Illicit opioid use following changes in opioids prescribed for chronic non-cancer pain

Abstract

Background After decades of increased opioid pain reliever prescribing, providers are rapidly reducing prescribing. We hypothesized that reduced access to prescribed opioid pain relievers among patients previously reliant upon opioid pain relievers would result in increased illicit opioid use. Methods and findings We conducted a retrospective cohort study among 602 publicly insured primary care patients who had been prescribed opioids for chronic non-cancer pain for at least three consecutive months in San Francisco, recruited through convenience sampling. We conducted a historical reconstruction interview and medical chart abstraction focused on illicit substance use and opioid pain reliever prescriptions, respectively, from 2012 through the interview date in 2017-2018. We used a nested-cohort design, in which patients were classified, based on opioid pain reliever dose change, into a series of nested cohorts starting with each follow-up quarter. Using continuation-ratio models, we estimated associations between opioid prescription discontinuation or 30% increase or decrease in dose, relative to no change, and subsequent frequency of heroin and non-prescribed opioid pain reliever use, separately. Models controlled for demographics, clinical and behavioral characteristics, and past use of heroin or non-prescribed opioid pain relievers. A total of 56,372 and 56,484 participant-quarter observations were included from the 597 and 598 participants available for analyses of heroin and non-prescribed opioid pain reliever outcomes, respectively. Participants discontinued from prescribed opioids were more likely to use heroin (Adjusted Odds Ratio (AOR) = 1.57, 95% CI: 1.25-1.97) and non-prescribed opioid pain relievers (AOR = 1.75, 1.45-2.11) more frequently in subsequent quarters compared to participants with unchanged opioid prescriptions. Participants whose opioid pain reliever dose increased were more likely to use heroin more frequently (AOR = 1.67, 1.32-2.12). Results held throughout sensitivity analyses. The main limitations were the observational nature of results and limited generalizability beyond safety-net settings.

Evaluating the Effects of Opioid Prescribing Policies on Patient Outcomes in a Safety-net Primary Care Clinic

“…However, multiple studies have linked prescription opioid discontinuation with adverse patient outcomes, including mortality and heroin use. [28][29][30][31] A study among the entire parent study sample observed associations between opioid discontinuations and dose reductions and non-prescribed opioid analgesic use, 28 which is consistent with our findings that the interventions under study may have increased the use of non-prescribed opioid analgesics. Also, the treated clinic implemented an integrative pain management program to advance the use of multimodal pain treatments in 2016, which was associated with self-reported improvements in pain, social satisfaction, and mental health outcomes among participating patients.…”

“…13,18,19 Evidence regarding the effects of opioid prescribing policies is largely limited to opioid prescribing outcomes. [20][21][22][23][24][25][26] However, several studies have linked reduction or discontinuation of prescribed opioids to adverse patient outcomes, including dropping out of care, 27 illicit use of opioids, 28,29 and death by overdose and suicide. 30,31 In light of these risks, critical examination of the effects of specific policies on both opioid prescribing and unintended patient outcomes, such as illicit opioid use, is needed to identify strategies that are both effective and safe.…”

Opioid Policy and Chronic Pain Treatment Access Experiences: A Multi-Stakeholder Qualitative Analysis and Conceptual Model

“…5 These issues are associated with negative opioid-related outcomes such as hospitalization, suicidal ideation, and transition to illicit use. [38][39][40][41][42] In conclusion, this study highlights heterogeneous treatment barriers, including lack of time and resources for clinicians, liability concerns, and scrutiny from pharmacists and insurers. Future interventions to address access barriers for this high-risk patient population need to address the many breakdowns in care and consider all involved stakeholders: patients, clinicians, office staff, pharmacists, and payers.…”

Factors Associated with Pain Treatment Satisfaction Among Patients with Chronic Non-Cancer Pain and Substance Use

“…46,47 Despite a lack of evidence supporting long-term opioid efficacy in CNCP treatment and some evidence suggesting improved pain scores with opioid tapering, 48,49 recent studies have cited potential harms of opioid discontinuations, including increased suicidal ideation from uncontrolled pain, return or initiation of illicit drug use leading to increased overdose risk and death, and increased emergency department visits and hospitalizations from adverse health events. [50][51][52][53][54][55][56] While we do not know whether participants consented to opioid discontinuations, mounting pressure from regulators to curb opioid prescriptions suggests many were likely provider-directed. 18,21,24,45 Even as discontinuations likely had justifications in prioritizing safety, our finding highlights the need for providers and policy makers to further examine the potential negative impacts of opioid prescribing policy changes.…”