Risk factors for clinically recognized opioid abuse and dependence among veterans using opioids for chronic non-cancer pain

Abstract A central question in prescribing opioids for chronic non‐cancer pain (CNCP) is how to best balance the risk of opioid abuse and dependence with the benefits of pain relief. To achieve this balance, clinicians need an understanding of the risk factors for opioid abuse, an issue that is only partially understood. We conducted a secondary data analysis of regional VA longitudinal administrative data (years 2000–2005) for chronic users of opioids for CNCP (n = 15,160) to investigate risk factors for the development of clinically recognized (i.e., diagnosed) opioid abuse or dependence among these individuals. We analyzed four broad groups of possible risk factors: (i) non‐opioid substance abuse disorders, (ii) painful physical health disorders, (iii) mental health disorders, and (iv) socio‐demographic factors. In adjusted models, a diagnosis of non‐opioid substance abuse was the strongest predictor of opioid abuse/dependence (OR = 2.34, p < 0.001). Mental health disorders were moderately strong predictors (OR = 1.46, p = 0.005) of opioid abuse/dependence. However, the prevalence of mental health disorders was much higher than the prevalence of non‐opioid substance abuse disorders (45.3% vs. 7.6%) among users of opioids for CNCP, suggesting that mental health disorders account for more of the population attributable risk for opioid abuse than does non‐opioid substance abuse. Males, younger adults, and individuals with greater days supply of prescription opioids dispensed in 2002 were more likely to develop opioid abuse/dependence. Clinicians need to carefully screen for substance abuse and mental health disorders in candidates for opioid therapy and facilitate appropriate treatment of these disorders.

[1]  Lisa M. Schwartz,et al.  Office visits and analgesic prescriptions for musculoskeletal pain in US: 1980 vs. 2000 , 2004, Pain.

[2]  Eija Kalso,et al.  Opioids in chronic non-cancer pain: systematic review of efficacy and safety , 2004, Pain.

[3]  P. Yarnold,et al.  Screening for undetected mental disorders in high utilizers of primary care services , 1999, Journal of General Internal Medicine.

[4]  B. Naliboff,et al.  Pain medication beliefs and medication misuse in chronic pain. , 2005, The journal of pain : official journal of the American Pain Society.

[5]  B. Druss,et al.  Quality of medical care and excess mortality in older patients with mental disorders. , 2001, Archives of general psychiatry.

[6]  A. Stewart,et al.  The functioning and well-being of depressed patients. Results from the Medical Outcomes Study. , 1989, JAMA.

[7]  W M Tierney,et al.  Improving Treatment of Late Life Depression in Primary Care: A Randomized Clinical Trial , 1994, Journal of the American Geriatrics Society.

[8]  S Greenfield,et al.  Detection of depressive disorder for patients receiving prepaid or fee-for-service care. Results from the Medical Outcomes Study. , 1989, JAMA.

[9]  B. Grant,et al.  Prevalence and Co-Occurrence of Substance Use Disorders and Independent Mood and Anxiety Disorders , 2004, Archives of general psychiatry.

[10]  R. Spitzer,et al.  Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire. , 1999, JAMA.

[11]  K. Wells,et al.  Do users of regularly prescribed opioids have higher rates of substance use problems than nonusers? , 2007, Pain medicine.

[12]  M. Erjavec,et al.  Prescription opiate abuse in chronic pain patients: clinical criteria, incidence, and predictors. , 1997, The Clinical journal of pain.

[13]  Lisa V. Rubenstein,et al.  Who is at risk of nondetection of mental health problems in primary care? , 2000, Journal of General Internal Medicine.

[14]  John F. Hurdle,et al.  Measuring diagnoses: ICD code accuracy. , 2005, Health services research.

[15]  G. Simon,et al.  Recognition, management, and outcomes of depression in primary care. , 1995, Archives of family medicine.

[16]  M. Aronson,et al.  Prevalence and recognition of alcohol abuse in a primary care population. , 1988, The American journal of medicine.

[17]  R. Kerns,et al.  Veterans' reports of pain and associations with ratings of health, health-risk behaviors, affective distress, and use of the healthcare system. , 2003, Journal of rehabilitation research and development.

[18]  J. L. Dahl,et al.  A reassessment of trends in the medical use and abuse of opioid analgesics and implications for diversion control: 1997-2002. , 2004, Journal of pain and symptom management.

[19]  K. Harris,et al.  Self-medication of mental health problems: new evidence from a national survey. , 2005, Health services research.

[20]  R. Deyo,et al.  Potent opioids for chronic musculoskeletal pain: flying blind? , 2004, Pain.

[21]  Hude Quan,et al.  Comparison of the Elixhauser and Charlson/Deyo Methods of Comorbidity Measurement in Administrative Data , 2004, Medical care.

[22]  M. Hegel,et al.  Effect of improving depression care on pain and functional outcomes among older adults with arthritis: a randomized controlled trial. , 2003, JAMA.

[23]  O. Gureje,et al.  Persistent Pain and Well Being: a World Health Organization Study in Primary Care , 1999 .

[24]  T. Miller,et al.  A primary care, multi-disciplinary disease management program for opioid-treated patients with chronic non-cancer pain and a high burden of psychiatric comorbidity , 2005, BMC health services research.

[25]  G. Duncan,et al.  Evidence on the Validity of Cross-Sectional and Longitudinal Labor Market Data , 1994, Journal of Labor Economics.

[26]  O. Gureje,et al.  Persistent pain and well-being: a World Health Organization Study in Primary Care. , 1998, JAMA.

[27]  R. Kerns,et al.  Use of opioid medications for chronic noncancer pain syndromes in primary care , 2002, Journal of General Internal Medicine.

[28]  P. J. Huber.  The behavior of maximum likelihood estimates under nonstandard conditions , 1967 .

[29]  H. White.  Maximum Likelihood Estimation of Misspecified Models , 1982 .

[30]  C. Steiner,et al.  Comorbidity measures for use with administrative data. , 1998, Medical care.

[31]  H. L. Le Roy,et al.  Proceedings of the Fifth Berkeley Symposium on Mathematical Statistics and Probability; Vol. IV , 1969 .

[32]  K. Wells,et al.  Association between mental health disorders, problem drug use, and regular prescription opioid use. , 2006, Archives of internal medicine.

[33]  J. Wilson‐Barnett,et al.  A survey of chronic noncancer pain patients prescribed opioid analgesics. , 2003, Pain medicine.

[34]  R. Deyo,et al.  Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. , 1992, Journal of clinical epidemiology.

[35]  R. Kessler,et al.  The epidemiology of co-occurring addictive and mental disorders: implications for prevention and service utilization. , 1996, The American journal of orthopsychiatry.

[36]  J. Bensing,et al.  Prevalence of chronic benign pain disorder among adults: a review of the literature , 1998, Pain.

[37]  Ricardo Pietrobon,et al.  Patterns and Trends in Opioid Use among Individuals with Back Pain in the United States , 2004, Spine.

[38]  D. Carr,et al.  The use of opioids for the treatment of chronic pain. A consensus statement from the American Academy of Pain Medicine and the American Pain Society. , 1998, The Clinical journal of pain.

[39]  R. Jamison,et al.  Predicting aberrant drug behavior in patients treated for chronic pain: importance of abuse history. , 2004, Journal of pain and symptom management.

[40]  S. Schnoll,et al.  Physician detection of drinking problems in patients attending a general medicine practice , 1992, Journal of General Internal Medicine.

[41]  K. Foley,et al.  College on Problems of Drug Dependence taskforce on prescription opioid non-medical use and abuse: position statement. , 2003, Drug and alcohol dependence.