Risks and responsibilities in prescribing opioids for chronic noncancer pain, part 2: best practices

Psychosocial problems and high amount of opioid administration are associated with opioid dependence and abuse after first exposure for chronic pain patients

Controversy surrounding the use of opioids for the treatment and the unique characteristics of chronic pain heighten the risks for abuse and dependence; however, it's unclear if higher doses of opioids and first exposure are associated with dependence and abuse. This study aimed to identify patients who developed dependence or opioid abuse after exposed to opioids for the first time and what were the risks factors associated with the outcome. A retrospective observational cohort study analyzed 2,411 patients between 2011 and 2017 who had a diagnosis of chronic pain and received opioids for the first time. A logistic regression model was used to estimate the likelihood of opioid dependence/abuse after the first exposure based on their mental health conditions, prior substance abuse disorders, demographics, and the amount of MME per day patients received. From 2,411 patients, 5.5 % of the patients had a diagnosis of dependence or abuse after the first exposure. Patients who were depressed (OR = 2.09), previous non-opioid substance dependence or abuse (OR = 1.59) or received greater than 50 MME per day (OR = 1.03) showed statistically significant relationship with developing opioid dependence or abuse, while age (OR = -1.03) showed to be a protective factor. Further studies should stratify chronic pain patients into groups who is in higher risk in developing opioid dependence or abuse and develop alternative strategies for pain management and treatments beyond opioids. This study reinforces the psychosocial problems as determinants of opioid dependence or abuse and risk factors, and the need for safer opioid prescribing practices.

Prescription drug monitoring programs: Assessing the association between "best practices" and opioid use in Medicare

OBJECTIVE

To estimate the impact of implementing prescription drug monitoring program (PDMP) best practices on prescription opioid use.

DATA SOURCES

2007-2012 Medicare claims for noncancer pain patients, and PDMP attributes from the Prescription Drug Abuse Policy System.

STUDY DESIGN

We derived PDMP composite scores using the number of best practices adopted by states (range: 0-14), classifying states as either no PDMP, low strength (0 < score < median), or high strength (score ≥ median). Using generalized linear models, we quantified the association between the PDMP score category and opioid use measures-overall and stratified by disability/age. Sensitivity analyses assessed the general Medicare sample regardless of pain diagnoses, individual PDMP characteristics, and compared GEE model findings to models with state fixed effects.

PRINCIPAL FINDINGS

Compared to non-PDMP states, strong PDMP states had lower opioid cumulative doses (-296 mg; 95% CI: -512, -132), days supplied (-7.84; 95% CI: -10.6, -5.04), prescription fill rates (0.97; 95% CI: 0.95, 0.98), and mean daily doses (-2.31 mg; 95% CI: -3.14, -1.48) but greater prevalence of high opioid doses in disabled adults, whereas there was little or no change in older adults. Findings in states with weak PDMPs were substantively similar to those of strong PDMPs. Results from sensitivity analyses were mostly consistent with main findings except there was a null relationship with mean daily doses and high doses in models with state fixed effects.

CONCLUSIONS

Comprehensive or minimal adoption of PDMP best practices was associated with mostly comparable effects on Medicare beneficiaries' opioid use; however, these effects were concentrated among nonelderly disabled adults.