Health-Related Quality of Life among Chronic Opioid Users, Nonchronic Opioid Users, and Nonopioid Users with Chronic Noncancer Pain

Relationships of self-reported opioid and benzodiazepine use with health-related quality of life among adults with spinal cord injury

BACKGROUND

There is limited understanding of the relationships between prescription opioid and benzodiazepine use and indices of health-related quality of life (HRQOL) among those with spinal cord injuries (SCI).

OBJECTIVE

To identify the relationships between self-reported prescription opioid and benzodiazepine use and two indicators of HRQOL, number of days in poor physical health and poor mental health in the past 30 days among adults with SCI.

METHODS

A cross-sectional cohort study of 918 adults with chronic (>1 year), traumatic SCI living in the Southeastern United States was conducted. Participants completed a self-report assessment (SRA).

RESULTS

In the preliminary model, both opioid and benzodiazepine use were associated with a greater number of days in poor physical health and poor mental health in the past month. After controlling for health conditions (pain intensity, spasticity, anxiety and perceived sleep insufficiency), opioid use was associated with 2.04 (CI = 0.69; 3.39) additional poor physical health days in the past 30 days, and benzodiazepine use was associated with 2.18 (CI = 0.70; 3.64) additional days of poor mental health. Age was associated with greater number of poor physical health days and fewer poor mental health days. Lower income was associated with poor mental health days. Most of the health conditions were significantly related to the number of past month poor physical and mental health days.

CONCLUSIONS

Opioid and benzodiazepine use are associated with poor physical and mental HRQOL, even after controlling for health conditions. Treatment strategies should consider potential unanticipated negative consequences of pharmacological interventions.

An economic evaluation of community pharmacy-dispensed naloxone in Canada

Aims

To determine the cost-effectiveness of pharmacy-based intranasal (IN) and intramuscular (IM) naloxone distribution in Canada.

Methods

We developed a state-transition model for pharmacy-based naloxone distribution, every 3 years, to illicit, prescription, opioid-agonist therapy and nonopioid use populations compared to no naloxone distribution. We used a monthly cycle length, lifetime horizon and a Canadian provincial Ministry of Health perspective. Transition probabilities, cost and utility data were retrieved from the literature. Costs (2020) and quality-adjusted life years (QALY) were discounted 1.5% annually. Microsimulation, 1-way and probabilistic sensitivity analyses were conducted.

Results

Distribution of naloxone to all Canadians compared to no distribution prevented 151 additional overdose deaths per 10,000 persons, with an incremental cost-effectiveness ratio (ICER) of $50,984 per QALY for IM naloxone and an ICER of $126,060 per QALY for IN naloxone. Distribution of any naloxone to only illicit opioid users was the most cost-effective. One-way sensitivity analysis showed that survival rates for illicit opioid users were most influenced by the availability of either emergency medical services or naloxone.

Conclusion

Distribution of IM and IN naloxone to all Canadians every 3 years is likely cost-effective at a willingness-to-pay threshold of $140,000 Canadian dollars/QALY (~3 × gross domestic product from the World Health Organization). Distribution to people who use illicit opioids was most cost-effective and prevented the most deaths. This is important, as more overdose deaths could be prevented through nationwide public funding of IN naloxone kits through pharmacies, since individuals report a preference for IN naloxone and these formulations are easier to use, save lives and are cost-effective. Can Pharm J (Ott) 2024;157:xx-xx.

A population-based study on the risk of prescription opioid abuse in patients with chronic opioid use and cost-effectiveness of prescription drug monitoring program using a patient simulation model in South Korea

BACKGROUND

Concerns regarding the burden of inappropriate opioid use are growing. We examined the association between prescription opioid abuse and patient characteristics and estimated the cost-effectiveness of the prescription drug monitoring program (PDMP) implemented in South Korea, considering patient-level information.

METHODS

A retrospective cohort study was conducted to explore the association between opioid abuse and patient characteristics using the National Health Insurance Service-National Sample Cohort (NHIS-NSC) database. We selected non-cancer patients with chronic opioid use and investigated the incidence of opioid abuse between 2010 and 2015. The association between opioid abuse and patient characteristics was assessed using the Cox proportional hazards model. The cost-effectiveness of the PDMP was assessed using discrete event simulation (DES) with a time horizon of 30 years from a societal perspective. Time-to-event data and event costs were obtained from the NHIS-NSC database. The abuse rate was adjusted for each patient based on the baseline characteristics and history of abuse experienced in the model. Program effectiveness, program costs, and health-state utilities were obtained from the published literature. The incremental cost-utility ratio (ICUR) was estimated at a discount rate of 5% for both costs and quality-adjusted life-years (QALYs).

RESULTS

We identified 22,524 patients with chronic opioid use in the NHIS-NSC database. Every one-year increase in age (hazard ratio: 1.002 [95% CI: 1.000-1.003]), medical aid program (1.130 [95% CI: 1.072-1.191]), high Charlson Comorbidity Index (1.054 [95% CI: 1.044-1.065]), and history of opioid abuse (1.501 [95% CI: 1.391-1.620] and 3.005 [95% CI: 2.387-3.783] for 1-2 and ≥3 abuse events, respectively) significantly increased the risk of opioid abuse. In the DES, the PDMP was cost-effective, with an estimated ICUR of $2,227/QALY, which was most affected by the program's effectiveness.

CONCLUSION

Patient characteristics and history of opioid abuse affected the risk of opioid abuse. Considering patient-level information, the PDMP implemented in South Korea is likely to be cost-effective.

Association Between Chiropractic Utilization and Opioid Prescriptions Among People With Back or Neck Pain: Evaluation of the Medical Expenditure Panel Survey

OBJECTIVE

The purpose of this study was to assess the association between patients in the United States seeing a chiropractor and receiving an opioid prescription for back or neck pain.

METHODS

Medical Expenditure Panel Survey (Years 2012 to 2015) respondents for longitudinal panels 17 to 19 who participated in all 5 rounds were at least 18 years of age, did not have cancer, and reported back or neck pain. We defined chiropractic users as participants reporting at least 1 chiropractic visit for back or neck pain and opioid users as participants reporting purchase or receipt of a prescription classified as Multum Lexicon "60" and "191" for back or neck pain. We adjusted for socioeconomic and clinical variables using multiple logistic regression.

RESULTS

The sample contained 4686 people, 21% of whom reported an opioid prescription for back or neck pain. Among opioid users, 14% reported a chiropractic visit for back or neck pain compared to 31% of nonopioid users. The adjusted odds ratio for chiropractic use among opioid users compared to nonopioid users was 0.46 (95% confidence interval, 0.36-0.57).

CONCLUSION

Patients with back or neck pain who saw a chiropractor had approximately half the odds of reporting an opioid prescription compared to those who did not see a chiropractor.

Endogenous opiates and behavior: 2019

This paper is the forty-second consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2019 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).

The Prevalence of Opioid Analgesic Use in People with Chronic Noncancer Pain: Systematic Review and Meta-Analysis of Observational Studies

OBJECTIVE

To review studies examining the proportion of people with chronic noncancer pain who report consuming opioids and characteristics associated with their use.

DESIGN

Systematic review.

METHODS

We searched databases from inception to February 8, 2020, and conducted citation tracking. We included observational studies reporting the proportion of adults with chronic noncancer pain who used opioid analgesics. Opioids were categorized as weak (e.g., codeine) or strong (e.g., oxycodone). Study risk of bias was assessed, and Grading of Recommendations Assessment, Development and Evaluations provided a summary of the overall quality. Results were pooled using a random-effects model. Meta-regression determined factors associated with opioid use.

RESULTS

Sixty studies (N=3,961,739) reported data on opioid use in people with chronic noncancer pain from 1990 to 2017. Of these 46, 77% had moderate risk of bias. Opioid use was reported by 26.8% (95% confidence interval [CI], 23.1-30.8; moderate-quality evidence) of people with chronic noncancer pain. The use of weak opioids (17.3%; 95% CI 11.9-24.4; moderate-quality evidence) was more common than the use of strong opioids (9.8%; 95% CI, 6.8-14.0; low-quality evidence). Meta-regression determined that opioid use was associated with geographic region (P=0.02; lower in Europe than North America), but not sampling year (P=0.77), setting (P=0.06), diagnosis (P=0.34), or disclosure of funding (P=0.77).

CONCLUSIONS

Our review summarized data from over 3.9 million people with chronic noncancer pain reporting their opioid use. Between 1990 and 2017, one-quarter of people with chronic noncancer pain reported taking opioids, and this proportion did not change over time.

Cost-Effectiveness of an Opioid Abuse-Prevention Program Using the Narcotics Information Management System in South Korea

OBJECTIVES

To assess the cost-effectiveness of an opioid abuse-prevention program embedded in the Narcotics Information Management System ("the Network System to Prevent Doctor-Shopping for Narcotics") in South Korea.

METHODS

Using a Markov model with a 1-year cycle length and 30-year time horizon, we estimated the incremental cost-utility ratio (ICUR) of implementing an opioid abuse-prevention program in patients prescribed outpatient opioids from a Korean healthcare payer's perspective. The model has 6 health states: no opioid use, therapeutic opioid use, opioid abuse, overdose, overdose death, and all-cause death. Patient characteristics, healthcare costs, and transition probabilities were estimated from national population-based data and published literature. Age- and sex-specific utilities of the general Korean population were used for the no-use state, whereas the other health-state utilities were obtained from published studies. Costs (in 2019 US dollars) included the expenses of the program, opioids, and overdoses. An annual 5% discount rate was applied to the costs and quality-adjusted life-years (QALYs). Parameter uncertainties were explored via deterministic and probabilistic sensitivity analyses.

RESULTS

The program was associated with 2.27 fewer overdoses per 100 000 person-years, with an ICUR of $227/QALY. The ICURs were generally robust to parameter changes, although the program's effect on abuse reduction was the most influential parameter. Probabilistic sensitivity analysis showed that the program reached a 100% probability of cost-effectiveness at a willingness-to-pay threshold of $900/QALY.

CONCLUSIONS

The opioid abuse-prevention program appears to be cost-effective in South Korea. Mandatory use of the program should be considered to maximize clinical and economic benefits of the program.

Health-related quality of life of long-term patients receiving opioid agonist therapy: a nested prospective cohort study in Norway

Background

Opioid dependence carries the highest disease burden of all illicit drugs. Opioid agonist therapy (OAT) is an evidence-based medical intervention that reduces morbidity and mortality. There is limited knowledge on the health-related quality of life (HRQoL) of long-term patients in OAT. This study measures HRQoL and self-perceived health of long-term patients on OAT, compares the scores to a Norwegian reference population, and assesses changes in these scores at 1-year follow up.

Methods

We conducted a nested prospective cohort study among nine OAT outpatient clinics in Norway. 609 OAT patients were included, 245 (40%) followed-up one year later. Data on patient characteristics, HRQoL, and self-perceived health was collected. HRQoL was assessed with the EQ-5D-5L, which measures five dimensions (mobility, self-care, usual activities, pain/discomfort and anxiety/depression) on a five-point Likert scale (from “no problems” to “extreme problems”). An UK value set was applied to calculate index values (from 0 to 1) for the EQ-5D-5L and compare them to a Norwegian reference population. Self-perceived health was measured with EQ-VAS (from 0 to 100).

Results

Mean (standard deviation (SD)) EQ-5D-5L index value at baseline was 0.699 (0.250) and EQ-VAS 57 (22) compared to 0.848 (0.200) and 80(19) for the Norwegian reference population. There were large variations in EQ-5D-5L index values, where 43% had > 0.8 and 5% had < 0.2 at baseline. The lowest EQ-5D-5L index values were observed for female patients, age groups older than 40 years and for methadone users. At follow-up, improvements in HRQoL were observed across almost all dimensions and found significant for mobility and pain/discomfort. Mean (SD) overall index value and EQ-VAS at follow up were 0.729 (0.237) and 59 (22) respectively.

Conclusion

The average HRQoL and self-perceived health of OAT patients is significantly lower than that of the general population, and lower than what has been found among other severe somatic and psychiatric conditions. Around 34% had very good HRQoL, higher than average Norwegian values, and around 5% had extremely poor HRQoL.

Cost-Effectiveness of Intranasal Naloxone Distribution to High-Risk Prescription Opioid Users

OBJECTIVES

To determine the cost-effectiveness of pharmacy-based intranasal naloxone distribution to high-risk prescription opioid (RxO) users.

METHODS

We developed a Markov model with an attached tree for pharmacy-based naloxone distribution to high-risk RxO users using 2 approaches: one-time and biannual follow-up distribution. The Markov structure had 6 health states: high-risk RxO use, low-risk RxO use, no RxO use, illicit opioid use, no illicit opioid use, and death. The tree modeled the probability of an overdose happening, the overdose being witnessed, naloxone being available, and the overdose resulting in death. High-risk RxO users were defined as individuals with prescription opioid doses greater than or equal to 90 morphine milligram equivalents (MME) per day. We used a monthly cycle length, lifetime horizon, and US healthcare perspective. Costs (2018) and quality-adjusted life-years (QALYs) were discounted 3% annually. Microsimulation was performed with 100 000 individual trials. Deterministic and probabilistic sensitivity analyses were conducted.

RESULTS

One-time distribution of naloxone prevented 14 additional overdose deaths per 100 000 persons, with an incremental cost-effectiveness ratio (ICER) of $56 699 per QALY. Biannual follow-up distribution led to 107 additional lives being saved with an ICER of $84 799 per QALY compared with one-time distribution. Probabilistic sensitivity analyses showed that a biannual follow-up approach would be cost-effective 50% of the time at a willingness-to-pay (WTP) threshold of $100 000 per QALY. Naloxone effectiveness and proportion of overdoses witnessed were the 2 most influential parameters for biannual distribution.

CONCLUSION

Both one-time and biannual follow-up naloxone distribution in community pharmacies would modestly reduce opioid overdose deaths and be cost-effective at a WTP of $100 000 per QALY.

A Longitudinal Study of the Association of Opioid Use with Change in Pain Interference and Functional Limitations in a Nationally Representative Cohort of Adults with Osteoarthritis in the United States

Introduction

Real-world data are sparse on longitudinal associations of opioid use with pain interference with activities (PIA) and daily function with osteoarthritis (OA) in the USA.

Methods

Data from the 2010–2015 Medical Expenditure Panel Surveys were analyzed for community-dwelling adults with OA. Opioid use patterns were defined as persistent, intermittent, and no use. Evaluated outcomes were a change in PIA and functional limitations (activities of daily living [ADL], instrumental ADL [IADL], social and work activities, and cognitive function). Multivariable regression analyses explored the association of persistent/intermittent versus no opioid use with PIA and functional limitations. Results were weighted for the US population.

Results

Among 4172 patients (66.2% female, 80.8% white, mean age 61.7 years), 62.1% reported no PIA change at follow-up, 17.9% worsened, and 20.0% improved. Although 51.0–93.1% of patients reported no functional limitations, 3.8–13.1% worsened (1.1–11.3% improved). Relative to no opioid use, persistent users had higher odds of severe/extreme PIA (adjusted odds ratio [AOR], 2.91; 95% confidence interval [CI], 1.95–4.32; P < 0.001) and moderate PIA (AOR, 2.04; 95% CI, 1.31–3.20; P < 0.01) at follow-up. For patients with baseline functional limitations, persistent opioid users were more likely to report physical and work limitations at follow-up (both P < 0.05). For patients without baseline functional limitations, persistent opioid users had higher odds than those without use of reporting IADL, physical, social, and cognitive limitations at follow-up (all P < 0.05); intermittent users were more likely to report physical and social limitations (both P < 0.05).

Conclusions

Persistent opioid use for pain in patients with OA appeared to be associated with poorer PIA and functional outcomes, regardless of baseline functional status. These findings highlight the importance of patient-reported outcomes for opioid benefit–risk assessment and suggest the need for alternative analgesic approaches.

Positive allosteric modulators of nonbenzodiazepine γ-aminobutyric acidA receptor subtypes for the treatment of chronic pain

Chronic neuropathic pain may be caused, in part, by loss of inhibition in spinal pain processing pathways due to attenuation of local GABAergic tone. Nociception and nocifensive behaviors are reduced after enhancement of tonically activated extrasynaptic GABAAR-mediated currents by agonist ligands for δ subunit-containing GABAARs. However, typical ligands that target δ subunit-containing GABAARs are limited due to sedative effects at higher doses. We used the spinal nerve ligation (SNL) and gp120 models of experimental neuropathic pain to evaluate compound 2-261, a nonbenzodiazepine site positive allosteric modulator of α4β3δ GABAARs optimized to be nonsedative by selective activation of β2/3-subunit-containing GABAARs over receptor subtypes incorporating β1 subunits. Similar levels of 2-261 were detected in the brain and plasma after intraperitoneal administration. Although systemic 2-261 did not alter sensory thresholds in sham-operated animals, it significantly reversed SNL-induced thermal and tactile hypersensitivity in a GABAAR-dependent fashion. Intrathecal 2-261 produced conditioned place preference and elevated dopamine levels in the nucleus accumbens of nerve-injured, but not sham-operated, rats. In addition, systemic pretreatment with 2-261 blocked conditioned place preference from spinal clonidine in SNL rats. Moreover, 2-261 reversed thermal hyperalgesia and partially reversed tactile allodynia in the gp120 model of HIV-related neuropathic pain. The effects of 2-261 likely required interaction with the α4β3δ GABAAR because 2-301, a close structural analog of 2-261 with limited extrasynaptic receptor efficacy, was not active. Thus, 2-261 may produce pain relief with diminished side effects through selective modulation of β2/3-subunit-containing extrasynaptic GABAARs.

Frailty, Psychoactive Medications, and Cognitive Dysfunction Are Associated With Poor Patient-Reported Outcomes in Cirrhosis

Cirrhosis is associated with disabling symptoms and diminished health-related quality of life (HRQOL). However, for patients with compensated disease, data are limited regarding associations with poor patient-reported outcomes (PROs). We prospectively enrolled 300 patients with cirrhosis and portal hypertension without a history of hepatic encephalopathy (HE) and reviewed medical and pharmacy records. We characterized determinants of PROs using the 8-item Short-Form Health Survey (SF-8) scale (0-100) and sleep quality using the Pittsburgh Sleep Quality Index (PSQI; poor sleep >5). Disability and frailty measures were assessed using activities of daily living (ADLs), falls, hand-grip, and chair-stands. Cognitive function was measured using weighted-lures from the Inhibitory Control Test (ICT). The median age of our cohort was 60 (interquartile range [IQR], 52-66) years, 56.3% were male, and 70% Child class A. All patients had portal hypertension, 76% had varices, and 41% had a history of ascites (predominantly well controlled). The median Model for End-Stage Liver Disease with Sodium (MELD-Na) score was 9 (IQR, 7-13). The overall median SF-8 was 70 (IQR, 54-86). Multivariate analysis showed that after adjusting for age, sex, education, and MELD-Na, performance on chair-stands (9.28 HRQOL points [95% confidence interval {CI}, 4.76-13.8] per 10-stands), ADL dependence (-6.06 [-10.8 to -1.36]), opiate use (-5.01 [-7.84 to -2.19]), benzodiazepine use (-3.50 [-6.58 to -0.42]), and ICT performance (-0.10 [-0.20 to 0.001] per weighted-lure) were significantly associated with HRQOL. Among patients completing the ICT, poor HRQOL (score <50) was significantly associated with chair-stands (odds ratio [OR] per 10-stands, 0.24; 95% CI [0.11-0.56]) and weighted lures (OR per weighted-lure, 1.01 [1.00-1.03]). Poor sleep quality was associated with opiate use (OR, 2.85 [1.11-7.29]) and lures (OR per-lure, 1.03 [1.00-1.05]). Conclusion: Disability, chair-stand performance, cognitive dysfunction, as well as psychoactive medication use are significantly associated with PROs in patients with clinically stable cirrhosis.