Depression in chronic pain: might opioids be responsible?

Association between opioid utilization and patient-reported outcome measures following lumbar spine surgery

BACKGROUND CONTEXT

The patient-reported outcomes measurement information system (PROMIS), created by the National institute of Health, is a reliable and valid survey for patients with lumbar spine pathology. Preoperative opioid use has been shown to be an important predictor variable of self-reported health status in legacy patient-reported outcome measures.

PURPOSE

To investigate the impact of chronic preoperative opiate use on PROMIS survey scores.

STUDY DESIGN

Retrospective database analysis.

PATIENT SAMPLE

Between March 2019 and November 2021, 227 patients underwent lumbar decompression ± ≤ 2 level fusion. Fifty-seven patients (25.11%) had chronic preoperative opioid use.

OUTCOME MEASURES

Oswestry disability index (ODI) and PROMIS survey scores.

METHODS

A retrospective analysis of a prospectively maintained single center patient-reported outcome database was performed with a minimum of 2 year follow-up. PROMIS Anxiety, Depression, Fatigue, Pain Interference (PI), Physical Function (PF), Sleep disturbance (SD), and Social Roles (SR) surveys were recorded at preoperative intake with subsequent follow-up at 6, 12, and 24 months postoperatively. Patients were grouped into chronic opioid users as defined by >6-month duration of use. Differences in mean survey scores were evaluated using Welch t-tests.

RESULTS

Two hundred and twenty-seven patients met our inclusion criteria of completed PROMIS surveys at the designated timepoints. A total of 57 (25.11%) were chronic opioid users (COU) prior to surgery. Analysis of patient-reported health outcomes shows that long term opioid use correlated with worse ODI and PROMIS scores at baseline compared to nonchronic users (NOU). At 1 and 2 year follow-up, the COU cohort continued to have significantly worse ODI, PROMIS Fatigue, PF, PI, SD, and SR scores. There is a statistical difference in the magnitude of change in health status between the 2 cohorts at 1 year follow-up in PROMIS Depression (-5.04±7.88 vs -2.49±8.73, p=.042), PF (6.25±7.11 vs 9.03±9.04, p=.019), and PI (-7.40±7.37 vs -10.58±9.87, p=.011) and 2 year follow-up in PROMIS PF (5.58±6.84 vs 7.99±9.64, p=.041) and PI (-6.71±8.32 vs -9.62±10.06, p=.032). Mean improvement in PROMIS scores for the COU cohort at 2 year follow-up exceeded minimal clinically important difference (MCID) in all domains except PROMIS Depression, SR and SD.

CONCLUSION

Patients with chronic opioid use status have worse baseline PROMIS scores compared with patients who had nonchronic use. However, patients in the COU cohort displayed clinically significant postoperative improvement in multiple PROMIS domains. These results show that patients with chronic opioid use can benefit greatly from surgical intervention and will allow physicians to better set expectations with their patients.

Concepts and Approaches in the Management of Transgender and Gender-Diverse Patients

The terms transgender and gender diverse (TGD) describe persons whose gender is different from the sex assigned to them at birth. While TGD persons have experienced a rise in cultural and social visibility in recent decades, they continue to experience significant health inequities, including adverse health outcomes and multiple barriers to accessing medical care. Transgender and gender-diverse persons are at a higher risk for pain conditions than their cisgender counterparts, but research on chronic pain management for TGD persons is lacking. Clinicians from all disciplines must be informed of best practices for managing chronic pain in the TGD population. This includes all aspects of care including history, physical examination, diagnosis, treatment, and perioperative management. Many TGD persons report delaying or avoiding care because of negative interactions with medical practitioners who do not have sufficient training in navigating the specific health care needs of TGD patients. Furthermore, TGD persons who do seek care are often forced to educate their practitioners on their specific health care needs. This paper provides an overview of existing knowledge and recommendations for physicians to provide culturally and medically appropriate care for TGD persons.

Does opioid therapy enhance quality of life in patients suffering from chronic non-malignant pain? A systematic review and meta-analysis

Background and objective

Chronic pain is associated with a poor health-related quality of life (HRQL). Whereas the prescription rate of opioids increased during the last decades, their use in chronic non-malignant pain remains unclear. However, there is currently no clinical consensus or evidence-based guidelines that consider the long-term effects of opioid therapy on HRQL in patients with chronic non-cancer pain. This systematic review aims to address the question of whether opioid therapy improves HRQL in patients with chronic non-malignant pain and provide some guidance to practitioners.

Databases and data treatment

PubMed, EMBASE and CENTRAL were searched in June 2020 for double-blind, randomized trials (RCTs), comparing opioid therapy to placebo and assessed a HRQL questionnaire. The review comprises a qualitative vote counting approach and a meta-analysis of the Short Form Health Survey (SF-36), EQ-5D questionnaire and the pain interference scale of the Brief pain inventory (BPI).

Results

35 RCTs were included, of which the majority reported a positive effect of opioids for the EQ-5D, the BPI and the physical component score (PCS) of the SF-36 compared to placebo. The meta-analysis of the PCS showed a mean difference of 1.82 [confidence interval: 1.32, 2.32], the meta-analysis of the EQ-5D proved a significant advantage of 0.06 [0.00, 0.12]. In the qualitative analysis of the mental component score (MCS) of the SF-36, no positive or negative trend was seen. No significant differences were seen in the MCS (MD: 0.65 [-0.43, 1.73]). A slightly higher premature dropout rate was found in the opioid group (risk difference: 0.04 [0.00, 0.07], p = .07). The body of evidence is graded as low to medium.

Conclusion

Opioids have a statistically significant, but small and clinical not relevant effect on the physical dimensions of HRQL, whereas there is no effect on mental dimensions of HRQL in patients with chronic non-malignant pain during the initial months of treatment. In clinical practice, opioid prescriptions for chronic non-cancer pain should be individually assessed as their broad efficacy in improving quality of life is not confirmed. The duration of opioid treatment should be determined carefully, as this review primarily focuses on the initial months of therapy.

The contribution of pain catastrophizing, depression and anxiety symptoms among patients with persistent pain and opioid misuse behaviours

BACKGROUND

Anxiety, depression and pain catastrophizing are independently associated with risk of opioid misuse in patients with persistent pain but their relationship to current opioid misuse, when considered together, is poorly understood. This study will assess the relative contribution of these modifiable, and distinct psychological constructs to current opioid misuse in patients with persistent pain.

METHODS

One hundred and twenty-seven patients referred to a specialized opioid management clinic for prescription opioid misuse within a tertiary pain service were recruited for this study. The Pain Catastrophizing Scale, Depression, Anxiety and Stress Scales and the Current Opioid Misuse Measure were administered pre-treatment. Pain severity and morphine equivalent dose based on independent registry data were also recorded.

RESULTS

Higher levels of pain catastrophizing, depression, and anxiety were significantly associated with higher current opioid misuse (r = .475, 0.599, and 0.516 respectively, p < .01). Pain severity was significantly associated with pain catastrophizing (r = .301, p < .01). Catastrophizing, depression, and anxiety explained an additional 11.56% of the variance (R2 change = 0.34, p < .01) over and above age, gender, pain severity and morphine equivalent dose. Depression was the only significant variable at Step 2 (β = 0.62, p < .01).

CONCLUSION

Findings show that in a sample of people with persistent pain referred for treatment for opioid misuse, depression contributes over and above that of anxiety and pain catastrophizing. Theoretical and clinical practice implications are presented.

Problems with opioids - beyond misuse

The U.S. is grappling with an opioid epidemic, with millions of adults on long-term opioid therapy (LTOT). Although patients often report pain relief and improved daily function with opioids, research shows no significant differences in short-term outcomes between opioid and non-opioid users, as well as no long-term opioid benefits. This scoping review aims to identify lesser-known side effects of long-term opioid use and increase awareness of them, allowing healthcare providers and patients to better assess the risks and benefits of opioid use. Our data search from PubMed and Google Scholar used keywords related to opioids, chronic pain, hypogonadism, endocrinopathies, cancer progression, cardiovascular events, renovascular events, sleep disturbances, mood disorders and others, narrowing down to English-language full articles published from January 2018 to April 2023. This review emphasizes the probable serious adverse consequences of long-term opioid use on various body systems in patients with chronic pain. Given the lack of long-term benefits and significant adverse effects, our review underscores the critical need for healthcare providers to include these risks in discussions with patients when considering the long-term use of opioid therapy.

Influence of controlled environmental conditions in potential salivary ocular pain biomarkers for enhancing the assessment of ocular pain

PURPOSE

We endeavored to identify objective salivary biomarkers for pain, a subjective sensation with a biological basis, using molecules already described related to pain. The study aimed to analyze inter-individual differences and intersession variability in salivary potential ocular pain biomarkers on healthy subjects, in samples obtained under the influence of controlled environmental conditions.

METHODS

Thirty-four healthy subjects, 20 male, 14 female, median age 35.44 years (range 30-40) were exposed for 30 minutes under standard environmental conditions (T: 22°C, 50% relative humidity) in the Controlled Environmental Research Laboratory (CE-Lab, Vision R&D, Valladolid Spain) in two separate visits (V1, V2) at least 24 hours apart. Saliva was collected after the exposure in each of the visits, and cortisol, α-amylase (sAA), secretory IgA (sIgA), testosterone, and soluble fraction of TNFα receptor II (sTNFαRII) were analyzed by ELISA. Repeatability of inter-subject inter-session measurements was assayed by intraclass correlation coefficient (ICC).

RESULTS

There were no significant inter-session differences in testosterone (p = 0.2497), sTNFαRII (p = 0.6451) and sIgA (p = 0.9689) salivary levels. The reproducibility for salivary cortisol, sAA, testosterone, sTNFαRII and sIgA were 0.98 ng/ml, 20.58 U/ml, 21.07 μg/ml, 24.68 pg/ml and 0.19 pg/ml, respectively. Salivary cortisol, sAA, testosterone, sTNFαRII and sIgA yielded the following ICCs: 0.506, 0.569, 0.824, 0.870 and 0.4295, respectively; all these ICCs (except that for cortisol and sIgA) were found to be improved compared to those found previously by our group in a previous study in salivary samples obtained from healthy subjects under non-controlled environmental conditions; Cortisol´s ICC didn´t improve and was in both cases at the limit of acceptability.

CONCLUSION

Environmental factors such as temperature and relative humidity affect the reproducibility of measurement of some salivary molecules which have been proposed as potential pain biomarkers. The exposure of subjects to standard controlled environmental conditions before salivary sample obtention would improve the reproducibility of these molecule measures' as potential biomarkers of chronic ocular pain.

The soluble epoxide hydrolase inhibitor TPPU improves comorbidity of chronic pain and depression via the AHR and TSPO signaling

BACKGROUND

Patients suffering from chronic pain often also exhibit depression symptoms. Soluble epoxide hydrolase (sEH) inhibitors can decrease blood levels of inflammatory cytokines. However, whether inhibiting sEH signaling is beneficial for the comorbidity of pain and depression is unknown.

METHODS

According to a sucrose preference test (SPT), spared nerve injury (SNI) mice were classified into pain with or without an anhedonia phenotype. Then, sEH protein expression and inflammatory cytokines were assessed in selected tissues. Furthermore, we used sEH inhibitor TPPU to determine the role of sEH in chronic pain and depression. Importantly, agonists and antagonists of aryl hydrocarbon receptor (AHR) and translocator protein (TSPO) were used to explore the pathogenesis of sEH signaling.

RESULTS

In anhedonia-susceptible mice, the tissue levels of sEH were significantly increased in the medial prefrontal cortex (mPFC), hippocampus, spinal cord, liver, kidney, and gut. Importantly, serum CYP1A1 and inflammatory cytokines, such as interleukin 1β (IL-1β) and the tumor necrosis factor α (TNF-α), were increased simultaneously. TPPU improved the scores of mechanical withdrawal threshold (MWT) and SPT, and decreased the levels of serum CYP1A1 and inflammatory cytokines. AHR antagonist relieved the anhedonia behaviors but not the algesia behaviors in anhedonia-susceptible mice, whereas an AHR agonist abolished the antidepressant-like effect of TPPU. In addition, a TSPO agonist exerted a similar therapeutic effect to that of TPPU, whereas pretreatment with a TSPO antagonist abolished the antidepressant-like and analgesic effects of TPPU.

CONCLUSIONS

sEH underlies the mechanisms of the comorbidity of chronic pain and depression and that TPPU exerts a beneficial effect on anhedonia behaviors in a pain model via AHR and TSPO signaling.

The Association of Opioid Misuse and Suicidality among People with Disabilities

Background/Purpose: Past research has linked non-medical prescription opioid use (NMPOU) with suicide, though less focus has been placed among people with disabilities impacted by the opioid epidemic. This study examined the relationship of NMPOU and suicidality among people with and without disabilities while controlling for sociodemographic and other variables. Method: Using the 2019 National Survey on Drug Use and Health, weighted logistic regression analyses were conducted on a cross-sectional sample of 38,088 respondents 18 and older to examine the effect of opioid misuse and disability on serious thoughts of suicide, having a suicide plan, and making a suicide attempt. Results: Findings indicated opioid misuse was associated with 37% higher odds for having a suicide plan in the past year (OR = 1.37, p < .05). The main results indicated the people with disabilities had 30% higher odds for having a suicide plan (OR = 1.30, p < .05) and 73% higher odds for a suicide attempt in the past year (OR = 1.73, p < .001). Interaction analysis found that opioid misuse was associated with higher odds for having a suicide plan (OR = 1.89, p < .01), and having a suicide attempt among those with disabilities (OR = 2.57, p < .01). Conclusion: Results indicated that opioid misuse is a risk factor for suicide, and people with disabilities were at greater risk. Health workers can serve as a nexus point in effectively engaging at-risk people with disabilities in substance use and mental health prevention and recovery services.

Reward drive moderates the effect of depression-related cognitive mechanisms on risk of prescription opioid misuse among patients with chronic non-cancer pain

Depression, a prognostic factor for prescription opioid misuse commonly occurs in people with chronic non-cancer pain (CNCP). However, the mechanisms linking depression and prescription opioid misuse remain unclear. This study examined the potential mediating role of pain catastrophizing in the association between depressive symptoms and prescription opioid misuse risk, and impulsivity traits as possible moderators of these relationships. Individuals (N = 198; 77% women) with CNCP using prescription opioids participated in a cross-sectional online survey with validated measures of depression, pain catastrophizing, rash impulsiveness, reward drive, anxiety, pain severity and prescription opioid misuse. Meditation analyses with percentile-based bootstrapping examined pathways to prescription opioid use, controlling for age, sex, pain severity, and anxiety symptoms. Partial moderated mediation of the indirect effect of depressive symptoms on prescription opioid misuse risk through pain catastrophizing by rash impulsiveness and reward drive were estimated. Pain catastrophizing mediated depressive symptoms and prescription opioid misuse risk. Indirect effects were stronger when moderate to high levels of reward drive were included in the model. Findings suggest the risk of prescription opioid misuse in those experiencing depressive symptoms and pain catastrophizing is particularly higher for those higher in reward drive. Treatments targeting these mechanisms may reduce opioid misuse risk. PERSPECTIVE: This article identifies reward drive as a potentially important factor increasing the effects of depression-related cognitive mechanisms on risk of prescription opioid misuse in those with CNCP. These findings could assist in personalizing clinical CNCP management to reduce the risks associated with opioid misuse.

Substance use and common contributors to morbidity: A genetics perspective

Excessive substance use and substance use disorders (SUDs) are common, serious and relapsing medical conditions. They frequently co-occur with other diseases that are leading contributors to disability worldwide. While heavy substance use may potentiate the course of some of these illnesses, there is accumulating evidence suggesting common genetic architectures. In this narrative review, we focus on four heritable medical conditions - cardiometabolic disease, chronic pain, depression and COVID-19, which are commonly overlapping with, but not necessarily a direct consequence of, SUDs. We find persuasive evidence of underlying genetic liability that predisposes to both SUDs and chronic pain, depression, and COVID-19. For cardiometabolic disease, there is greater support for a potential causal influence of problematic substance use. Our review encourages de-stigmatization of SUDs and the assessment of substance use in clinical settings. We assert that identifying shared pathways of risk has high translational potential, allowing tailoring of treatments for multiple medical conditions. FUNDING: SSR acknowledges T29KT0526, T32IR5226 and DP1DA054394; RLK acknowledges AA028292; AA acknowledges DA054869 & K02DA032573. The funders had no role in the conceptualization or writing of the paper.

Early Optimized Pharmacological Treatment in Patients With Depression and Chronic Pain

Major depressive disorder (MDD) is the leading cause of disability worldwide. Patients with MDD have high rates of comorbidity with mental and physical conditions, one of which is chronic pain. Chronic pain conditions themselves are also associated with significant disability, and the large number of patients with MDD who have chronic pain drives high levels of disability and compounds healthcare burden. The management of depression in patients who also have chronic pain can be particularly challenging due to underlying mechanisms that are common to both conditions, and because many patients with these conditions are already taking multiple medications. For these reasons, healthcare providers may be reluctant to treat such patients. The Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines provide evidence-based recommendations for the management of MDD and comorbid psychiatric and medical conditions such as anxiety, substance use disorder, and cardiovascular disease; however, comorbid chronic pain is not addressed. In this article, we provide an overview of the pathophysiological and clinical overlap between depression and chronic pain and review evidence-based pharmacological recommendations in current treatment guidelines for MDD and for chronic pain. Based on clinical experience with MDD patients with comorbid pain, we recommend rapidly and aggressively treating depression according to CANMAT treatment guidelines, using antidepressant medications with analgesic properties, while addressing pain with first-line pharmacotherapy as treatment for depression is optimized. We review options for treating pain symptoms that remain after response to antidepressant treatment is achieved.

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.

New Opioid Use and Risk of Emergency Department Visits Related to Motor Vehicle Collisions in Ontario, Canada

IMPORTANCE

Opioids can impair motor skills and may affect the ability to drive; however, the association of opioid use with driving ability is not well established.

OBJECTIVE

To examine the risk of motor vehicle collisions (MVCs) among drivers starting opioid therapy compared with that among drivers starting nonsteroidal anti-inflammatory drug (NSAID) therapy.

DESIGN, SETTING, AND PARTICIPANTS

This population-based, retrospective cohort study included all residents of Ontario aged 17 years or older who started new prescription analgesic therapy between March 1, 2008, and March 17, 2019.

EXPOSURES

Initiation of opioid therapy or NSAID therapy, ascertained through prescription dispensing records in administrative data.

MAIN OUTCOMES AND MEASURES

The primary outcome was an emergency department visit for injuries sustained as a driver in an MVC during the 14 days after starting analgesic therapy. Inverse probability treatment weighting was used to balance baseline covariates, and weighted Cox proportional hazards regression models were used to assess the association between new analgesic therapy and hazard of an emergency department visit after an MVC.

RESULTS

Of the 1 454 824 individuals included in the study, 765 464 (52.6%) were new opioid recipients and 689 360 (47.4%) were new NSAID recipients. Most participants were aged 65 years or older (75.2%), and 55.2% were women. Of 194 individuals who had emergency department visits for injuries from an MVC within 14 days of initiating therapy, 98 (50.5%) were opioid recipients (3.41 per 1000 person-years; 95% CI, 2.80-4.15 per 1000 person-years) and 96 (49.5%) were NSAID recipients (3.64 per 1000 person-years; 95% CI, 2.98-4.45 per 1000 person-years). There was no significant difference in the risk of an emergency department visit for MVC injuries between opioid and NSAID recipients (weighted hazard ratio, 0.94; 95% CI, 0.70-1.25).

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that the hazard of an emergency department visit for injuries relating to an MVC as a driver is similar between individuals starting prescription opioids and those starting prescription NSAIDs. These results may be useful for patients, clinicians, and caregivers when considering new analgesic therapy.

New-Onset Depression After Total Knee Arthroplasty: Consideration of the At-Risk Patient

BACKGROUND

Postoperative new-onset depression (NOD) has gained recent attention as a previously unrecognized complication which may put patients at risk for poor outcomes after elective total hip arthroplasty. We aimed to investigate risk factors for the development of NOD after total knee arthroplasty (TKA) and assess its association with postoperative complications.

METHODS

This is a retrospective, population-level investigation of elective TKA patients. Patients with a preoperative diagnosis of depression were excluded from this study. Two groups were compared: patients who were diagnosed with depression within one year after TKA (NOD) and those who did not (control). The association of both preoperative patient factors and postoperative surgical and medical complications with NOD was then determined using multivariate and univariate analyses.

RESULTS

Of 196,728 unique TKA patients in our cohort, 5351 (2.72%) were diagnosed with NOD within one year of TKA. Age <54 year old, female gender, preoperative anxiety disorder, drug, alcohol, and/or tobacco use, multiple comorbidities, and opioid use before TKA were all associated with a diagnosis of NOD postoperatively (all P < .001). Postoperative NOD was associated with periprosthetic fracture (OR 2.11; 95% CI 1.29-3.52; P = .033), aseptic failure (OR 1.61; 95% CI 1.24-2.07; P = .020), prosthetic joint infection (OR 1.55, 95% CI 1.30-1.85; P < .001), stroke (OR 1.24; 95% CI 1.09-1.42; P = .006), and venous thromboembolism (OR 1.24; 95% CI 1.12-1.37; P < .001).

CONCLUSION

Post-TKA NOD is common and is associated with poor outcomes. This may aid surgeons in developing both anticipatory measures and institute preventative measures for patients at risk for developing NOD.

Prevalence of long-term opioid therapy in spine center outpatients the spinal pain opioid cohort (SPOC)

PURPOSE

No reference material exists on the scope of long-term problems in novel spinal pain opioid users. In this study, we evaluate the prevalence and long-term use of prescribed opioids in patients of the Spinal Pain Opioid Cohort.

METHODS

The setting was an outpatient healthcare entity (Spine Center). Prospective variables include demographics, clinical data collected in SpineData, and The Danish National Prescription Registry. Patients with a new spinal pain episode lasting for more than two months, aged between 18 and 65 years, who had their first outpatient visit. Based on the prescription of opioids from 4 years before the first spine center visit to 5 years after, six or more opioid prescriptions in a single 1-year interval fulfilled the main outcome criteria Long-Term Opioid Therapy (LTOT).

RESULTS

Overall, of 8356 patients included in the cohort, 4409 (53%) had one or more opioid prescriptions in the registered nine years period. Of opioid users, 2261 (27%) were NaiveStarters receiving their first opioid prescription after a new acute pain episode; 2148(26%) PreStarters had previously received opioids. The prevalence of LTOT in PreStarters/NaiveStarters was 17.2%/11.2% in their first outpatient year. Similar differences between groups were seen in all follow-up intervals. In the last follow-up year, LTOT prevalence in Prestarters/NaiveStarters was 12.5%/7.0%.

CONCLUSIONS

Previous opioid treatment-i.e., before a new acute spinal pain episode and referral to a Spine Center-doubled the risk of LTOT 5 years later. The results underscore clinicians' obligation to carefully and individually weigh the benefits against the risks of prescribing opioid therapy.

LEVEL OF EVIDENCE I

Diagnostic: individual cross-sectional studies with consistently applied reference standard and blinding.

Predictors of pain-related functional impairment among people living with HIV on long-term opioid therapy

People living with HIV (PLWH) have high levels of functional impairment due to pain, also called pain interference. Long-term opioid therapy (LTOT) is commonly prescribed for chronic pain among PLWH. We sought to better understand the predictors of pain interference, measured with the Brief Pain Inventory Interference subscale (BPI-I), among PLWH with chronic pain on LTOT. Using a prospective cohort of PLWH on LTOT we developed a model to identify predictors of increased pain interference over 1 year of follow up. Participants (n = 166) were 34% female, 72% African American with a median age of 55 years, and 40% had severe pain interference (BPI-I ≥ 7). In multivariable models, substance use disorder, depressive symptoms, PTSD symptoms, financial instability, and higher opioid doses were associated with increased pain interference. Measures of behavioral health and socioeconomic status had the most consistent association with pain interference. In contrast, the biomedical aspects of chronic pain and LTOT - comorbidities, duration of pain - were not predictive of pain interference. PLWH with chronic pain on LTOT with lower socioeconomic status and behavioral health symptoms have higher risk of pain interference. Addressing the social determinants of health and providing access to behavioral health services could improve patients' pain-related functional status.

Examining opioid prescribing trends for non-cancer pain using an estimated oral morphine equivalence measure: a retrospective cohort study between 2005 and 2015

Background

Over the past 20 years prescription of opioid medicines has markedly increased in the UK, despite a lack of supporting evidence for use in commonly occurring, painful conditions. Prescribing is often monitored by counting numbers of prescriptions dispensed, but this may not provide an accurate picture of clinical practice.

Aim

To use an estimated oral morphine equivalent (OMEQ_e) dose to describe trends in opioid prescribing in non-cancer pain, and explore if opioid burden differed by deprivation status.

Design & setting

A retrospective cohort study using cross-sectional and longitudinal trend analyses of opioid prescribing data from Welsh Primary Care General Practices (PCGP) took place. Data were used from the Secure Anonymised Information Linkage (SAIL) databank.

Method

An OMEQ_e measure was developed and used to describe trends in opioid burden over the study period. OMEQ_e burden was stratified by eight drug groups, which was based on usage and deprivation.

Results

An estimated 643 436 843 milligrams (mg) OMEQ_e was issued during the study. Annual number of prescriptions increased 44% between 2005 and 2015, while total daily OMEQ_e per 1000 population increased by 95%. The most deprived areas of Wales had 100 711 696 mg more OMEQ_e prescribed than the least deprived over the study period.

Conclusion

Over the study period, OMEQ_e burden nearly doubled, with disproportionate OMEQ_e prescribed in the most deprived communities. Using OMEQ_e provides an alternative measure of prescribing and allows easier comparison of the contribution different drugs make to the overall opioid burden.

The Relationship Between Education and Pain Among Adults Aged 30-49 in the United States

Pain is a major health problem among U.S. adults. Surprisingly little, however, is known about educational disparities in pain, especially among the nonelderly. In this study, we analyze disparities in pain across levels of educational attainment. Using data from the 2010 to 2017 National Health Interview Survey among adults aged 30 to 49 (N = 74,051), we estimate logistic regression models of pain prevalence using a dichotomous summary pain index and its 5 constituent pain sites (low back, joint, neck, headache/migraine, and facial/jaw). We find a significant and steep pain gradient: greater levels of educational attainment are associated with less pain, with 2 important exceptions. First, adults with a high-school equivalency diploma (GED) and those with "some college" have significantly higher pain levels than high school graduates despite having an equivalent or higher attainment, respectively. Second, the education-pain gradient is absent for Hispanic adults. After taking into account important covariates including employment, economic resources, health behaviors, physical health conditions, and psychological wellbeing, educational disparities in pain are no longer statistically significant except for the GED and "some college" categories, which still show significantly higher pain levels than high school graduates. We thus document the overall education-pain gradient in most younger U.S. adult populations, and identify groups where pain is higher than expected (certain educational categories) or lower than expected (eg, less-educated Hispanics). Understanding the causes of these anomalous findings could clarify factors shaping pain prevalence and disparities therein. PERSPECTIVE: Over 50% of U.S. adults age 30 to 49 report pain. Overall, more educated Americans report substantially less pain than the less educated. However, adults with a GED and "some college" report more pain than other groups. Understanding the causes could help illuminate the mechanisms through which social factors influence pain.

Long-Term Opioid Therapy in Spine Center Outpatients: Protocol for the Spinal Pain Opioid Cohort (SPOC) Study

Background

Spinal pain is the leading cause of patient-years lived with chronic pain and disability worldwide. Although opioids are well documented as an effective short-term pain-relieving medication, more than a few weeks of treatment may result in a diminishing clinical effect as well as the development of addictive behavior. Despite recognition of opioid addiction in pain patients as a major problem commonly experienced in the clinic, no reference material exists on the scope of long-term problems in novel opioid users and the link to clinical outcomes.

Objective

The main aims of this study are to describe baseline and follow-up characteristics of the Spinal Pain Opioid Cohort (SPOC), to evaluate the general use of opioids in spinal pain when an acute pain episode occurs, and to demonstrate the prevalence of long-term opioid therapy (LTOT).

Methods

Prospective clinical registry data were collected from an outpatient spine center setting during 2012-2013 including patients with a new spinal pain episode lasting for more than 2 months, aged between 18 and 65 years who had their first outpatient visit in the center. Variables include demographics, clinical data collected in SpineData, the Danish National Patient Register, and The Danish National Prescription Registry. The primary outcome parameter is long-term prescription opioid use registered from 4 years before the first spine center visit to 5 years after.

Results

This is an ongoing survey. It is estimated that more than 8000 patients fulfill the SPOC inclusion criteria. In 2019, we began the intellectual process of identifying the most relevant supplementary data available from the wide range of existing national registries available in Denmark. We have now begun merging SpineData with relevant opioid data from Danish national registers and will continue to extract data up to 2021-2022. We will also be looking at data regarding somatic or psychiatric hospitalization patterns, patient usage of health care resources, as well as their working status and disability pensions.

Conclusions

To our knowledge, this survey will be the first to document the scope of long-term problems regarding LTOT and opioid addiction following new spinal pain episodes and comparing descriptive follow-up data between substance users and nonusers.

Trial Registration

ISRCTN Registry ISRCTN69685117; http://www.isrctn.com/ISRCTN69685117

International Registered Report Identifier (IRRID)

DERR1-10.2196/21380

Nonconsensual Dose Reduction Mandates are Not Justified Clinically or Ethically: An Analysis

This manuscript describes the institutional and clinical considerations that apply to the question of whether to mandate opioid dose reduction in patients who have received opioids long-term. It describes how a calamitous rise in addiction and overdose involving opioids has both led to a clinical recalibration by healthcare providers, and to strong incentives favoring forcible opioid reduction by policy making agencies. Neither the 2016 Guideline issued by the Centers for Disease Control and Prevention nor clinical evidence can justify or promote such policies as safe or effective.

Oxycodone, Hydromorphone, and the Risk of Suicide: A Retrospective Population-Based Case-Control Study

INTRODUCTION

Opioids have been increasingly associated with suicide, but whether they are independent contributors is unclear. Oxycodone and hydromorphone are commonly prescribed high-potency opioids that can differentially affect mood.

OBJECTIVE

The objective of this study was to explore whether oxycodone and hydromorphone are differentially associated with suicide.

METHODS

We conducted a retrospective population-based case-control study in Ontario, Canada, from 1992 to 2014. Using coronial data, we defined case subjects as individuals who died by suicide involving an opioid overdose. Each of these was matched with up to four controls who died of accidental opioid overdose. We ascertained exposure to oxycodone, hydromorphone, and other opioids from postmortem toxicology testing. We used odds ratios and 95% confidence intervals to examine whether opioid-related suicide was disproportionately associated with oxycodone relative to hydromorphone.

RESULTS

We identified 438 suicides and 1212 accidental deaths, each of which involved either oxycodone or hydromorphone but not both. The median age at death was 49 years and 51% were men. After adjusting for a history of self-harm, psychiatric illness, and exposure to other opioids, we found that oxycodone was more strongly associated with suicide than hydromorphone (adjusted odds ratio 1.59; 95% confidence interval 1.20-2.11). In a secondary analysis, we observed a trend of similar magnitude in which combined exposure to oxycodone and hydromorphone was more strongly associated with suicide than hydromorphone alone (adjusted odds ratio 1.68; 95% confidence interval 0.92-3.09).

CONCLUSIONS

While preliminary, these findings support the possibility that some high-potency opioids might independently influence the risk of suicide in susceptible individuals.

Factors associated with the prescribing of high-dose opioids in primary care: a systematic review and meta-analysis

BACKGROUND

The risks of harms from opioids increase substantially at high doses, and high-dose prescribing has increased in primary care. However, little is known about what leads to high-dose prescribing, and studies exploring this have not been synthesized. We, therefore, systematically synthesized factors associated with the prescribing of high-dose opioids in primary care.

METHODS

We conducted a systematic review of observational studies in high-income countries that used patient-level primary care data and explored any factor(s) in people for whom opioids were prescribed, stratified by oral morphine equivalents (OME). We defined high doses as ≥ 90 OME mg/day. We searched MEDLINE, Embase, Web of Science, reference lists, forward citations, and conference proceedings from database inception to 5 April 2019. Two investigators independently screened studies, extracted data, and appraised the quality of included studies using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. We pooled data on factors using random effects meta-analyses and reported relative risks (RR) or mean differences with 95% confidence intervals (CI) where appropriate. We also performed a number needed to harm (NNT_H) calculation on factors when applicable.

RESULTS

We included six studies with a total of 4,248,119 participants taking opioids, of whom 3.64% (n = 154,749) were taking high doses. The majority of included studies (n = 4) were conducted in the USA, one in Australia and one in the UK. The largest study (n = 4,046,275) was from the USA. Included studies were graded as having fair to good quality evidence. The co-prescription of benzodiazepines (RR 3.27, 95% CI 1.32 to 8.13, I² = 99.9%), depression (RR 1.38, 95% CI 1.27 to 1.51, I² = 0%), emergency department visits (RR 1.53, 95% CI 1.46 to 1.61, I² = 0%, NNT_H 15, 95% CI 12 to 20), unemployment (RR 1.44, 95% CI 1.27 to 1.63, I² = 0%), and male gender (RR 1.21, 95% CI 1.14 to 1.28, I² = 78.6%) were significantly associated with the prescribing of high-dose opioids in primary care.

CONCLUSIONS

High doses of opioids are associated with greater risks of harms. Associated factors such as the co-prescription of benzodiazepines and depression identify priority areas that should be considered when selecting, identifying, and managing people taking high-dose opioids in primary care. Coordinated strategies and services that promote the safe prescribing of opioids are needed.

STUDY REGISTRATION

PROSPERO, CRD42018088057.

Age Differences in Non-Medical Prescription Opioid Use and Psychological Distress

Background/Purpose: Prescription opioid use has been recognized as an epidemic in the United States and globally. More research is needed to understand the association of opioids and mental health for older adults. This study examined age differences in the association of non-medical prescription opioid use (NMPOU) and psychological distress, with a focus on older adult populations. Methods: This study used the 2016 National Survey on Drug Use and Health (NSDUH), and included 37,842 adults aged 18 and older. Weighted multiple regression and logistic regression analyses were used to examine the association of NMPOU and psychological distress, measured by the Kessler Psychological Distress Scale (K6). Results: NMPOU was associated with higher psychological distress (b = 0.48, SE = 0.16, p < .01). For those 50 and older, NMPOU was associated with 224% increased odds of meeting the clinical threshold for having a serious mental illness (SMI; OR = 2.24, p < .01, 95% CI: 1.23, 4.09). Conclusions: Although the prevalence of NMPOU and psychological distress trended downward throughout the lifespan, the association of NMPOU on SMI was highest among the youngest and oldest adults. These findings highlight the need for services and supports that are tailored for older adult populations. Future research is needed to investigate vulnerabilities from life stage stressors specific to older adults, which may account for the disproportionate odds of opioid use on mental health pathology. Interprofessional collaboration is needed among geriatric professionals to provide effective mental health treatment for this at-risk population.

High-Frequency Medical Cannabis Use Is Associated With Worse Pain Among Individuals With Chronic Pain

Cannabis is widely used for chronic pain. However, there is some evidence of an inverse dose-response relationship between cannabis effects and pain relief that may negatively affect analgesic outcomes. In this cross-sectional survey, we examined whether daily cannabis use frequency was associated with pain severity and interference, quality of life measures relevant to pain (eg, anxiety and depressive symptoms), and cannabis use preferences (administration routes and cannabinoid ratio). Our analysis included 989 adults who used cannabis every day for chronic pain. Participant use was designated as light, moderate, and heavy (1-2, 3-4, and 5 or more cannabis uses per day, respectively). The sample was also subgrouped by self-reported medical-only use (designated MED, n = 531, 54%) versus medical use concomitant with a past-year history of recreational use (designated MEDREC, n = 458, 46%). In the whole sample, increased frequency of use was significantly associated with worse pain intensity and interference, and worse negative affect, although high-frequency users also reported improved positive affect. Subgroup analyses showed that these effects were driven by MED participants. Heavy MED participant consumption patterns showed greater preference for smoking, vaporizing, and high tetrahydrocannabinol products. In contrast, light MED participants had greater preference for tinctures and high cannabidiol products. Selection bias, our focus on chronic pain, and our cross-sectional design likely limit the generalizability of our results. Our findings suggest that lower daily cannabis use frequency is associated with better clinical profile as well as lower risk cannabis use behaviors among MED participants. Future longitudinal studies are needed to examine how high frequency of cannabis use interacts with potential therapeutic benefits. PERSPECTIVE: Our findings suggest that lower daily cannabis use frequency is associated with better clinical profile as well as safer use behaviors (eg, preference for cannabidiol and noninhalation administration routes). These trends highlight the need for developing cannabis use guidelines for clinicians to better protect patients using cannabis.