Associations Between Prescription Opioid Use and Sleep Impairment among Veterans with Chronic Pain

Baseline Characteristics From a New Longitudinal Cohort of Patients With Noncancer Pain and Chronic Opioid Use in the United States

Retrospective cohort studies have consistently observed that long-term prescription opioid use is a risk factor for new major depressive episodes. However, prospective studies are needed to confirm these findings and establish evidence for causation. The Prescription Opioids and Depression Pathways cohort study is designed for this purpose. The present report describes the baseline sample and associations between participant characteristics and odds of daily versus nondaily opioid use. Second, we report associations between participant characteristics and odds of depression, dysthymia, anhedonia, and vital exhaustion. Patients with noncancer pain were eligible if they started a new period of prescription opioid use lasting 30 to 90 days. Participants were 54.8 (standard deviation ± 11.3) years of age, 57.3% female and 73% White race. Less than college education was more common among daily versus nondaily opioid users (32.4% vs 27.3%; P = .0008), as was back pain (64.2% vs 51.3%; P < .0001), any nonopioid substance use disorder (12.8% vs 4.8%; P < .0001), and current smoking (30.7% vs 18.4% P < .0001). High pain interference (50.9% vs 28.4%; P < .0001) was significantly associated with depression, as was having more pain sites (6.9 ± 3.6 vs 5.7 ± 3.6; P < .0001), and benzodiazepine comedication (38.2% vs 23.4%; P < .0001). High pain interference was significantly more common among those with anhedonia (46.8% vs 27.4%; P < .0001), and more pain sites (7.0 ± 3.7 vs 5.6 ± 3.6; P < .0001) were associated with anhedonia. Having more pain sites (7.9 ± 3.6 vs 5.5 ± 3.50; P < .0001) was associated with vital exhaustion, as was back pain (71.9% vs 56.8%; P = .0001) and benzodiazepine comedication (42.8% vs 22.8%; P < .0001). Patients using prescription opioids for noncancer pain have complex pain, psychiatric, and substance use disorder comorbidities. Longitudinal data will reveal whether long-term opioid therapy leads to depression or other mood disturbances such as anhedonia and vital exhaustion. PERSPECTIVE: This study reports baseline characteristics of a new prospective, noncancer pain cohort study. Risk factors for adverse opioid outcomes were most common in those with depression and vital exhaustion and less common in dysthymia and anhedonia. Baseline data highlight the complexity of patients receiving long-term opioid therapy for noncancer pain.

Associations between insomnia symptoms and prescription opioid and benzodiazepine misuse in a nationally representative sample

BACKGROUND

There are complex associations between insomnia symptoms and misuse of prescription drugs. The aim of this study was to examine prospective associations between insomnia symptoms and prescription opioid and benzodiazepine misuse among a nationally representative sample of adults.

METHODS

Utilizing data from the National Longitudinal Study of Adolescent to Adult Health (N = 10,685), we conducted log-binomial regression to examine associations of insomnia symptoms at Wave IV (2008-2009; 24-32 years) with prescription opioid and benzodiazepine misuse at Wave V (2016-2018; 33-43 years). We adjusted analyses for prior insomnia symptoms and substance misuse, as well as potential demographic and health-related confounders.

RESULTS

Each unit increase in insomnia symptoms at Wave IV was associated with a small increase in the likelihood of prescription opioid (RR = 1.08, 95 % CI 1.01, 1.15) but not benzodiazepine (RR = 1.09, 95 % CI 0.99, 1.21) use at Wave V. Both prescription opioid (β = 0.20, 95 % CI 0.09, 0.031) and benzodiazepine (β = 0.21, 95 % CI 0.10, 0.33) misuse at Wave IV had small associations with elevated insomnia symptoms at Wave V.

CONCLUSIONS

Results support associations between prescription opioid and benzodiazepine misuse and later insomnia symptoms. There was a small association between insomnia symptoms and later prescription opioid misuse worthy of future study. These results fit within a broad line of research suggesting that insomnia symptoms are associated with future substance use and vice versa. Future research is needed explore mechanisms (e.g., mental health, pain) underlying these associations.

Healthcare resource utilisation and cost analysis associated with opioid analgesic use for non-cancer pain: A case-control, retrospective study between 2005 and 2015

Objective

To examine differences in healthcare utilisation and costs associated with opioid prescriptions for non-cancer pain issued in primary care.

Method

A longitudinal, case-control study retrospectively examined Welsh healthcare data for the period 1 January 2005–31 December 2015. Data were extracted from the Secure Anonymised Information Linkage (SAIL) databank. Subjects, aged 18 years and over, were included if their primary care record contained at least one of six overarching pain diagnoses during the study period. Subjects were excluded if their record also contained a cancer diagnosis in that time or the year prior to the study period. Case subjects also received at least one prescription for an opioid analgesic. Controls were matched by gender, age, pain-diagnosis and socioeconomic deprivation. Healthcare use included primary care visits, emergency department (ED) and outpatient (OPD) attendances, inpatient (IP) admissions and length of stay. Cost analysis for healthcare utilisation used nationally derived unit costs for 2015. Differences between case and control subjects for resource use and costs were analysed and further stratified by gender, prescribing persistence (PP) and deprivation.

Results

Data from 3,286,215 individuals were examined with 657,243 receiving opioids. Case subjects averaged 5 times more primary care visits, 2.8 times more OPD attendances, 3 times more ED visits and twice as many IN admissions as controls. Prescription persistence over 6 months and greater deprivation were associated with significantly greater utilisation of healthcare resources. Opioid prescribing was associated with 69% greater average healthcare costs than in control subjects. National Health Service (NHS) healthcare service costs for people with common, pain-associated diagnoses, receiving opioid analgesics were estimated to be £0.9billion per year between 2005 and 2015.

Conclusion

Receipt of opioid prescriptions was associated with significantly greater healthcare utilisation and accompanying costs in all sectors. Extended prescribing durations are particularly important to address and should be considered at the point of initiation.

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.

Sleep Disturbance Predicts Less Improvement in Pain Outcomes: Secondary Analysis of the SPACE Randomized Clinical Trial

OBJECTIVE

Sleep disturbance may limit improvement in pain outcomes if not directly addressed in treatment. Moreover, sleep problems may be exacerbated by opioid therapy. This study examined the effects of baseline sleep disturbance on improvement in pain outcomes using data from the Strategies for Prescribing Analgesics Comparative Effectiveness (SPACE) trial, a pragmatic 12-month randomized trial of opioid vs nonopioid medication therapy.

DESIGN

Participants with chronic back pain or hip or knee osteoarthritis pain were randomized to either opioid therapy (N = 120) or nonopioid medication therapy (N = 120).

METHODS

We used mixed models for repeated measures to 1) test whether baseline sleep disturbance scores modified the effect of opioid vs nonopioid treatment on pain outcomes and 2) test baseline sleep disturbance scores as a predictor of less improvement in pain outcomes across both treatment groups.

RESULTS

The tests for interaction of sleep disturbance by treatment group were not significant. Higher sleep disturbance scores at baseline predicted less improvement in Brief Pain Inventory (BPI) interference (β = 0.058, P = 0.0002) and BPI severity (β = 0.026, P = 0.0164).

CONCLUSIONS

Baseline sleep disturbance adversely affects pain response to treatment regardless of analgesic regimen. Recognition and treatment of sleep impairments that frequently co-occur with pain may optimize outcomes.

Daily associations between sleep and opioid use among adults with comorbid symptoms of insomnia and fibromyalgia

STUDY OBJECTIVES

Disturbed sleep and use of opioid pain medication are common among individuals with chronic pain. Anecdotally, opioids are thought to promote sleep by relieving pain. This study aimed to determine whether opioid use is associated with daily sleep parameters (and vice versa) in adults with comorbid symptoms of insomnia and fibromyalgia.

METHODS

Individuals reporting symptoms of insomnia and opioid use for fibromyalgia (n = 65, 93% women, 79% White) wore wrist actigraphy and completed daily diaries for 14 days (910 observations). Analyses examined daily associations between opioid dose (measured in lowest recommended dosage units) and three sleep parameters (actigraphy/self-reported total wake time and self-reported sleep quality). Multilevel models were used to account for the clustering of daily sleep and opioid assessments (level 1) within individuals (level 2).

RESULTS

Opioid use did not have a significant daily effect on total wake time or sleep quality, and sleep parameters did not significantly impact opioid use the next day; however, participants reported worse sleep quality and greater doses of opioids on evenings that they experienced greater pain.

CONCLUSIONS

Among adults reporting symptoms of insomnia and opioid use for fibromyalgia pain, opioid use is not reliably associated with wake time or sleep quality that night, and these sleep parameters are not significantly associated with opioid use the next day; however, evening pain has an adverse daily impact on both sleep quality and opioid use. Studies identifying strategies to prevent and manage fibromyalgia pain are needed, especially for individuals reporting comorbid insomnia and opioid use.

Prevalence and drug use correlates of extra-medical use of prescription medications for sleep among adults in the United States: Results of the 2015-2018 National Survey on Drug Use and Health

BACKGROUND

This paper examines the epidemiology of extra-medical use of prescription medications for sleep among a nationally representative sample of U.S. adults.

METHODS

We analyzed data from the 2015-2018 National Surveys on Drug Use and Health. The sample includes 3410 U.S. adults who reported extra-medical use of prescription medications for sleep. Multinomial logistic regression models identified correlates of type of drug used [i.e., sedatives and/or tranquilizers-only (ST-only), prescription pain relievers-only (PPR-only), or sedatives, tranquilizers, and prescription pain relievers (ST + PPR)], and logistic regression models identified correlates of reasons for extra-medical use (i.e., sleep-only vs. sleep and recreational).

RESULTS

About 60% (95%CI = 58.9, 63.5) of the sample reported extra-medical use of ST-only, followed by PPR-only (29.9%, 95%CI = 27.5, 32.5), and ST + PPR (8.9%, 95%CI = 7.7, 10.4). Recreational use was reported by 28.4% (95% CI = 26.5, 30.4) of the sample. The odds of extra-medical use of PPR-only (aRRR = 3.1, 95%CI = 2.1, 4.5) and ST + PPR (aRRR = 1.9, 95%CI = 1.2, 3.1) as opposed to ST-only, were greater among Non-Hispanic Blacks than Non-Hispanic Whites. Compared to non-alcohol users, those with a past-12 months diagnosis of alcohol use disorder were more likely to use ST + PPR rather than ST-only (aIRR = 2.0, 95%CI = 1.1, 3.7). Non-Hispanic Blacks (aOR = 0.6, 95%CI = 0.4, 08) and individuals living in rural areas (aOR = 0.5, 95%CI = 0.3, 09) were less likely to report extra-medical use of prescription medications for recreational reasons than Non-Hispanic Whites and those residing in large metropolitan areas, respectively.

CONCLUSIONS

Extra-medical use of PPR-only and ST + PPR as an aid to sleep, is prevalent among Non-Hispanic Blacks, young adults, and those residing in rural areas. Most individuals reported that extra-medical use of prescription medications was primarily motivated by sleep reasons, rather than by sleep and recreational reasons. Potential interventions include access to sleep treatments, education on the effectiveness and risk associated with extra-medical use and co-use of prescription medications for sleep, and research on sleep-related disparities.

The influence of sleep disturbances and sleep disorders on pain outcomes among veterans: A systematic scoping review

Chronic nonmalignant pain, sleep disturbances and sleep disorders are highly prevalent conditions among U.S. military veterans. Evidence summaries highlight the influence of sleep on pain outcomes in the general adult population but not for the military veteran population. This is a significant gap as U.S. military veterans are an exceedingly high-risk population for both chronic pain and sleep disturbances and/or disorders. We aimed to review the influence of sleep disturbances and sleep disorders on pain outcomes among veterans with chronic nonmalignant pain. A systematic scoping review was conducted using PubMed/Medline, EMBASE, Scopus, CINAHL, and PsycINFO. Twenty-six out of 1450 studies from initial search were included in this review resulting in a combined sample size of N = 923,434 participants. Sleep disturbances and sleep disorders were associated with worse pain outcomes among veterans with chronic pain. Treatment-induced sleep improvements ameliorated pain outcomes in veterans with sleep disorders and sleep disturbances. Research is indicated to address an overlooked pain treatment opportunity - that of sleep disturbance and sleep disorder management.

Patterns and predictors of opioid use among migraine patients at emergency departments: A retrospective database analysis

Objectives

To compare medication use and health resource utilization between migraineurs with evidence of opioid use at emergency department visit versus no opioid use at emergency department visit, and to examine predictors of opioid use among migraineurs at emergency department visits.

Methods

This was a retrospective study using REACHnet electronic health records (December 2013 to April 2017) from Baylor Scott & White Health Plan. The index date was defined as the first migraine-related emergency department visit after ≥6 months of enrollment. Adult patients with a migraine diagnosis and ≥6 months of continuous enrollment before and after their index dates were included. Descriptive statistics and bivariate analyses were used to compare medication use and health resource utilization between opioid users and non-opioid users. Multivariable logistic regression was used to examine predictors of opioid use at emergency department visits.

Results

A total of 788 migraineurs met eligibility criteria. Over one-third (n = 283, 35.9%) received ≥1 opioid medication during their index date emergency department visit. Morphine (n = 103, 13.1%) and hydromorphone (n = 85, 10.8%) were the most frequently used opioids. Opioid users had more hospitalizations and emergency department visits during their pre-index period (both p < 0.05). Significant ( p < 0.05) predictors of opioid use at emergency department visits included past migraine-related opioid use (2–4 prescriptions, Odds Ratio = 1.66; 5–9 prescriptions, Odds Ratio = 2.12; ≥10 prescriptions, Odds Ratio = 4.43), past non-migraine-related opioid use (≥10 prescriptions, Odds Ratio = 1.93), past emergency department visits (1–3 visits, Odds Ratio = 1.84), age (45–64 years, Odds Ratio = 1.45), and sleep disorder (Odds Ratio = 1.43), controlling for covariates.

Conclusion

Opioids were commonly given to migraineurs at emergency departments. Previous opioid use, health resource utilization, age, and specific comorbidities might be used to identify migraineurs with a high risk of opioid use.

Opioid use, pain intensity, age, and sleep architecture in patients with fibromyalgia and insomnia

Opioid use and sleep disruption are prevalent in fibromyalgia. Yet, the effects of opioids on physiological sleep in fibromyalgia are unclear. This study assessed associations between opioid use/dosage and polysomnographically assessed sleep in patients with fibromyalgia and insomnia (FMI) and examined moderating effects of age and pain. Participants (N = 193, Mage = 51.7, SD = 11.8, range = 18-77) with FMI completed ambulatory polysomnography and 14 daily diaries. Multiple regression determined whether commonly prescribed oral opioid use or dosage (among users) independently predicted or interacted with age/pain intensity to predict sleep, controlling for sleep medication use and apnea hypopnea index. Opioid use predicted greater %stage 2 and lower %slow-wave sleep (%SWS). Opioid use interacted with age to predict greater sleep onset latency (SOL) in middle-aged/older adults. Among opioid users (n = 65, ∼3 years usage), opioid dose (measured in lowest recommended dosage) interacted with age to predict SOL and sleep efficiency; specifically, higher dosage predicted longer SOL and lower sleep efficiency for older, but not middle-aged/younger adults. Opioid dose interacted with pain to predict %SWS and arousal index. Specifically, higher dosage predicted reduced %SWS and higher arousal index for individuals with lower pain, increased %SWS for individuals with higher pain, and did not predict %SWS for patients with average pain. Opioid use/dosage did not predict wake after sleep onset, total sleep time, %stage 1 or %rapid eye movement sleep. Opioid use prompts changes in sleep architecture among individuals with FMI, increasing lighter sleep and reducing SWS. Sleep disruption is exacerbated at higher opioid doses in older adults and patients with low pain.

Nonpharmacological Treatment of Army Service Members with Chronic Pain Is Associated with Fewer Adverse Outcomes After Transition to the Veterans Health Administration

BACKGROUND

Potential protective effects of nonpharmacological treatments (NPT) against long-term pain-related adverse outcomes have not been examined.

OBJECTIVE

To compare active duty U.S. Army service members with chronic pain who did/did not receive NPT in the Military Health System (MHS) and describe the association between receiving NPT and adverse outcomes after transitioning to the Veterans Health Administration (VHA).

DESIGN AND PARTICIPANTS

A longitudinal cohort study of active duty Army service members whose MHS healthcare records indicated presence of chronic pain after an index deployment to Iraq or Afghanistan in the years 2008-2014 (N = 142,539). Propensity score-weighted multivariable Cox proportional hazard models tested for differences in adverse outcomes between the NPT group and No-NPT group.

EXPOSURES

NPT received in the MHS included acupuncture/dry needling, biofeedback, chiropractic care, massage, exercise therapy, cold laser therapy, osteopathic spinal manipulation, transcutaneous electrical nerve stimulation and other electrical manipulation, ultrasonography, superficial heat treatment, traction, and lumbar supports.

MAIN MEASURES

Primary outcomes were propensity score-weighted proportional hazards for the following adverse outcomes: (a) diagnoses of alcohol and/or drug disorders; (b) poisoning with opioids, related narcotics, barbiturates, or sedatives; (c) suicide ideation; and (d) self-inflicted injuries including suicide attempts. Outcomes were determined based on ICD-9 and ICD-10 diagnoses recorded in VHA healthcare records from the start of utilization until fiscal year 2018.

KEY RESULTS

The propensity score-weighted proportional hazards for the NPT group compared to the No-NPT group were 0.92 (95% CI 0.90-0.94, P < 0.001) for alcohol and/or drug use disorders; 0.65 (95% CI 0.51-0.83, P < 0.001) for accidental poisoning with opioids, related narcotics, barbiturates, or sedatives; 0.88 (95% CI 0.84-0.91, P < 0.001) for suicide ideation; and 0.83 (95% CI 0.77-0.90, P < 0.001) for self-inflicted injuries including suicide attempts.

CONCLUSIONS

NPT provided in the MHS to service members with chronic pain may reduce risk of long-term adverse outcomes.

Using Pain Medication Intensity to Stratify Back Pain Among Older Adults

Objective

To examine the prevalence of musculoskeletal back pain among older adults stratified by pain medication intensity to 1) review treatment patterns and 2) consider targeted back pain prevention interventions.

Methods

A random sample of older adults age 64 years and older was utilized to identify new and recurring back pain. Prescription pain medications from drug claims were used to stratify to five unique intensity levels. The characteristics of each level were determined using regression models.

Results

About 10% had musculoskeletal back pain. Of these, 54% (N = 20,645) had new back pain and 46% (N = 17,252) had recurring back pain. Overall, about 35% received physical therapy. Pain medication intensity levels included no prescription pain medications, nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, low-dose opioids, and high-dose opioids (new back pain: 39%, 10%, 6%, 23%, and 23%, respectively; recurring back pain 32%, 9%, 4%, 17%, and 38%, respectively). NSAID and muscle relaxant users were younger, healthier, and received physical therapy. Opioid users were younger, in poorer health, used sleep medications, received physical therapy, and had more falls and higher health care utilization and expenditures.

Conclusions

New and recurring back pain patients can be stratified by pain medication intensity to review treatment patterns and target back pain prevention programs. Those with back pain but taking no prescription pain medications may benefit from back pain prevention programs. More research on guidelines for treatment options for those on high levels of pain medications is warranted.

Differential Effects of Addictive Drugs on Sleep and Sleep Stages

Addictive drugs affect sleep both in individuals currently using drugs and in individuals who have withdrawn from drugs. In fact, sleep disturbances are reported by individuals for some drugs long after they have quit taking them and after other withdrawal symptoms have subsided. This suggests that addictive drugs and sleep share some of the same neurobiological mechanisms. Sleep researchers may be studying the neurobiology of addictive drugs without knowing it. The purpose of this survey is to summarize the effects that addictive drugs have on sleep and stages of sleep. We demonstrate that different addictive drugs have differential effects on disturbance of sleep, in general, and on specific stages of sleep either while the drug is on board or after withdrawal. Accordingly, these results are intended to encourage sleep researchers to use their knowledge of sleep mechanisms to offer researchers of addictive drugs new insights of how addictive drugs might affect brain mechanisms. Also, these results should alert researchers of addiction that treatment for drug effects needs to consider treatment for sleep disturbances as well. Treatment for addiction is rarely accompanied by treatment for sleep disturbances even though this survey demonstrates they are clearly related.

Delivering Cognitive Behavioral Therapy for Insomnia in Military Personnel and Veterans

Insomnia is commonly reported by military populations, especially those with comorbid mental and physical health conditions. Co-occurring conditions result in an altered presentation of insomnia symptoms, and complicate provision of cognitive-behavioral therapy for insomnia (CBT-I), requiring supplementary assessment or modifications to traditional techniques. CBT-I has consistently demonstrated positive outcomes for active-duty service members and veterans, even in the context of significant comorbidities such as post-traumatic stress disorder, depression, sleep apnea, and chronic pain. Despite its promise, studies of CBT-I in some populations, including women and individuals with substance use disorders, remain relatively understudied in active-duty and veteran populations.

The Mediating Effect of Sleep Disturbance on the Relationship Between Nonmalignant Chronic Pain and Suicide Death

IMPORTANCE

Few studies have examined the relationship between nonmalignant chronic pain (NMCP) and suicide death, and even fewer have specifically explored what role sleep disturbance might play in the association between NMCP and suicide death.

OBJECTIVE

To assess whether sleep disturbance mediates the relationship between NMCP and suicide death.

DESIGN

This case-control study included 2,674 individuals who died by suicide between 2000 and 2013 (cases) and 267,400 matched individuals (controls).

SETTING

Eight Mental Health Research Network (MHRN)-affiliated healthcare systems.

PARTICIPANTS

All cases and matched controls were health plan members for at least 10 months during the year prior to the index date.

MAIN OUTCOMES AND MEASURES

Sociodemographic data and diagnosis codes for NMCP and sleep disorders were extracted from the MHRN's Virtual Data Warehouse. Suicide mortality was identified using International Statistical Classification of Diseases and Related Health Problems (ICD)-10 codes from official government mortality records matched to health system records.

RESULTS

After accounting for covariates, there was a significant relationship between NMCP and sleep disturbance; those who were diagnosed with NMCP were more likely to develop subsequent sleep disturbance. Similarly, sleep disturbance was significantly associated with suicide death. Finally, a significant indirect effect of NMCP on suicide death, through sleep disturbance, and a nonsignificant direct effect of NMCP on suicide death provide support for a fully mediated model.

CONCLUSIONS AND RELEVANCE

There is a need for clinicians to screen for both sleep disturbance and suicidal ideation in NMCP patients and for health systems to implement more widespread behavioral treatments that address comorbid sleep problems and NMCP.

Pain intensity as a moderator of the association between opioid use and insomnia symptoms among adults with chronic pain

OBJECTIVE

Research documenting the impact of opioid use on sleep among individuals with chronic pain has been mixed. This study aimed to determine if pain intensity moderates the association between opioid use and insomnia symptoms among adults with comorbid symptoms of insomnia and chronic widespread pain.

METHODS

Participants (N = 144; 95% female; mean age = 51.6, SD = 11.4) completed assessments of insomnia symptoms, pain and use of sleep/pain medication. Multiple regression was used to determine if pain intensity moderates the association between opioid use (yes/no) sleep onset latency (SOL), wake after sleep onset (WASO), sleep quality, or time in bed. Analyses controlled for gender, symptoms of sleep apnea, symptoms of depression, use of sleep medication (yes/no), and use of non-opioid pain medication (yes/no).

RESULTS

Stronger pain intensity was associated with longer self-reported WASO and worse sleep quality, independent of opioid use. Conversely, opioid use was associated with longer time in bed, independent of pain intensity. Opioid use and pain intensity interacted in the prediction of SOL, such that opioid use (vs. non-use) was associated with longer SOL in the context of mild but not moderate to severe pain intensity.

CONCLUSIONS

Opioid use was associated with more difficulty falling asleep among adults with chronic pain; however, this cross-sectional effect was only significant among those reporting lower pain intensity. Authors speculate that this effect is masked among those with severe pain because the pain-related sleep debt they acquire throughout the night then facilitates sleep onset the next day.

Traumatic Brain Injury and Receipt of Prescription Opioid Therapy for Chronic Pain in Iraq and Afghanistan Veterans: Do Clinical Practice Guidelines Matter?

Clinical practice guidelines admonish against prescribing opioids for individuals with chronic pain and traumatic brain injury (TBI) because of increased risk for adverse outcomes, yet no studies have described opioid prescribing patterns in these higher-risk patients. Between October 2007 and March 2015, 53,124 Iraq and Afghanistan veterans with chronic pain not prescribed opioids in the previous year were followed for 1 year after completing a Comprehensive TBI Evaluation within the Department of Veterans Affairs health care facilities. Veterans reporting the most severe TBI sequelae (eg, loss of consciousness >30 minutes) were significantly more likely to receive short-term and long-term opioid therapy than those with less severe or no TBI sequelae (P values < .001). In analyses adjusted for sociodemographic characteristics, military service, pain disability, and previous nonopioid treatment modalities, veterans with moderate to severe TBI had a significantly increased risk of receiving opioid therapy. Veterans with moderate to severe TBI and comorbid post-traumatic stress disorder and depression had an even greater risk of initiating long-term opioid therapy in the year after the Comprehensive TBI Evaluation (adjusted relative risk = 3.57 [95% confidence interval = 2.85-4.47]). Higher-risk patients with chronic pain and TBI with mental health comorbidities may benefit from improved access to behavioral health and nonpharmacological therapies for chronic pain.

PERSPECTIVE

Paradoxically, veterans with greater TBI severity and comorbid mental health burden are more likely to be prescribed opioids for chronic pain. More vulnerable veterans may benefit from improved access to behavioral health and nonpharmacological modalities for chronic pain, because of the health and safety risks of opioids.

Long-term Correction in Sleep Disturbance Is Sustained After Arthroscopic Rotator Cuff Repair

BACKGROUND

Sleep disturbance is a major complaint of patients with rotator cuff disease that often leads them to seek treatment. The authors previously reported a prospective analysis of patients who underwent rotator cuff repair and found that sleep disturbance significantly improved at 3 months after surgery. That improvement in sleep was maintained at 6 months.

HYPOTHESIS

In the current study, the authors sought to gain medium-term data on this same population at greater than 2 years. The hypotheses were that improvement in sleep disturbance after arthroscopic rotator cuff repair is maintained at 2-year follow-up and that the continued use of narcotic pain medication has a negative effect on sleep quality at 2-year follow-up.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

The original cohort of patients was contacted at a minimum of 24 months after their surgery. Thirty-seven of the 56 patients (66%) involved in the original study were available. Patient outcomes were scored using the Pittsburgh Sleep Quality Index (PSQI), Simple Shoulder Test (SST), visual analog scale (VAS) for pain, and Single Assessment Numeric Evaluation (SANE). The newly obtained scores were compared with prior scores, which ranged from preoperatively to 6 months postoperatively.

RESULTS

The statistically significant improvement of the PSQI score demonstrated in our prior analysis at 6 months postoperatively was maintained, with a mean PSQI score of 5.5 for the 37 patients followed beyond 24 months. Of those patients, 41% still had a PSQI score >5, indicative of sleep disturbance. However, even those patients in our study with a PSQI score >5, indicative of sleep disturbance, had an improved mean score of 9.3 at greater than 24 months compared with those patients with a PSQI score >5 at 6 months, who had a mean PSQI score of 11.5 ( P = .13). Both the SST and VAS scores displayed continued improvement at greater than 24 months, with both displaying moderate strength correlation to the PSQI score (VAS: Spearman rho = 0.479, P < .001; SST: Spearman rho = -0.505, P < .001). Regression models again demonstrated the continued use of narcotic pain medication correlating with poor sleep as the difference in the mean PSQI score between users and nonusers increased as postoperative time increased. At greater than 24 months after surgery, patients using narcotics had a mean PSQI score that was 7.4 points higher than narcotic nonusers (standard error [SE] = 1.93; P = .00017).

CONCLUSION

At greater than 24 months, 41% of patients still demonstrated sleep disturbance, with both SST and VAS scores showing improvement. The prolonged use of narcotic medication negatively affects sleep, with a greater effect seen over time.

Evaluation of the Sleepy Patient: Differential Diagnosis

Excessive daytime sleepiness is defined as the inability to maintain wakefulness during waking hours, resulting in unintended lapses into sleep. It is important to distinguish sleepiness from fatigue. The evaluation of a sleep patient begins with a careful clinical assessment that includes a detailed sleep history, medical and psychiatric history, a review of medications, as well as a social and family history. Physical examination should include a general medical examination with careful attention to the upper airway and the neurologic examination. Appropriate objective testing with a polysomnogram and a multiple sleep latency test if needed will help confirm the diagnosis and direct the appropriate treatment plan.

Psychiatric comorbidities in opioid-dependent patients undergoing a replacement therapy programme in Spain: The PROTEUS study

Opioid-dependent patients show a high rate of psychiatric comorbidities. The prevalence and characteristics of patients with dual diagnosis have not been well established in Spanish opioid agonist treatment (OAT) programmes. Thus, 621 opioid-dependent patients enrolled in OAT programmes were assessed, using the EuropASI questionnaire, for psychiatric comorbidities, which were detected in 67% of patients (anxiety 53%, mood disorders 48%, sleep disorders 41%, substance-related disorders 36%). In addition, compared with patients without a dual diagnosis, patients with dual pathology were significantly older, used benzodiazepines and cannabis in significantly greater percentages, and showed significantly more frequent infectious and non-infectious comorbidities, worse overall working status, a lower proportion of drivers and higher levels of severity regarding medical, employment, alcohol, legal, family and psychological issues. Therefore, the data showed a very high prevalence of psychiatric comorbidity in opioid-dependent patients receiving OAT in Spain and several problems frequently associated with patients with dual diagnosis. Physicians treating opioid-dependent patients should be aware of these facts to correctly identify and manage patients with a dual diagnosis.

A prospective, longitudinal study of sleep disturbance and comorbidity in opiate dependence (the ANRS Methaville study)

RATIONALE/OBJECTIVES

Sleep disturbance is frequent in opioid-dependent patients. To date, no data are available about the impact of methadone maintenance treatment on sleep disturbance. Using 1-year follow-up data from the Methaville trial, we investigated the impact of methadone initiation and other correlates on sleep disturbance in opioid-dependent patients.

METHODS

Sleep disturbance severity was evaluated using two items from different scales (Center for Epidemiological Studies Depression Scale for depression and Opiate Treatment Index). We assessed the effect of methadone and other correlates on sleep disturbance severity during follow-up (months 0, 6, and 12) using a mixed multinomial logistic regression model.

RESULTS

We included 173 patients who had 1-year follow-up data on sleep disturbance, corresponding to 445 visits. At enrolment, 60.5 % reported medium to severe sleep disturbance. This proportion remained stable during methadone treatment: 54.0 % at month 6 and 55.4 % at month 12. The final multivariate model indicated that younger patients (odds ratio (OR) [95 % CI] 0.95 [0.90-1.00]), patients with pain (OR [95 % CI] 2.45 [1.13-5.32]), patients with high or very high nicotine dependence (OR [95 % CI] 5.89 [2.41-14.39]), and patients at suicidal risk (2.50 [1.13-5.52]) had a higher risk of severe sleep disturbance. Because of collinearity between suicidal risk and attention deficit hyperactivity disorder (ADHD) symptoms, ADHD was not associated with sleep disturbance in the final model. Receiving methadone treatment had no significant effect on sleep disturbance.

CONCLUSIONS

Sleep disturbance is frequent among opioid-dependent patients. It can be regarded as an important signal of more complex psychiatric comorbidities such as suicidal risk and ADHD. However, sleep disturbance should not be considered an obstacle to methadone maintenance treatment (MMT) initiation or continuation.