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

Age-related changes in peripheral nociceptor function

Pain and pain management in the elderly population is a significant social and medical problem. Pain sensation is a complex phenomenon that typically involves activation of peripheral pain-sensing neurons (nociceptors) which send signals to the spinal cord and brain that are interpreted as pain, an unpleasant sensory experience. In this work, young (4-5 months) and aged (26-27 months) Fischer 344 x Brown Norway (F344xBN) rats were examined for nociceptor sensitivity to activation by thermal (cold and heat) and mechanical stimulation following treatment with inflammatory mediators and activators of transient receptor potential (TRP) channels. Unlike other senses that decrease in sensitivity with age, sensitivity of hindpaw nociceptors to thermal and mechanical stimulation was not different between young and aged F344xBN rats. Intraplantar injection of bradykinin (BK) produced greater thermal and mechanical allodynia in aged versus young rats, whereas only mechanical allodynia was greater in aged rats following injection of prostaglandin E₂ (PGE₂). Intraplantar injection of TRP channel activators, capsaicin (TRPV1), mustard oil (TRPA1) and menthol (TRPM8) each resulted in greater mechanical allodynia in aged versus young rats and capsaicin-induced heat allodynia was also greater in aged rats. A treatment-induced allodynia that was greater in young rats was never observed. The anti-allodynic effects of intraplantar injection of kappa and delta opioid receptor agonists, salvinorin-A and D-Pen²,D-Pen⁵]enkephalin (DPDPE), respectively, were greater in aged than young rats, whereas mu opioid receptor agonists, [D-Ala2, N-MePhe4, Gly-ol]-enkephalin (DAMGO) and morphine, were not effective in aged rats. Consistent with these observations, in primary cultures of peripheral sensory neurons, inhibition of cAMP signaling in response to delta and kappa receptor agonists was greater in cultures derived from aged rats. By contrast, mu receptor agonists did not inhibit cAMP signaling in aged rats. Thus, age-related changes in nociceptors generally favor increased pain signaling in aged versus young rats, suggesting that changes in nociceptor sensitivity may play a role in the increased incidence of pain in the elderly population. These results also suggest that development of peripherally-restricted kappa or delta opioid receptor agonists may provide safer and effective pain relief for the elderly.

Differential patterns of opioid misuse between younger and older adults - a retrospective observational study using data from South Carolina's prescription drug monitoring program

Background: Most research on opioid misuse focuses on younger adults, yet opioid-related mortality has risen fastest among older Americans over age 55.Objectives: To assess whether there are differential patterns of opioid misuse over time between younger and older adults and whether South Carolina's mandatory Prescription Drug Monitoring Program (PDMP) affected opioid misuse differentially between the two groups.Methods: We used South Carolina's Reporting and Identification Prescription Tracking System from 2010 to 2018 to calculate an opioid misuse score for 193,073 patients (sex unknown) using days' supply, morphine milligram equivalents (MME), and the numbers of unique prescribers and dispensaries. Multivariable regression was used to assess differential opioid misuse patterns by age group over time and in response to implementation of South Carolina's mandatory PDMP in 2017.Results: We found that between 2011 and 2018, older adults received 57% (p < .01) more in total MME and 25.4 days more (p < .01) in supply, but received prescriptions from fewer doctors (-0.063 doctors, p < 01) and pharmacies (-0.11 pharmacies, p < 01) per year versus younger adults. However, older adults had lower odds of receiving a high misuse score (OR 0.88, p < .01). After the 2017 legislation, misuse scores fell among younger adults (OR 0.79, p < .01) relative to 2011, but not among older adults.Conclusion: Older adults may misuse opioids differently compared to younger adults. Assessment of policies to reduce opioid misuse should take into account subgroup differences that may be masked at the population level.

Factors associated with potentially inappropriate opioid use in community-living older adults consulting in primary care

OBJECTIVE

To study the factors associated with opioid use and potentially inappropriate opioid use (PIOU) in primary care older adults with non-cancer pain referring to the conceptual framework developed by the American Agency for Healthcare Research and Quality.

METHODS

This is a secondary analysis of health survey and medico-administrative data from Québec, Canada. Individuals aged ≥65 were recruited between 2011 and 2013 in primary care clinics to participate in face-to-face interviews. The sample included 945 older adults without a malignant tumor over the study period or any tumor in the 2 years surrounding opioid use. Opioid use within a 3 year follow-up period was identified from the public drug plan database. Potentially inappropriate opioid use (PIOU) was defined using the American Geriatrics Society Beers 2019 list. Multinomial regression analyses were performed to study the factors (patient, pain, substance use, provider, healthcare system) associated with opioid use and PIOU.

RESULTS

In this sample of older adults, 26.2% used an opioid and 18.4% were categorized as PIOU. Factors associated with PIOU compared to opioid use included female sex, higher psychological distress, number of emergency department visits, and recruitment type of healthcare practice. Factors associated with PIOU compared to no use included female sex, country of origin, presence of a trauma, physical/psychiatric multimorbidity, number of outpatient consultations, pain severity/type, and number of prescribers.

CONCLUSIONS

Mental health and health system factors were associated with PIOU. Results highlights the importance of a multidisciplinary approach for pain management, and the urgent need for implementing organizational efforts to optimize opioid use in primary care.

Recruitment and retention for chronic pain clinical trials: a narrative review

Opioid misuse is at a crisis level. In response to this epidemic, the National Institutes of Health has funded $945 million in research through the Helping to End Addiction Long-term (HEAL) Pain Management Initiative, including funding to the Vanderbilt Recruitment Innovation Center (RIC) to strategize methods to catalyze participant recruitment. The RIC, recognizing the challenges presented to clinical researchers in recruiting individuals experiencing pain, conducted a review of evidence in the literature on successful participant recruitment methods for chronic pain trials, in preparation for supporting the HEAL Pain trials. Study design as it affects recruitment was reviewed, with issues such as sufficient sample size, impact of placebo, pain symptom instability, and cohort characterization being identified as problems. Potential solutions found in the literature include targeted electronic health record phenotyping, use of alternative study designs, and greater clinician education and involvement. For retention, the literature reports successful strategies that include maintaining a supportive staff, allowing virtual study visits, and providing treatment flexibility within the trial. Community input on study design to identify potential obstacles to recruitment and retention was found to help investigators avoid pitfalls and enhance trust, especially when recruiting underrepresented minority populations. Our report concludes with a description of generalizable resources the RIC has developed or adapted to enhance recruitment and retention in the HEAL Pain studies. These resources include, among others, a Recruitment and Retention Plan Template, a Competing Trials Tool, and MyCap, a mobile research application that interfaces with Research Electronic Data Capture (REDCap).

Concurrent Use of Prescription Opioids and Gabapentinoids in Older Adults

INTRODUCTION

Concurrent use of prescription opioids with gabapentinoids may pose risks of serious drug interactions. Yet, little is known about the trends in and patient characteristics associated with concurrent opioid-gabapentinoid use among older Medicare opioid users with chronic noncancer pain.

METHODS

A cross-sectional study was conducted among Medicare older beneficiaries (aged ≥65 years) with chronic noncancer pain who filled ≥1 opioid prescription within 3 months after a randomly selected chronic noncancer pain diagnosis (index date) in a calendar year between 2011 and 2018. Patient characteristics were measured in the 6-month baseline before the index date, and concurrent opioid-gabapentinoid use for ≥1 day was measured in the 3-month follow-up after the index date. Multivariable modified Poisson regression hwas used to assess the trends and characteristics of concurrent opioid-gabapentinoid use. Analyses were conducted from January to June 2021.

RESULTS

Among 464,721 eligible older beneficiaries with chronic noncancer pain and prescription opioids, the prevalence of concurrent opioid-gabapentinoid use increased from 17.0% in 2011 to 23.5% in 2018 (adjusted prevalence ratio=1.48, 95% CI=1.45, 1.53). Concurrent users versus opioid-only users tended to be non-Black, low-income subsidy recipients, and Southern residents. The clinical factors associated with concurrent opioid-gabapentinoid use included having a diagnosis of neuropathic pain, polypharmacy, and risk factors for opioid-related adverse events.

CONCLUSIONS

Concurrent opioid-gabapentinoid use among older Medicare beneficiaries with chronic noncancer pain and prescription opioids has increased significantly between 2011 and 2018. Future studies are warranted to investigate the impact of concurrent use on outcomes in older patients. Interventions that reduce inappropriate concurrent use may target older patients with identified characteristics.

Adverse childhood events and substance use history or recent opioid use among women with chronic pelvic pain

Introduction:

We aimed describe the association of adverse childhood events (ACEs) with a history of substance use disorder and recent opioid use among women with chronic pelvic pain (CPP).

Methods:

This cohort study investigated two data sets of women presenting to subspecialty gynecologic and pelvic floor disorder clinics where questionnaires querying substance use disorder, opioid use in the last 3 months, and ACEs (BRFSS-ACE questionnaire) were obtained. We compared the recent opioid use, morphine milligram equivalents (MMEs) per dose, pills used per month, and minimum MMEs reported per month between women with high (⩾4) or low (<4) reported ACEs.

Results:

Patients completing the BRFSS-ACE ( n = 113) were older, more likely to be Hispanic/Latina, had higher levels of education, a higher prevalence of pain syndromes, and a greater degree of bother from pelvic floor disorders than those not completing the BRFSS-ACE. Women reporting a high number of (⩾4) ACEs ( n = 56) were younger, less likely to identify as Hispanic, had higher co-occurrence of fibromyalgia and IBS, and a higher prevalence of a history of substance use disorder (18% vs 2%, p < 0.01) than women with low (<4) ACEs ( n = 57). High ACEs were not significantly associated with recent opioid use (43% vs 39%, p = 0.83), opioid pills used per month, MMEs per dose, or the minimum MMEs used per month.

Conclusion:

Women with CPP reporting higher numbers of ACEs are more likely to report a history of substance use disorder but were not more likely to have used opioids in the last 3 months.

Misuse of Prescription Medications among Individuals with Mobility Disability

BACKGROUND

The ability of walking a quarter mile is predictive of subsequent disability, mortality, and health care costs. Individuals with mobility disability are at increased risk of chronic conditions and unmet care needs. Thus they may misuse prescription medications to self-medicate.

OBJECTIVES

We aimed to explore the difference of misuse of four types of prescription medications (sedatives, tranquilizers, painkillers, depression medications) and overall misuse by mobility status and identify the correlates of overall misuse.

METHODS

A national probability sample from the survey Midlife in the United States (MIDUS) was used to assess the difference in misuse by mobility status during 2011-2014. To assess the correlates of misuse, mobility status, usual source of care, unmet care needs, insurance coverage, sociodemographic variables, and clinical conditions were added to a survey weighted logistic regression model with backward selection.

RESULTS

Compared to those without mobility disability, individuals with mobility disability had higher risk of misuse in most types of medications and in overall misuse. Mobility disability, lower education, unmarried status, the emergency room or public health clinic as the most often used care, pain, and depressed affect were identified as correlates of overall misuse of studied medications.

CONCLUSIONS

Individuals with mobility disability are a vulnerable group susceptible to medication misuse, which warrants the urgent need for interventions to ameliorate misuse and reduce risks in this population.

Problematic Opioid Use Among Older Adults: Epidemiology, Adverse Outcomes and Treatment Considerations

With the aging population, an increasing number of older adults (> 65 years) will be affected by problematic opioid use and opioid use disorder (OUD), with both illicit and prescription opioids. Problematic opioid use is defined as the use of opioids resulting in social, medical or psychological consequences, whereas OUD is a form of problematic use that meets diagnostic criteria as defined by the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. Problematic use of opioids by older adults is associated with a number of pertinent adverse effects, including sedation, cognitive impairment, falls, fractures and constipation. Risk factors for problematic opioid use in this population include pain, comorbid medical illnesses, concurrent alcohol use disorder and depression. Treatment of OUD consists of acute detoxification and maintenance therapy. At this time, there have been no randomized controlled trials examining the effectiveness of pharmacological interventions for OUD in this population, with recommendations based on data from younger adults. Despite this, opioid agonist therapy (OAT) is recommended for both stages of treatment in older adults with OUD. Buprenorphine is recommended as a first line agent over methadone in the older adult population, due to a more favourable safety profile and relative accessibility. Use of methadone in this population is complicated by risk of QT interval prolongation and respiratory depression. Available observational data suggests that older adults respond well to OAT and age should not be a barrier to treatment. Further research is required to inform treatment decisions in this population.

Sociodemographic and Clinical Predictors of Prescription Opioid Use in a Longitudinal Community-Based Cohort Study of Middle-Aged and Older Adults

Objectives

Identifying factors associated with opioid use in middle-aged and older adults is a fundamental step in the mitigation of potentially unnecessary opioid consumption and opioid-related harms.

Methods

Using longitudinal data on a community-based cohort of adults aged 50–90 years residing in Johnston County, North Carolina, we examined sociodemographic and clinical factors in non-opioid users (n = 786) at baseline (2006–2010) as predictors of opioid use at follow-up (2013–2015). Variables included age, sex, race, obesity, educational attainment, employment status, household poverty rate, marital status, depressive symptoms, social support, pain catastrophizing, pain sensitivity, insurance status, polypharmacy, and smoking status.

Results

At follow-up, 13% of participants were using prescription opioids. In the multivariable model, high pain catastrophizing (adjusted odds ratio; 95% confidence interval = 2.14; 1.33–3.46), polypharmacy (2.08; 1.23–3.53), and history of depressive symptoms (2.00; 1.19–3.38) were independent markers of opioid use.

Discussion

Findings support the assessment of these modifiable factors during clinical encounters in patients ≥ 50 years old with chronic pain.

Mind-body approaches targeting the psychological aspects of opioid use problems in patients with chronic pain: evidence and opportunities

Opioids are commonly prescribed for the management of patients with chronic noncancer pain. Despite the potential analgesic benefits of opioids, long-term opioid therapy (LTOT) may be accompanied by problems such as opioid misuse and opioid use disorder (OUD). In this review, we begin with a description of opioid misuse and OUD and the patient-specific factors associated with these problems among patients with chronic pain. We will focus primarily on highlighting the predominant role played by psychological factors in the occurrence of opioid misuse and OUD in these patients. Several psychological factors have been found to be associated with opioid use problems in patients with chronic pain, and evidence indicates that patients presenting with psychological disturbances are particularly at risk of transitioning to long-term opioid use, engaging in opioid misuse behaviors, and developing OUD. The biological factors that might underlie the association between psychological disturbances and opioid use problems in patients with chronic pain have yet to be fully elucidated, but a growing number of studies suggest that dysfunctions in reward, appetitive, autonomic, and neurocognitive systems might be involved. We end with an overview of specific types of psychological interventions that have been put forward to prevent or reduce the occurrence of opioid misuse and OUD in patients with chronic pain who are prescribed LTOT.

Social Isolation Profiles and Older Adult Substance Use: A Latent Profile Analysis

OBJECTIVES

The aim of this study was to determine substance use among older adults based upon their social isolation and loneliness profiles.

METHODS

Data were derived from the New Jersey Older Adult Survey on Drug Use and Health (OASDUH). Latent profile Analysis (LPA) was used to determine the profiles of older adults (N = 801) based on five dimensions of social isolation and loneliness. Logistic and generalized ordered logistic regressions were conducted to assess the relationship between the latent profiles and substance use.

RESULTS

LPA identified five social isolation/loneliness profiles. The "connected and active" group had the lowest odds of cigarette use. The "alone but not lonely" group had the highest odds of cigarette use, alcohol use, and high-risk drinking. The "alone and lonely" group had the highest odds of non-medical drug use.

DISCUSSION

In working with older adults who are using substances, it is important to inquire about their social isolation and loneliness. Cognitive behavioral therapy for the "alone and lonely" group may be beneficial, as it has been deemed effective in reducing loneliness and enhancing social network.

Health Literacy, Opioid Misuse, and Pain Experience Among Adults with Chronic Pain

BACKGROUND

Chronic pain is a significant public health problem that is associated with several negative health outcomes, including increased health care cost, decreased productivity, and prescription opioid misuse. Although efforts have been made to curb the growing opioid epidemic in the United States, further research is needed to better understand individual difference factors that may be associated with greater pain and opioid misuse. Lower levels of health literacy, defined as the ability to obtain, understand, and use health information to make important decisions regarding health and medical care, has been associated with several chronic illnesses. Yet little work has examined the relationship between health literacy, pain, and opioid misuse among individuals with chronic pain.

METHODS

The current study examined health literacy in relation to current opioid misuse, severity of opioid dependence, pain severity, and pain disability among 445 adults with chronic pain (74.6% female, Mage [SD] = 38.45 [11.06] years).

RESULTS

Results indicated that health literacy was significantly negatively associated with each of the criterion variables.

CONCLUSIONS

These results suggest that health literacy may contribute to opioid misuse and pain experience among individuals with chronic pain. Interventions targeting health literacy among individuals with chronic illness may help to address the opioid public health crisis.

Association of opioid misuse with anxiety and depression: A systematic review of the literature

The opioid epidemic is a public health problem associated with a host of negative outcomes. Although clinicians recognize covariation between opioid misuse with anxiety and depressive symptoms and disorders, research on this topic has only recently accumulated. Progress in this domain is impeded by the lack of systematic and integrative research to better understand and treat these co-occurring problems. This paper represents the first attempt to systematically review the empirical literature examining relations between opioid use and misuse, and anxiety and depression. In the first section, we define key terms and describe the article selection strategy. In the second section, we review the prevalence of anxiety and depressive symptoms among individuals who use and misuse prescription and illicit opioids. In the third section, we review the magnitude of associations between anxiety and depressive symptoms and disorders with opioid misuse, as well as highlight studies examining the longitudinal and temporal sequence of the relations between these variables. In the fourth section, we focus on experimental therapeutics, reviewing what is known about individual difference and transdiagnostic vulnerability factors for anxiety and depression that might contribute to opioid misuse and its symptoms. Finally, we discuss current knowledge gaps and present a heuristic model to guide future research.

Examining the Relationship between Social Connection and Opioid Misuse: A Systematic Review

METHODS

We used a Boolean search strategy of PubMed, PsycINFO, and Embase to identify eligible publications from January 1990 to March 2020 and narrative analysis to synthesize the evidence.

RESULTS

The database search identified 1267 independent citations; 29 publications met inclusion criteria. Nearly all the studies demonstrated high risk of bias, most often due to selection and confounding bias. Most of the studies in the review (k = 20, 69%) found at least one significant association between social connection and opioid outcomes. Although no two studies included the same measures of social connection or opioid misuse, and social connection was both positively and negatively associated with opioid misuse, results support that social connection is an important correlate of opioid misuse.

CONCLUSIONS

This review highlights the importance of social connection as a correlate to opioid misuse. However, the extensive variability among research studies points to a need for standardization of measurement and larger studies with diverse populations to allow for consequential recommendations for prevention or treatment of opioid misuse. Evidence regarding the associations between social connection and opioid misuse or disorder is sparse. We provide suggestions for advancing this research, including clarification of the complex influences between social connections and opioid misuse.

Opioid Prescribing in the Elderly: A Systematic Review

Objective: To characterize the literature describing the therapeutic use of opioids in the elderly. Data Sources: Two electronic databases, EMBASE and MEDLINE, were searched from years 1990 to September 5, 2018. Relevant reference lists were reviewed. Searches were restricted to English language. Study Selection and Data Extraction: Two reviewers independently screened 827 citations to identify observational studies, population-based cohort studies, retrospective analyses, and control trials looking at the management of persistent pain in patients aged ≥65 years and/or frail patients. Data Synthesis: Thirty-nine articles were included in the systematic review. More specifically, 17 observational studies, 7 population-based cohort studies, 10 retrospective analyses, and 4 controlled trials. The most common etiology of persistent pain was musculoskeletal (50%), and the most often adverse effects reported were central nervous system related (41%) and falls/fractures (39%). Relevance to Patient Care and Clinical Practice: As there is a lack of strong evidence-based recommendations for opioid use in the elderly, this review aims to evaluate opioid use in the elderly and compare their efficacy and safety among this population. Conclusions: Overall, central nervous system adverse effects were most commonly seen in the elderly. However, higher quality evidence is required to further appreciate the dose-related effects on efficacy and safety of opioids in the elderly.

Chronic pain diagnoses and opioid dispensings among insured individuals with serious mental illness

BACKGROUND

Individuals with major depressive disorder (MDD) and bipolar disorder (BD) have particularly high rates of chronic non-cancer pain (CNCP) and are also more likely to receive prescription opioids for their pain. However, there have been no known studies published to date that have examined opioid treatment patterns among individuals with schizophrenia.

METHODS

Using electronic medical record data across 13 Mental Health Research Network sites, individuals with diagnoses of MDD (N = 65,750), BD (N = 38,117) or schizophrenia or schizoaffective disorder (N = 12,916) were identified and matched on age, sex and Medicare status to controls with no documented mental illness. CNCP diagnoses and prescription opioid medication dispensings were extracted for the matched samples. Multivariate analyses were conducted to evaluate (1) the odds of receiving a pain-related diagnosis and (2) the odds of receiving opioids, by separate mental illness diagnosis category compared with matched controls, controlling for age, sex, Medicare status, race/ethnicity, income, medical comorbidities, healthcare utilization and chronic pain diagnoses.

RESULTS

Multivariable models indicated that having a MDD (OR = 1.90; 95% CI = 1.85-1.95) or BD (OR = 1.71; 95% CI = 1.66-1.77) diagnosis was associated with increased odds of a CNCP diagnosis after controlling for age, sex, race, income, medical comorbidities and healthcare utilization. By contrast, having a schizophrenia diagnosis was associated with decreased odds of receiving a chronic pain diagnosis (OR = 0.86; 95% CI = 0.82-0.90). Having a MDD (OR = 2.59; 95% CI = 2.44-2.75) or BD (OR = 2.12; 95% CI = 1.97-2.28) diagnosis was associated with increased odds of receiving chronic opioid medications, even after controlling for age, sex, race, income, medical comorbidities, healthcare utilization and chronic pain diagnosis; having a schizophrenia diagnosis was not associated with receiving chronic opioid medications.

CONCLUSIONS

Individuals with serious mental illness, who are most at risk for developing opioid-related problems, continue to be prescribed opioids more often than their peers without mental illness. Mental health clinicians may be particularly well-suited to lead pain assessment and management efforts for these patients. Future research is needed to evaluate the effectiveness of involving mental health clinicians in these efforts.

Social isolation proxy variables and prescription opioid and benzodiazepine misuse among older adults in the U.S.: A cross-sectional analysis of data from the National Survey on Drug Use and Health, 2015-2017

BACKGROUND

Prescription drug misuse in older adults is a growing public health problem. It is important to understand factors which predispose older adults to misuse prescription drugs, and social isolation may play an important role. In this study, we examined the association between social isolation proxy variables (living alone, being unmarried, and not attending religious services) and prescription opioid/benzodiazepine misuse in older adults.

METHODS

With pooled cross-sectional data from the National Survey on Drug Use and Health (2015-2017), we used multinomial multiple logistic regression models to analyze the association between each social isolation proxy variable and past-year prescription opioid/benzodiazepine misuse. We controlled for potentially confounding variables including sociodemographic, physical/mental health, and substance use variables.

RESULTS

Being unmarried was associated with approximately three times increased odds of combined opioid and benzodiazepine misuse (OR 2.98, 95% CI 1.75, 5.08), a finding that persisted after adjusting for multiple potential confounders. Further analysis showed this finding persisted for divorced/separated and never married individuals, but not widowed. Not attending religious services was also associated with prescription opioid/benzodiazepine misuse, but only in unadjusted analyses. There was no association between living alone and opioid/benzodiazepine misuse.

CONCLUSION

Increased odds of combined opioid and benzodiazepine prescription drug misuse was observed among unmarried older adults. Given the susceptibility of older adults to the harms of these medications, further exploration of the role of marital relationships and other forms of social connectedness in prescription drug misuse in this vulnerable population is indicated.

Trends in prior receipt of prescription opioid or adjuvant analgesics among patients with incident opioid use disorder or opioid-related overdose from 2006 to 2016

BACKGROUND

With increasing efforts to scrutinize and reduce opioid prescribing, limited data exist on the recent trend in receipt of prescription pain medications before diagnosis of opioid use disorder (OUD) or opioid-related overdose (OD).

METHODS

Using 2005-2016 Truven MarketScan Commercial Claims databases, we assessed trends in annual 1) incidence of OUD or OD and 2) prevalence of receipt of prescription opioids or four commonly-prescribed adjuvant analgesics among patients newly diagnosed with OUD/OD. Trends were examined in the overall sample and by 3 age groups, including youths (≤18 years), adults (19-64 years), and older adults (≥65 years).

RESULTS

The incidence of diagnosed OUD or OD increased more than 3-fold from 4.99 to 23.81 per 10,000 persons from 2006 to 2016, with the highest increase (14.18-fold) seen in older adults, followed by adults (3.53-fold), and youths (0.16-fold). Between 2006 and 2016, the proportion of patients with incident OUD/OD who received anticonvulsant adjuvant analgesics in the year before diagnosis increased (from 23.4% to 34.3% [P-trend = .005]) whereas the proportion receiving high-dose prescriptions opioids decreased (from 45.5% to 34.8% [P-trend =< .001]). A decreasing trend was observed in general for tricyclic antidepressants and serotonin and norepinephrine reuptake inhibitors.

DISCUSSION

In US commercially insured patients newly diagnosed with OUD/OD, receipt of high-dose opioid prescriptions preceding the diagnosis decreased over time, paralleled by increased use of anticonvulsants commonly prescribed for pain conditions. Further investigations are warranted to understand how prescribed and anticonvulsants contribute to the development of OUD/OD.

Disability status and prescription drug misuse among U.S. adults

BACKGROUND

The U.S. is in the midst of a public health crisis related to drug overdose deaths. Largely responsible for the dramatic increase in overdose deaths is the misuse of prescription drugs such as opioids and benzodiazepines. While much research attention has focused on correlates of prescription drug misuse in recent years, notable gaps in the literature remain. The current research addresses one of these gaps by examining the relationship between disability status and prescription drug misuse.

METHOD

We examine data from the 2015 National Survey on Drug use and Health, a leading source of epidemiological data on drug use in the United States that added questions related to disability status to the 2015 survey. The current research assessed the relationship between disability status (i.e. activities of daily living and instrumental activities of daily living) and prescription drug misuse (i.e. opioids and benzodiazepines) among adults.

RESULTS

Findings from multinomial logistic regression analysis showed that a disability related to activities of daily living was correlated with opioid misuse, while a disability associated with instrumental activities of daily living was associated with benzodiazepine misuse and misuse of both. In addition, health related measures had a greater impact on the relationship between disability status and prescription drug misuse than did the social engagement/isolation measures.

CONCLUSION

Findings indicated that disability status is a significant correlate of prescription drug misuse. However, this relationship was largely mediated by measures associated with poor health and social engagement/isolation.

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

BACKGROUND

In light of the increased rates of Prescription Opioid (PO) misuse and associated mortality in several developed countries in recent years, efforts have been made to identify populations who may be at increased risk for misuse of POs. Though the association between depression and PO misuse among pain patients is well documented, little is known regarding the effects of severity of depression on rates of misuse. In this study we explored rates of PO misuse among chronic pain patients screening positive for depression according to level of severity.

METHODS

Participants included chronic pain patients receiving POs (N = 554). All participants were screened for depression using the Patient Health Questionnaire (PHQ-9; cut-off scores of 5, 10, 15, and 20 for mild, moderate, moderate-severe and severe depression, respectively) and for opioid misuse using the Current Opioid Misuse Measure (COMM). Logistic regression analyses controlling for additional sociodemographic and clinical factors were conducted.

RESULTS

Participants who screened positive for depression were at significantly increased odds to screen positive for opioid misuse (Adjusted Odds Ratio (AOR) = 3.63; 95% Confidence Interval (CI) = 1.71-7.7) compared to those without depression. Severity of depression was significantly associated with increased odds for opioid misuse for moderate (AOR = 3.71; 95% CI = 1.01-13.76), moderate-severe (AOR = 6.28; 95% CI = 1.6-24.57) and severe (AOR = 14.66; 95% CI = 3.28-65.52) depression but not among those who screened positive for mild depression (AOR = 1.49; 95% CI = 0.39-5.68).

LIMITATIONS

Cross-sectional study.

CONCLUSIONS

Our results highlight the need to properly asses and address level of severity of co-morbid depression among chronic pain patients receiving POs.

Abhängigkeitspotenzial und andere Risiken von Opioidanalgetika im Alter

Zusammenfassung. Zielsetzung: Übersicht über Suchtpotenzial und andere Risiken von Opioidanalgetika im höheren Lebensalter. Methodik: Narrativ review. Literaturrecherche in PubMed (Suchbegriffe: opioid analgesics UND abuse; opioid analgesics UND dependence; opioid analgesics UND addiction; opioid analgesics UND adverse effects; jeweils UND elderly) sowie aktuellen einschlägigen Standardwerken; Auswahl nach altersmedizinischer Relevanz und Aktualität. Ergebnisse: Die Verordnung von Opioidanalgetika (OA) hat in den letzten 25 Jahren massiv zugenommen, die weitaus meisten Verordnungen entfallen auf alte Menschen und Menschen mit chronischen Nicht-Tumorschmerzen (CNTS). Die diagnostischen Kriterien für die Opiatabhängigkeit in ICD-10 und DSM-5 sind für die OA-Behandlung von CNTS ungeeignet. Bei langfristiger OA-Behandlung bei CNTS kann eine spezifische Form von Abhängigkeit entstehen, die nicht mit der illegalen Opiat-(Heroin-)Sucht gleichzusetzen ist. Vorbestehende Suchterkrankungen und andere psychische Störungen sind die wesentlichsten Risikofaktoren. Weitere Nebenwirkungen sind zu beachten. Schmerztherapie bei Suchtkranken stellt eine besondere Herausforderung dar. Schlussfolgerungen: Die Anwendung von OA bei CNTS verlangt eine sorgfältige Indikationsstellung. Die besondere Form der Abhängigkeit von OA ist nicht ausreichend erforscht und wird zu wenig beachtet.

[Opioids for noncancer pain in the elderly]

BACKGROUND

Opioids are increasingly used in the elderly. Side effects differ compared to other analgesics.

PURPOSE

In this review article, special aspects about using opioids for noncancer pain in older people and in geriatric patients are identified.

CURRENT SITUATION

So far randomized controlled trials for the indication of and comparison between various opioids have been performed in middle-aged patients and not exclusively in geriatric patients or elderly (> 75 years). Furthermore, the evidence for multimorbid elderly patients with respect to side effects is also very poor.

RECOMMENDATIONS

The indication for opioid therapy should be narrow. The patient and their caregivers must be provided patient information regarding opioid therapy. The principle "start low, go slow" is highly recommended. To reduce the risk of falls, longer acting opioids should be used and short acting opioids should be avoided. Everyday relevant negative effects on cognition are possible in opioid use and have to be observed. As recommended in the recently published German guideline for long-term use of opioids in noncancer pain a critical check after 3 months and in case of dosing over 120 mg morphine equivalents is advisable, especially for older patients. Liver and kidney function and drug interactions have to be taken into consideration like in every age group.

Prescription pain reliever misuse prevalence, correlates, and origin of possession throughout the life course

INTRODUCTION

While a considerable amount of information is available concerning who is most likely to engage in prescription pain reliever misuse, few studies have examined whether the correlates of pain reliever misuse and sources of pain reliever possession are consistent across the life span.

METHODS

Data from the 2011-2012 National Survey in Drug Use and Health (NSDUH). Multivariate logistic regression examined clinical and social correlates of past-year pain reliever misuse, stratified by age. Additionally, bivariate analyses examined sources of pain reliever possession, and whether these origins differ by age.

RESULTS

Among respondents, 4.7% reported past-year prescription pain reliever misuse. Prevalence for individuals aged 12 to 17 was 5.9%, 18 to 25 was 10.2%, 26-34 was 7.7%, 35 to 49 was 4.3%, and individuals aged 50 or older was 1.7%. While many social and clinical correlates of pain reliever misuse emerged among younger respondents, these correlates diminished in significance among older adults. Only past-year illicit drug use disorders (marijuana, cocaine, crack cocaine, heroin, and hallucinogen use) was a significant predictor of pain reliever misuse among all age groups. Also, older adults were more likely to report pain reliever possession from multiple medical doctors, whereas younger individuals were more likely to possess pain reliever from friends/relatives or through purchase from a drug dealer/stranger.

CONCLUSIONS

Increased efforts to better screen for illicit drug use and greater efforts to coordinate patient prescription records among medical care providers may be high priorities in developing interventions to reduce rates of misuse of prescription pain relievers, especially among older adults.

The Effect of Motivational Interviewing on Prescription Opioid Adherence Among Older Adults With Chronic Pain

PURPOSE

To test the effect of office-based motivational interviewing (MI) on prescription opioid adherence in older adults with chronic pain.

DESIGN AND METHODS

Pre- and post-design was used. Thirty chronic pain patients participated in a 4-week MI in two outpatient settings.

FINDINGS

Participants demonstrated a significantly reduced risk of prescription opioid misuse, decreased substance use, increased self-efficacy, increased motivation to change, and decreased depression at both the post-test and 1-month follow-up.

PRACTICE IMPLICATION

MI can be effectively delivered in outpatient settings for older adults who are at risk for opioid misuse. Clinicians could incorporate MI techniques to enhance prescription opioid adherence.

Screening for alcohol and substance use for older people in geriatric hospital and community health settings

BACKGROUND

We aimed to determine the rates of alcohol and substance use in geriatric hospital and community health settings, and to evaluate the performance of screening instruments.

METHOD

A two-phase cross-sectional study was undertaken in geriatric and aged care psychiatry wards and associated community services of a teaching hospital. Participants were screened with the Brief Alcohol Use Disorders Identification Test (AUDIT-C) and the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) for other substances; Geriatric Depression Scale-15 for mood; the Connor-Davidson Resilience Scale; and the Subjective Quality of Life scale. Medical conditions were established. Screen positives for risky substance use continued with the full AUDIT, full ASSIST, CAGE, Addenbrooke's Cognitive Examination-Revised, and the Functional Activities Questionnaire. Medical records were reviewed after three months to ascertain recognition and management of substance use.

RESULTS

Of 210 participants aged 60+ (mean age 81.9, 63.3% female) without dementia or delirium and Mini Mental State Examination score ≥24, 41 (19.5%) were screen positive - 36 (17.1%) for alcohol, seven for non-medical benzodiazepine use (3.3%) (four alcohol and benzodiazepine) and two for non-medical opioid use (0.95%). Screen positives differed from screen negatives on few demographic or health measures. On the ASSIST, 26 (12.4%) were rated as medium/high risk. The AUDIT-C with cut-point of ≥5 was the optimal measure for detecting risky alcohol use.

CONCLUSIONS

Many patients in geriatric health services have risky alcohol or substance use, but few clinical features distinguish them from other patients. Routine screening of alcohol and substance use is recommended.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

DISCUSSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

A silent epidemic: community nursing and effective pain management

Effective pain management presents challenges to health care practitioners, particularly in the community setting. This is evident from the complexities associated with the phenomenon of pain and the circumstances for those patients suffering from pain. An overwhelming amount of literature and research surrounding pain exists in an effort to improve our understanding of pain, assessment and management strategies. But patients in pain are not managed well in the community or acute setting. Health care professionals continue to underestimate and under treat pain, failing to meet the patient's individual needs. Pain management it is not about cure, nor is it as simple as reporting zero on a pain score- it is about knowledge, expertise and understanding. Pain is a subjective and very personal experience, wherein health care professionals must listen to the patients' story. Myths and fears surrounding pain remains a barrier to effective management and care. This article aims to dispel the myths and improve clinical practice, particularly in effective pain assessment so patients in the community presenting with pain can be managed individually and effectively. Nurses need to be proactive in their approach, through effective communication and decision making, trusting in our patients' and their pain experience. This is key to a successful approach to managing patients' pain effectively.

The prevalence of mental health and pain symptoms in general population samples reporting nonmedical use of prescription opioids: a systematic review and meta-analysis

Nonmedical prescription opioid use (NMPOU) has become a substantial public health concern in North America. Existing epidemiological data suggest an association between NMPOU and mental health or pain symptoms in different populations, although these correlations are not systematically assessed. To address this gap, a systematic search, review, and meta-analysis were completed separately for both mental health problem symptoms and pain in general population samples reporting NMPOU. Overall, 9 unique epidemiological studies were identified and included in the review. The pooled prevalence of any mental health symptoms in general population samples reporting NMPOU was 32% (95% confidence interval [CI]: 24-40). Specifically, the pooled prevalence of depression was 17% (95% CI: 14-19) and the prevalence of anxiety in general population samples of NMPOU was 16% (95% CI: 1-30) The pooled prevalence of pain in the population of interest was found to be 48% (95% CI: 37-59). This systematic review found evidence for disproportionately high prevalence levels of mental health problems and pain among general population samples reporting NMPOU. While the data reviewed cannot interpret dynamics of potential causality, these findings have implications for interventions for NMPOU, as well as medical practice involving prescription opioids.

PERSPECTIVE

This systematic review and meta-analysis found evidence for disproportionately elevated rates of select mental health and pain problems in epidemiological studies based on general population samples reporting NMPOU. While causality cannot be established, these comorbidities may influence NMPOU behavior and hence ought to be considered in preventive and treatment interventions.

Depression and prescription opioid misuse among chronic opioid therapy recipients with no history of substance abuse

PURPOSE

Opioid misuse in the context of chronic opioid therapy (COT) is a growing concern. Depression may be a risk factor for opioid misuse, but it has been difficult to tease out the contribution of co-occurring substance abuse. This study aims to examine whether there is an association between depression and opioid misuse in patients receiving COT who have no history of substance abuse.

METHODS

A telephone survey was conducted at Group Health Cooperative and Kaiser Permanente of Northern California. We interviewed 1,334 patients on COT for noncancer pain who had no history of substance abuse. Patients were asked about 3 forms of opioid misuse: (1) self-medicating for symptoms other than pain, (2) self-increasing doses, and (3) giving to or getting opioids from others. Depression was evaluated by the 8-item Patient Health Questionnaire (PHQ-8).

RESULTS

Compared with patients who were not depressed (PHQ-8 score 0 to 4), patients with moderate depression (PHQ-8 score 10 to 14) and severe depression (PHQ-8 score 15 or higher) were 1.8 and 2.4 times more likely, respectively, to misuse their opioid medications for non-pain symptoms. Patients with mild (PHQ-8 score 5 to 9), moderate, and severe depression were 1.9, 2.9, and 3.1 times more likely, respectively, to misuse their opioid medications by self-increasing their dose. There was no statistically significant association between depression and giving opioids to or getting them from others.

CONCLUSION

In patients with no substance abuse history, depressive symptoms are associated with increased rates of some forms of self-reported opioid misuse. Clinicians should be alert to the risk of patients with depressive symptoms using opioids to relieve these symptoms and thereby using more opioids than prescribed.

Factors associated with primary care prescription of opioids for joint pain

BACKGROUND

Opioids are commonly prescribed in primary care and can offer pain relief but may also have adverse effects. Little is known about the characteristics of people likely to receive an opioid prescription in primary care. The aim is to identify what factors are associated with primary care prescribing of high-strength analgesics in a community sample of older people with joint pain.

METHODS

A prospective two-stage postal survey completed at baseline and 3-year follow-up in a population aged 50 and over registered with eight general practitioner (GP) practices in North Staffordshire (North Staffordshire Osteoarthritis Project cohorts) linked with data from medical records. Participants were selected who reported joint pain in one or more joints at baseline. Outcome measures were the number of prescriptions for high-strength pain medication (opioids) in the following 3 years. Socio-demographic and health status factors associated with prescription were assessed using a zero-inflated Poisson model.

RESULTS

873 (19%) people were prescribed opioids (out of 4652 providing complete data) ranging from 1 to 76 prescriptions over 3 years. Baseline factors significantly associated with increased rates of prescription were younger age group [65-74 group: incidence rate ratio (IRR) = 1.26 (1.18-1.35)], male gender [IRR = 1.17 (1.12-1.23)], severe joint pain [IRR = 1.19 (1.12-1.26)] poor physical function [IRR = 0.99 (0.99-0.99)] and lower frequency of alcohol consumption [once/twice a year: IRR = 1.13 (1.06-1.21), never: IRR = 1.14 (1.06-1.22)]. Restricting the analysis to those without prior prescriptions for strong opioids showed similar results.

CONCLUSION

Poor physical function and participation restrictions were strongly associated with prescriptions of stronger opioids in addition to several socio-demographic and lifestyle factors. Given the uncertainties over the effectiveness and risks of opioid use, future research could investigate decision making of GPs, exploring reasons for prescribing them.

A comprehensive review of telehealth for pain management: where we are and the way ahead

Pain is generally undertreated in the United States, owing to a number of barriers including geographic distance from specialty treatment providers; functional disability that limits mobility; treatment-related stigma; economic limitations; and educational barriers. Pain undertreatment exacerbates pain chronicity and emotional disruption that can significantly erode a pain patient's quality of life, and there is widespread agreement that pain care must evolve to address this significant problem. The growing field of telehealth (defined for the purposes of this paper as technology that allows for distance interaction between providers and/or patients) offers a novel opportunity to expand pain assessment, consultation, and treatment services beyond the walls of the specialty pain clinic, but there is limited availability of resources describing how to best use this technology to improve access to care. A recent literature review (September 2011) using universally endorsed MeSH search criteria revealed only 32 MEDLINE references focusing on telehealth for pain. This is surprising in light of the very large number of references covering telehealth (14,164 references) and pain (104,564 references), respectively. Of the studies available, there are very few randomized trials of telehealth pain care and only one general overview of e-health and chronic pain, which dedicates just a few paragraphs to telehealth. This manuscript represents one of the first comprehensive reviews of the current state of telehealth and pain management research and practice. The goals are to provide a rationale for the potential benefit of telehealth-based pain management services; describe the various applications of telehealth technology for pain management; orient the reader to cost models for telehealth; present examples of services in place; and offer recommendations for future research based on the current state of knowledge.

Concurrent use of alcohol and sedatives among persons prescribed chronic opioid therapy: prevalence and risk factors

Taking opioids with other central nervous system (CNS) depressants can increase risk of oversedation and respiratory depression. We used telephone survey and electronic health care data to assess the prevalence of, and risk factors for, concurrent use of alcohol and/or sedatives among 1,848 integrated care plan members who were prescribed chronic opioid therapy (COT) for chronic noncancer pain. Concurrent sedative use was defined by receiving sedatives for 45+ days of the 90 days preceding the interview; concurrent alcohol use was defined by consuming 2+ drinks within 2 hours of taking an opioid in the prior 2 weeks. Some analyses were stratified by substance use disorder (SUD) history (alcohol or drug). Among subjects with no SUD history, 29% concurrently used sedatives versus 39% of those with an SUD history. Rates of concurrent alcohol use were similar (12 to 13%) in the 2 substance use disorder strata. Predictors of concurrent sedative use included SUD history, female gender, depression, and taking opioids at higher doses and for more than 1 pain condition. Male gender was the only predictor of concurrent alcohol use. Concurrent use of CNS depressants was common among this sample of COT users regardless of substance use disorder status.

PERSPECTIVE

Risks associated with concurrent use of CNS depressants are not restricted to COT users who abuse those substances. And, the increased risk of concurrently using CNS depressants is not restricted to opioid users with a prior SUD history. COT requires close monitoring, regardless of substance use disorder history.

Psychological advances in chronic pain: a concise selective review of research from 2010

PURPOSE OF REVIEW

It is difficult to hold an organized view of psychological research related to chronic pain. There are many different theories and variables and the volume of literature is vast. The purpose of this review is to highlight some key trends in this research in 2010.

RECENT FINDINGS

We conducted a search of the output of four prominent scientific journals in the field of chronic pain management. Five research topics from among those identified are summarized. Identified topics include psychological factors related to analgesic use, efficacy of cognitive behavioral treatments, and contextual approaches (including acceptance and mindfulness).

SUMMARY

The largest number of psychological studies categorized for this review focused on psychological factors in relation to opioid use. These studies include ones to identify risk factors for aberrant drug behavior. This result seems to reflect that the dominant approach to chronic pain remains a pharmacological one. At the same time treatment from within a broadly cognitive behavioral approach seems to have reached a level of relative maturity with questions frequently being addressed with meta-analysis. Otherwise, there are developing and promising trends, such as in new treatment models and uses of information technology.

Elevated pain sensitivity in chronic pain patients at risk for opioid misuse

This study employed quantitative sensory testing (QST) to evaluate pain responses in chronic spinal pain patients at low risk and high risk for opioid misuse, with risk classification based on scores on the Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R). Patients were further subgrouped according to current use of prescription opioids. Of the 276 chronic pain patients tested, approximately 65% were taking opioids; a median split was used to further categorize these patients as being on lower or higher doses of opioids. The high-risk group (n = 161) reported higher levels of clinical pain, had lower pressure and thermal pain thresholds at multiple body sites, had lower heat pain tolerance, and rated repetitive mechanical stimuli as more painful relative to the low-risk group (n = 115; P's < .01). In contrast, QST measures did not differ across opioid groups. Multiple linear regression analysis suggested that indices of pain-related distress (ie, anxiety and catastrophizing about pain) were also predictive of hyperalgesia, particularly in patients taking opioids. Collectively, regardless of opioid status, the high-risk group was hyperalgesic relative to the low-risk group; future opioid treatment studies may benefit from the classification of opioid risk, and the examination of pain sensitivity and other factors that differentiate high- and low-risk groups.

PERSPECTIVE

This study demonstrates that chronic spinal pain patients at high risk for misuse of prescription opioids are more pain-sensitive than low-risk patients, whether or not they are currently taking opioids. Indices of pain-related distress were important predictors of pain sensitivity, particularly among those patients taking opioids for pain.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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