Predictors of Opioid Misuse in Patients with Chronic Pain: A Prospective Cohort Study

Division of General Internal Medicine and Clinical Epidemiology, Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
BMC Health Services Research (Impact Factor: 1.71). 04/2006; 6(1):46. DOI: 10.1186/1472-6963-6-46
Source: PubMed


Opioid misuse can complicate chronic pain management, and the non-medical use of opioids is a growing public health problem. The incidence and risk factors for opioid misuse in patients with chronic pain, however, have not been well characterized. We conducted a prospective cohort study to determine the one-year incidence and predictors of opioid misuse among patients enrolled in a chronic pain disease management program within an academic internal medicine practice.
One-hundred and ninety-six opioid-treated patients with chronic, non-cancer pain of at least three months duration were monitored for opioid misuse at pre-defined intervals. Opioid misuse was defined as: 1. Negative urine toxicological screen (UTS) for prescribed opioids; 2. UTS positive for opioids or controlled substances not prescribed by our practice; 3. Evidence of procurement of opioids from multiple providers; 4. Diversion of opioids; 5. Prescription forgery; or 6. Stimulants (cocaine or amphetamines) on UTS.
The mean patient age was 52 years, 55% were male, and 75% were white. Sixty-two of 196 (32%) patients committed opioid misuse. Detection of cocaine or amphetamines on UTS was the most common form of misuse (40.3% of misusers). In bivariate analysis, misusers were more likely than non-misusers to be younger (48 years vs 54 years, p < 0.001), male (59.6% vs. 38%; p = 0.023), have past alcohol abuse (44% vs 23%; p = 0.004), past cocaine abuse (68% vs 21%; p < 0.001), or have a previous drug or DUI conviction (40% vs 11%; p < 0.001%). In multivariate analyses, age, past cocaine abuse (OR, 4.3), drug or DUI conviction (OR, 2.6), and a past alcohol abuse (OR, 2.6) persisted as predictors of misuse. Race, income, education, depression score, disability score, pain score, and literacy were not associated with misuse. No relationship between pain scores and misuse emerged.
Opioid misuse occurred frequently in chronic pain patients in a pain management program within an academic primary care practice. Patients with a history of alcohol or cocaine abuse and alcohol or drug related convictions should be carefully evaluated and followed for signs of misuse if opioids are prescribed. Structured monitoring for opioid misuse can potentially ensure the appropriate use of opioids in chronic pain management and mitigate adverse public health effects of diversion.

  • Source
    • "A certain percentage of patients using opioids for pain will develop an OUD with the estimated percentage ranging anywhere from 1% to 40% depending on the criteria used to define an OUD (Fishbain et al., 2008; Reid et al., 2002; Katz et al., 2003; Ives et al., 2006; Martell et al., 2007). Patients may also engage in problematic drug seeking behavior estimated as occurring in 3% to 62% of patients with pain receiving long-term opioid therapy (Martell et al., 2007; Ballantyne and LaForge, 2007; Webster and Webster, 2005; Fleming et al., 2008). "
    [Show abstract] [Hide abstract]
    ABSTRACT: Opioid therapy is one component of an effective pain management regimen for patients with chronic pain and the majority of these patients use their medications responsibly. However, there are a growing number of these patients who develop an opioid use disorder and in some cases require opioid replacement therapy. Managing these patients is complex and the underlying mechanisms of pain and addiction are not well understood. Developing an effective interdisciplinary treatment program for the individual with pain and an opioid use disorder will depend on enhancing our knowledge of the psychophysiology of pain and addiction. Authors gathered key empirical and theoretical papers examining the psychophysiology of comorbid pain and opioid misuse disorders. This article reviews the current theory of the effect of pain on patients with pain and concomitant addiction, the psychophysiology of pain, opioid use and addiction, and future research in this area. Individuals with a history of opioid misuse have greater levels of hyperalgesia which may be due to alterations in psychophysiological pathways. More research is needed into the psychophysiological biomarkers among individuals with comorbid pain and addiction in order to develop better treatment approaches and improve outcomes among this difficult to treat population. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.
    Full-text · Article · Nov 2014 · Drug and Alcohol Dependence
  • Source
    • "HIV-infected individuals often present with conditions that are associated with prescription medication misuse. Pain, a common comorbidity in HIV-infected patients, is associated with misuse of prescription medications (Ives et al., 2006; Tsao, Plankey, & Young, 2012; Tsao, Stein, & Dobalian, 2007; Turk, Swanson, & Gatchel, 2008; Vijayaraghavan, Penko, Bangsberg, Miaskowski, & Kushel, 2013). "
    [Show abstract] [Hide abstract]
    ABSTRACT: HIV has become a highly treatable disease due to advances in antiretroviral therapy (ART). Additionally, HIV-infected individuals often take opiates, barbiturates, and benzodiazepines to treat co-occurring conditions, including pain and symptoms of HIV. We sought to examine prescription medication misuse by surveying 295 HIV-infected patients receiving ART. Participants answered questions about their demographics, alcohol and other drug use, psychiatric diagnoses, ART adherence and side effects, and quality of life. 11% of our sample acknowledged prescription medication misuse. In regression analysis, prescription medication misusers were more likely to report any drinking to intoxication (OR = 4.31, 95% CI: 1.35-13.76, p = 0.013), reported greater severity of ART side effects (OR = 1.05, 95% CI: 1.01-1.10, p = 0.041), and demonstrated poorer cognitive functioning (OR = 0.97, 95% CI: 0.94-0.99, p = 0.048) compared to those who did not misuse prescription medications. Special care should be taken by medical providers before prescribing medications that may be abused or diverted. Patients should also be screened for aberrant use, even if not prescribed. ART side effects, cognitive deficits, and alcohol abuse may serve as risk factors or indicators of prescription medication misuse, and should be monitored.
    Full-text · Article · Aug 2014 · Journal of Substance Abuse Treatment
  • Source
    • "The risk factors for opioid abuse, misuse, or other aberrant drug-related behaviors in chronic pain patients receiving COT have been well-described, with a prior history of opioid abuse being the best predictor for both current and lifetime opioid use disorder in chronic pain patients [18,42]. Other important but less consistent risk factors for opioid abuse include pain-related functional limitations/impairments (including sleep disturbances); current cigarette smoking; a family history of substance abuse; a history of a mood disorder (eg, current post-traumatic disorder or depression); history of child sexual abuse or child neglect; involvement in the legal system; and significant psychosocial stressors [43-45]. Demographic correlates of opioid misuse in this patient population include age, gender, ethnicity, and employment status. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Substance use disorders (SUDs), whether active or in remission, are often encountered in patients with chronic nonmalignant pain. Clinicians are challenged when managing chronic pain while facing substance abuse issues during the course of chronic opioid therapy (COT). Further, the interrelated behavioral symptomatology of addiction and chronic pain suggests that if one disorder is untreated, effective treatment of the other in not possible. Incomplete understanding of the overlapping presentations of the two disorders, coupled with insufficient management of both conditions, leads to undertreated pain and premature discharge of SUD patients from pain treatment. In order to achieve pain relief and optimal functionality, both conditions need to be carefully managed. This paper reviews the prevalence of SUDs in chronic pain patents; the overlapping presentation of the two disorders; risk factors and stratification for addiction; identification of addiction in the chronic pain population; and suggestions for treating patients with COT, with an emphasis on relapse prevention. With appropriate assessment and treatment, COT for chronic pain patients with a history of SUD can be successful, leading to improved functionality and quality of life.
    Full-text · Article · Dec 2013 · Addiction science & clinical practice
Show more