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

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

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

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

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