Elsevier

General Hospital Psychiatry

Volume 34, Issue 6, November–December 2012, Pages 581-587
General Hospital Psychiatry

Psychiatric–Medical Comorbidity1
Prescribed opioid difficulties, depression and opioid dose among chronic opioid therapy patients

https://doi.org/10.1016/j.genhosppsych.2012.06.018Get rights and content

Abstract

Background

Chronic opioid therapy has increased dramatically, as have complications related to prescription opioids. Little is known about the problems and concerns attributed to opioids by patients receiving different opioid doses.

Methods

We surveyed 1883 patients who were receiving chronic opioid therapy for chronic noncancer pain. Opioid regimen characteristics were ascertained from electronic pharmacy records. Patient-reported opioid-related problems and concerns were measured using the Prescription Opioid Difficulties Scale. Depression was assessed with the Patient Health Questionnaire.

Results

Patients prescribed higher opioid doses reported modestly higher pain intensity and pain impact. After adjustment, patients on higher doses attributed higher levels of psychosocial problems and control concerns to prescribed opioids (P< .0001). They also had higher levels of depression and were more likely to meet criteria for clinical depression. Over 60% of patients receiving 120 + mg daily (morphine equivalent) were clinically depressed, a 2.6-fold higher risk (95% confidence interval: 1.5–4.4) than patients on low-dose regimens (< 20 mg daily).

Conclusions

Higher opioid doses were associated with somewhat higher pain severity and higher levels of patient-reported opioid-related psychosocial problems, control concerns and depression. These findings may result from patient selection for high-dose therapy or problems caused by higher-dose opioids.

Introduction

Chronic opioid therapy for noncancer pain has become increasingly prevalent over the last decades [1], [2]. Accompanying this have been worrisome trends in prescription opioid abuse by youth, emergency department and addiction treatment admissions associated with prescription opioids, and opioid-related overdose deaths [3], [4], [5]. These trends highlight the importance of opioid prescribing decisions for chronic noncancer pain.

A key clinical decision confronting physicians is the dose of opioids during chronic opioid therapy. No clinical trials comparing opioid dose levels for chronic noncancer pain have been reported [6], and clinical guidelines suggest that opioid dose should be individualized, with caution recommended at higher doses [7], [8], [9]. While opioid dosing over 180 mg morphine equivalent has no clinical trial support [10], a recent guideline from Washington State generated controversy by recommending that physicians obtain specialty pain consultation for daily doses of 120 mg morphine equivalent with inadequate therapeutic response in terms of pain and function [11].

Recent reports have highlighted the association between higher prescribed opioid doses and complications of chronic opioid therapy, including risk for overdose and overdose death [12], [13], [14], fractures among the elderly [15], risk of opioid misuse [16], alcohol and drug-related emergency department visits [17], and opioid use disorder diagnoses [18]. However, little information is available about the clinical status of patients prescribed different opioid dose levels.

The effects of higher opioid doses may have a larger impact on patients whose chronic pain is complicated by depression. A growing body of evidence supports the association between mental health or addiction problems and the prescription of higher opioid doses [19], [20], [21], [22], [23]. However, these studies have rarely included self-report measures of pain and psychological status of chronic opioid therapy patients in relation to prescribed dose.

Measurement of problems during opioid therapy has primarily focused on the risk of addiction or aberrant behaviors [24], [25], [26], [27], although traditional constructs of abuse and dependence have been difficult to apply in this population [28]. A related approach has sought to understand patients’ perspective on problems they attribute to opioids [26], [29], [30]. Two types of patient-reported problems, psychosocial problems and opioid control concerns, have been identified among patients receiving chronic opioid therapy [31], [32]. Measurement of these patient-reported problems with opioid therapy provides an opportunity to explore the clinical status of patients prescribed differing opioid dose regimens.

We used data from a large study of opioid risks and trends that combines comprehensive pharmacy records and patient interview data to describe the characteristics and clinical status of patients prescribed different opioid dose levels. We assessed whether opioid dose was associated with differences in patient-reported psychosocial problems and control concerns attributed to opioids and with symptoms of depression.

Section snippets

Setting and participants

The CONsortium to Study Opioid Risks and Trends (CONSORT) was designed to study chronic opioid therapy for noncancer pain in Group Health Cooperative (GHC), in Washington State, and Kaiser Permanente of Northern California (KPNC) [33]. Together, these health plans include about four million patients. CONSORT research plans were approved by the Institutional Review Boards of both health plans. Patients in these analyses were receiving chronic opioid therapy and completed a telephone interview

Survey response

Overall, 3790 patients were approached (2185 at GHC and 1605 at KPNC), 185 were ineligible (76 at GHC and 109 at KPNC), and interviews were completed for 2163 (1191 at GHC and 972 at KPNC), for an overall response rate of 60% (57% at GHC and 65% at KPNC). Response rates were higher for patients over the age of 65 (65% at GHC and 68% at KPNC), but gender differences were small. Response rates increased with higher average daily dose at KPNC (58% for < 50 mg MED, 66% for 50 to < 100 mg MED and 71%

Discussion

This report provides new information about the characteristics, clinical status and patient-perceived opioid-related difficulties of patients prescribed different opioid dose regimens in a population-based sample. We found that higher-dose treatment was associated with increased rates of patient-reported opioid-related psychosocial problems and control concerns and with increased symptoms of depression. While differences in depression symptoms may result from the selection of patients for high

References (44)

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1

The Psychiatric–Medical Comorbidity section will focus on the prevalence and impact of psychiatric disorders in patients with chronic medical illness as well as the prevalence and impact of medical disorders in patients with chronic psychiatric illness.

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