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Research ArticleOriginal Research

Depression and Prescription Opioid Misuse Among Chronic Opioid Therapy Recipients With No History of Substance Abuse

Alicia Grattan, Mark D. Sullivan, Kathleen W. Saunders, Cynthia I. Campbell and Michael R. Von Korff
The Annals of Family Medicine July 2012, 10 (4) 304-311; DOI: https://doi.org/10.1370/afm.1371
Alicia Grattan
MD
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Mark D. Sullivan
MD, PhD
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  • For correspondence: sullimar@uw.edu
Kathleen W. Saunders
JD
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Cynthia I. Campbell
PhD, MPH
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Michael R. Von Korff
ScD
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  • What do we learn?
    Ajay D Wasan
    Published on: 16 August 2012
  • Re:An excellent first step
    Bill H McCarberg
    Published on: 27 July 2012
  • Treating Chronic Pain in Primary Care -- Without Opioids
    Robert C. Smith
    Published on: 23 July 2012
  • Authors' Response to Dr. Lavin's E-Letter
    Alicia Grattan
    Published on: 19 July 2012
  • An excellent first step
    Mark Unverzagt
    Published on: 19 July 2012
  • Re:Depression and Prescription Opioid Misuse Among Chronic Opioid Therapy Recipients with No History of Substance Abuse
    Robert A. Lavin
    Published on: 16 July 2012
  • Published on: (16 August 2012)
    Page navigation anchor for What do we learn?
    What do we learn?
    • Ajay D Wasan, Assistant Professor

    Dr. Grattan and colleagues should be congratulated for their excellent study demonstrating the association of greater misuse of opioids in a chronic pain population with major depression cormorbidity. Their work at a population level is consistent with smaller studies demonstrating the same result, that patients with chronic pain and psychiatric comorbidity are more likely to misuse opioids and self- medicate anxious and...

    Show More

    Dr. Grattan and colleagues should be congratulated for their excellent study demonstrating the association of greater misuse of opioids in a chronic pain population with major depression cormorbidity. Their work at a population level is consistent with smaller studies demonstrating the same result, that patients with chronic pain and psychiatric comorbidity are more likely to misuse opioids and self- medicate anxious and depressive feelings and sleep with opioids. Interestingly, this study also shows that just as there is a sizable population with significant rates of opioid misuse, there is a sizable population with considerable adherence to opioids, i.e, those with positive deviance. Hence, the decision to use opioids for non-cancer pain always requires (just as in nearly all areas of medicine) an individual assessment. It would be wrong to use the findings from this study to conclude that the risks of using opioids in noncancer pain outweigh the benefits. Instead, it is the understanding of subgroup responses in those on opioids that should be of clinical and research interest.

    Competing interests:   None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (27 July 2012)
    Page navigation anchor for Re:An excellent first step
    Re:An excellent first step
    • Bill H McCarberg, Physician

    I would like to commend doctor Zweifler on his well referenced plea for more objective evidence in our chronic pain patients. The FDA has described the "epidemic" of opioid use and has attempted to reduce the misuse, abuse, diversion and increasing deaths by instituting Risk Evaluation and Mitigation Strategy. Dr. Zweifler recommends only using opioids in those patients where "objective evidence of severe disease" can be...

    Show More

    I would like to commend doctor Zweifler on his well referenced plea for more objective evidence in our chronic pain patients. The FDA has described the "epidemic" of opioid use and has attempted to reduce the misuse, abuse, diversion and increasing deaths by instituting Risk Evaluation and Mitigation Strategy. Dr. Zweifler recommends only using opioids in those patients where "objective evidence of severe disease" can be found. The International Association for the Study of Pain, the American Pain Society, the American Academy of Pain Medicine, the Centers for Disease Control and Prevention just to mention a few organizations do not call for such objective evidence. Despite Dr. Zigler's well referenced article, there are no references to his recommendation that severity of pain is associated with physical findings that include "deformity, atrophy or asymmetry". There is also no reference to his claim that standard laboratory testing will help identify severity. The experience in primary care is just the opposite. Many pain syndromes lack objective evidence. Diabetic peripheral neuropathy can be found on monofilament exam, but pain can be present or absent. Imaging studies of the lumbar spine are poorly predictive of patient symptoms. The above organizations have not recommended objective evidence and recommend specifically trusting the patient descriptions of their pain since it is well known that severity and physical findings frequently mismatch. I understand the frustration of prescribing an abusable medication to a patient without knowing objectively the pain level. I also realize that much of the prescribing and misuse occurs from patients in primary care, patients who have not been adequately assessed. This assessment however, is not to objectify pain but assess risk of prescribing. Minimalizing the patient's experience to measurable outcomes (imaging studies, laboratory testing etc.) will result in an epidemic of undertreated pain. Our mission in primary care is to reduce patient suffering whenever possible. We also have a public safety responsibility. Until we have better objective measures of the patient experience, providers should always assess the patient but err on the side of reducing the suffering.

    Competing interests:   Advisor for Pfizer,Purdue,Pricara,Endo,Sucampo,Insys Therapeutics,QRx Pharma,Teva Pharma,Neurogesx,Salix,Pfizer

    Show Less
    Competing Interests: None declared.
  • Published on: (23 July 2012)
    Page navigation anchor for Treating Chronic Pain in Primary Care -- Without Opioids
    Treating Chronic Pain in Primary Care -- Without Opioids
    • Robert C. Smith, Professor of Medicine and Psychiatry

    The findings of Grattan et al. raise the problem of treating chronic pain when opioid misuse and depression co-exist.1 Because opioids can cause and aggravate depression, and because depression magnifies chronic pain and its disability, most would recommend that primary care providers (PCP) taper and discontinue opioids, particularly with no evidence that they are effective in chronic pain.

    Is there a way then...

    Show More

    The findings of Grattan et al. raise the problem of treating chronic pain when opioid misuse and depression co-exist.1 Because opioids can cause and aggravate depression, and because depression magnifies chronic pain and its disability, most would recommend that primary care providers (PCP) taper and discontinue opioids, particularly with no evidence that they are effective in chronic pain.

    Is there a way then for the PCP to treat chronic pain without opioids? We conducted two RCTs of high-utilizing patients with medically unexplained symptoms (almost all chronic pain) and very high rates of comorbid mental health disorders.2,3 In rare primary care interventions, we trained PCPs (nurse practitioners, family medicine physicians) to deploy treatment. One feature was to taper and discontinue opioids and other addicting agents.4 In addition to treatment with antidepressants for the common depressed patients, we followed cognitive-behavioral principles and integrated many modalities -- from exercise to relaxation to enhancing one's spiritual and social life.4 Anchoring this multi-factorial treatment was a consistent focus on being patient-centered, establishing a good relationship, and negotiating rather than prescribing all treatments. Patients averaged 12-14 visits per year before treatment and we prescribed a similar number of regularly scheduled visits over 12 months, starting with weekly visits and increasing the interval as they improved, to the point that most remained stable with quarterly visits. We observed clinically significant improvements in mental and physical health status, physical function, pain, and patient satisfaction; antidepressant use to full doses was increased and narcotic use was decreased.2,3 There was no net increase in cost.5

    It is important that we in primary care have an effective, evidence- based treatment option. I propose that opioids be used only after failure of such a multifactorial treatment program to which the patient has been adherent. In that case, integrate opioids into the program in small doses given at regular intervals. Small dosage increases are acceptable, many experts saying not beyond 120-180 morphine equivalents/day. Refractory pain at these doses indicates that the opioid likely will not be effective and is an indication for consultation with mental health, addiction, or pain specialists -- not further dosage increases. Happily, our clinical trials indicate that this will rarely be necessary and, indeed, that tapering the opioid as part of a patient-centered, multifaceted treatment program is more effective and, importantly, well received by patients.

    REFERENCES

    1. Grattan A, Sullivan MD, Saunders KW, Campbell CI, Von Korff MR. Depression and prescription opioid misuse among chronic opioid therapy recipients with no history of substance abuse. Ann Fam Med 2012;10:304-11.

    2. Smith R, Gardiner J, Luo Z, Schooley S, Lamerato L. Primary Care Physicians Treat Somatization. J Gen Int Med 2009;24:829-32.

    3. Smith RC, Lyles JS, Gardiner JC, et al. Primary Care Clinicians Treat Patients with Medically Unexplained Symptoms -- A Randomized Controlled Trial. J Gen Intern Med 2006;21:671-7; PMCID: PMC1924714.

    4. Smith RC, Lein C, Collins C, et al. Treating patients with medically unexplained symptoms in primary care. J Gen Intern Med 2003;18:478- 89.PMCID: PMC1494880.

    5. Luo Z, Goddeeris J, Gardiner J, Lyles J, Smith RC. Costs of an intervention for primary care patients with medically unexplained symptoms -- a randomized controlled trial. Psychiatr Serv 2007;58:1079-86. NIHMSID: PMCID: PMC2633637.

    Competing interests:   None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (19 July 2012)
    Page navigation anchor for Authors' Response to Dr. Lavin's E-Letter
    Authors' Response to Dr. Lavin's E-Letter
    • Alicia Grattan, Psychiatry Fellow

    Dr. Lavin brings up some very interesting points and potential hypotheses about why depressed patients on COT misuse opioids. It would be nice to look more closely at misuse of shorter-acting PRNs, as there are long-standing beliefs that these are more prone to abuse. We agree that it would be ideal to have a mental health evaluation prior to starting COT. Although a formal psychiatric evaluation may not be feasible in ma...

    Show More

    Dr. Lavin brings up some very interesting points and potential hypotheses about why depressed patients on COT misuse opioids. It would be nice to look more closely at misuse of shorter-acting PRNs, as there are long-standing beliefs that these are more prone to abuse. We agree that it would be ideal to have a mental health evaluation prior to starting COT. Although a formal psychiatric evaluation may not be feasible in many primary care settings, screening with some questionnaires (PHQ-9, PC-PTSD, CAGE) may be useful.

    Competing interests:   None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (19 July 2012)
    Page navigation anchor for An excellent first step
    An excellent first step
    • Mark Unverzagt, Physician

    The authors have done an excellent job of illuminating what those of us in practice have known to be an intuitive component of the dilemma of using opioids for chronic pain in patients who are also likely depressed. It is helpful to know that what seems to make sense, does. It is my hope that they will follow up with the all important issue of "What next?" What do best practices tell us about optimal management of this di...

    Show More

    The authors have done an excellent job of illuminating what those of us in practice have known to be an intuitive component of the dilemma of using opioids for chronic pain in patients who are also likely depressed. It is helpful to know that what seems to make sense, does. It is my hope that they will follow up with the all important issue of "What next?" What do best practices tell us about optimal management of this difficult population?

    Competing interests:   None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (16 July 2012)
    Page navigation anchor for Re:Depression and Prescription Opioid Misuse Among Chronic Opioid Therapy Recipients with No History of Substance Abuse
    Re:Depression and Prescription Opioid Misuse Among Chronic Opioid Therapy Recipients with No History of Substance Abuse
    • Robert A. Lavin, Director of Chronic Outpatient Pain Management

    It has been shown previously that depression, anxiety, and other mental health disorders are associated with opioid misuse. One of the interesting findings in this paper is that a lower daily opioid dose was associated with a higher percentage of misuse. The authors note that the lower opioid dose may be related to use of short-acting opioids. It has been a frequent clinical observation that depressed and anxious chronic...

    Show More

    It has been shown previously that depression, anxiety, and other mental health disorders are associated with opioid misuse. One of the interesting findings in this paper is that a lower daily opioid dose was associated with a higher percentage of misuse. The authors note that the lower opioid dose may be related to use of short-acting opioids. It has been a frequent clinical observation that depressed and anxious chronic pain patients who have been prescribed short-acting prn opioids often do not respond with pain relief when transitioned to substantially higher daily doses of sustained release opioids. They complain that they cannot "feel" the sustained release opioids, and they may self-escalate by taking these more potent sustained-release opioids on a schedule similar to the short-acting prn opioids. These behaviors suggest a strong psychogenic effect of the short-acting opioids, which is probably related to pharmacokinetics (i.e., more rapid and transiently higher serum levels), compared to the sustained-release opioids. This clinical response to short -acting opioids should lead practitioners to suspect an underlying mental health component. The truism of chronic pain is that mental health diagnoses remain underdiagnosed and undertreated in this population. Perhaps the requirement that patients undergo an psychological evaluation prior to opioid initiation and periodically when chronic opioid therapy is being prescribed as a standard of care would help to reduce the current epidemic of opioid prescribing and misuse. Finally, the authors may wish to consider a sequel to this paper examining the relationship between short-acting opioid use and depression.

    Competing interests:   None declared

    Show Less
    Competing Interests: None declared.
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The Annals of Family Medicine: 10 (4)
The Annals of Family Medicine: 10 (4)
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Depression and Prescription Opioid Misuse Among Chronic Opioid Therapy Recipients With No History of Substance Abuse
Alicia Grattan, Mark D. Sullivan, Kathleen W. Saunders, Cynthia I. Campbell, Michael R. Von Korff
The Annals of Family Medicine Jul 2012, 10 (4) 304-311; DOI: 10.1370/afm.1371

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Depression and Prescription Opioid Misuse Among Chronic Opioid Therapy Recipients With No History of Substance Abuse
Alicia Grattan, Mark D. Sullivan, Kathleen W. Saunders, Cynthia I. Campbell, Michael R. Von Korff
The Annals of Family Medicine Jul 2012, 10 (4) 304-311; DOI: 10.1370/afm.1371
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