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.

Preoperative Opioid Misuse is Associated With Increased Morbidity and Mortality After Elective Orthopaedic Surgery

“…The observation that patients having spinal fusion showed the highest prevalence of opioid abuse and dependence was not surprising given that opioids play an increasingly pivotal role in the long-term management of chronic back pain, which is the primary reason for patients to undergo such procedures [13,14]. Patients with mental health and nonopioid substance use disorders had greater odds of abusing or being dependent on opioids, thus confirming the generalizability of previous studies to orthopaedic surgical inpatients [16,17,46,49,55]. Quality and safety initiatives aimed at reducing opioid misuse in the orthopaedic setting should primarily target this at-risk population, and be particularly implemented at urban teaching hospitals in the Northeast and West that function as ''safety net'' providers.…”

“…On the basis of clinical plausibility and available evidence [1,17,18,27,48,49], we selected several comorbidities that potentially could act as confounders in the associations between opioid abuse and dependence and postoperative events: AIDS and HIV infection, tobacco use, chronic anemia, alcohol abuse and dependence, depression, anxiety, and nonopioid drug abuse and dependence. The nonopioid drugs-illicit and prescription drugs used illicitly-considered were cannabis (ICD-9-CM codes 305.2x, 304.3x), hallucinogens (ICD-9-CM codes 305.3x, 304.5x), sedatives/hypnotics/anxiolytics (ICD-9-CM codes 305.4x, 304.1x), cocaine (ICD-9-CM codes 305.6x, 304.2x), amphetamines (ICD-9-CM codes 305.7x, 304.4x), antidepressants (ICD-9-CM code 305.8x), and other/unspecified substances (ICD-9-CM codes 305.9x, 304.6x, 304.8x, 304.9x) [33].…”

Opioid Prescribing at Hospital Discharge Contributes to Chronic Opioid Use

“…3,[38][39][40][41][42][43] When a patient endorses pain, the physician must first determine the etiology of the pain and then decipher if the patient has risk factors for aberrant opioid use. The physician must then identify an appropriate treatment strategy for pain control, which may or may not include opioids.…”

Low Use of Opioid Risk Reduction Strategies in Primary Care Even for High Risk Patients with Chronic Pain

“…[7][8][9]13 Several patient characteristics have been associated with an increased risk of opioid misuse in observational studies. Younger age has been consistently associated with opioid misuse, [14][15][16][17][18] with more than 70% of opioid overdose deaths occurring in individuals under age 45. 19 Patients with a history of drug abuse or dependence have an increased risk of prescription opioid abuse or dependence 15 and up to six times greater risk of aberrant medication-related behaviors such as prescription forgery or obtaining opioids from lay persons.…”