establish predictors of neonatal abstinence syndrome (NAS).

METHODS

We used prescription and administrative data linked to vital statistics for mothers and infants enrolled in the Tennessee Medicaid program between 2009 and 2011. A random sample of NAS cases was validated by medical record review. The association of antenatal exposures with NAS was evaluated by using multivariable logistic regression, controlling for maternal and infant characteristics.

RESULTS

Of 112,029 pregnant women, 31,354 (28%) filled ≥ 1 opioid prescription. Women prescribed opioid pain relievers were more likely than those not prescribed opioids (P < .001) to have depression (5.3% vs 2.7%), anxiety disorder (4.3% vs 1.6%) and to smoke tobacco (41.8% vs 25.8%). Infants with NAS and opioid-exposed infants were more likely than unexposed infants to be born at a low birth weight (21.2% vs 11.8% vs 9.9%; P < .001). In a multivariable model, higher cumulative opioid exposure for short-acting preparations (P < .001), opioid type (P < .001), number of daily cigarettes smoked (P < .001), and selective serotonin reuptake inhibitor use (odds ratio: 2.08 [95% confidence interval: 1.67-2.60]) were associated with greater risk of developing NAS.

CONCLUSIONS

Prescription opioid use in pregnancy is common and strongly associated with neonatal complications. Antenatal cumulative prescription opioid exposure, opioid type, tobacco use, and selective serotonin reuptake inhibitor use increase the risk of NAS.