Elsevier

General Hospital Psychiatry

Volume 36, Issue 1, January–February 2014, Pages 99-104
General Hospital Psychiatry

Psychiatry and Primary Care1
The missing ‘P’ in pain management: how the current opioid epidemic highlights the need for psychiatric services in chronic pain care,

https://doi.org/10.1016/j.genhosppsych.2013.10.003Get rights and content

Abstract

Objective

The prevalence of opioid therapy for chronic noncancer pain has increased dramatically in recent years, with a parallel increase in opioid abuse, misuse and deaths from accidental overdose. We review epidemiological and clinical data that point to the important roles psychiatric disorders have in the use and abuse of opioids in patients with chronic pain.

Method

We conducted literature searches on the PubMed with the key phrases “chronic pain” and “opioid therapy” and selected those articles on the epidemiology of comorbidity between chronic pain and psychiatric disorders, the trends in long-term opioid therapy and the clinical trials that involved using opioid therapy for chronic pain or for mental health disorders. We then thoroughly reviewed the bibliography of all relevant articles to identify additional papers to be included in the present review.

Results

Chronic pain is highly comorbid with common psychiatric disorders. Patients with mental health and substance abuse disorders are more likely to receive long-term opioid therapy for chronic pain and more likely to have adverse outcomes from this therapy. Although opioids may exert brief antidepressant and anxiolytic effects in some patients with depression or anxiety, there is scant evidence for long-term benefit from opioid treatment of psychiatric disorders.

Conclusions

Opioids may be used in current clinical practice as the de facto and only psychiatric treatment for patients with chronic pain, despite little evidence for sustained benefit. The opioid epidemic thus reflects a serious unmet need for better recognition and treatment of common mental health problems in patients with chronic pain. Psychiatry is the missing P in chronic pain care.

Introduction

The Institute of Medicine recently estimated that 100 million Americans suffer from chronic pain at a cost of $600 billion [1]. As clinicians have sought to address this challenge, the use of long-term opioid therapy for chronic noncancer pain (CNCP) has quadrupled in the last 15 years [2], [3], [4]. This has been accompanied by increased opioid adverse events. The Centers for Disease Control (CDC) has published data showing parallel increases among opioid sales, overdose deaths and abuse from 1999 to 2010, with opioid deaths more than tripling between 1999 and 2008 [5]. More recent statistics indicate that this trend has continued [6]. We will argue in this paper that psychiatric disorders play an important role in linking these trends, because of a pervasive process of “adverse selection.” Adverse selection refers to the fact that patients with mental health and substance use disorders are more likely to receive opioid therapy at higher doses and for longer periods, and are more likely to suffer adverse outcomes. We will review evidence demonstrating that the opioid epidemic points toward a serious unmet need for psychiatric care for patients with CNCP.

Clinical decision making concerning opioid therapy for CNCP is complicated by the fact that randomized controlled trials of opioid efficacy for chronic pain conditions have excluded patients with psychiatric comorbidities, even though these are highly prevalent in patients with chronic pain [7], [8]. Common mental disorders, such as depression and anxiety, are known to be associated with higher pain intensity, more pain complaints as well as higher pain interference with daily activities [9], [10], [11]. The close association between both the prevalence and severity of chronic pain and psychiatric and substance use disorders makes the safety and efficacy data from randomized controlled trials of opioid therapy not directly applicable to the patients with chronic pain who are most likely to receive opioid therapy in actual clinical practice.

Below, we review recent research addressing the following clinically important questions: Does the presence of psychiatric disorders influence the likelihood of a patient receiving opioids for CNCP? Do mental disorders affect the outcome of opioid therapy? Are opioids effective treatment for mental health disorders? What are the effects of long-term opioid therapy on mental health outcomes?

Section snippets

Chronic pain and psychiatric disorders

The high rates of comorbidity among chronic pain and psychiatric disorders have been well documented [11], [12]. Studies of prevalence of pain in depression showed that various forms of chronic pain complaints (back/neck, arthritis and migraine/chronic headaches) were more common in depressed patients across different demographic groups [13], [14], [15], [16], [17], [18], [19], [20]. Patients with both pain and depression tend to have more pain complaints [21], higher pain intensity [22] and

Psychiatric disorders and the likelihood of receiving chronic opioid therapy

Studies using data from pain clinics, general population surveys and health insurance administrative data concerning general medical patients have suggested that patients with common psychiatric problems such as depression, anxiety and substance use disorders are more likely to receive opioids for CNCP than patients without mental disorders [3], [54], [55], [56].

Sullivan et al. [55], [56] published two reports involving epidemiological data from Health Care for Communities (HCC) survey. The HCC

Psychiatric disorders and the outcome of opioid therapy

The evaluation of the outcomes of opioid treatment for chronic pain is a complex issue and cannot be limited to reductions in pain intensity alone. Although clinical trials of long-term opioid therapy have included functional measures, these generally measured the function of a specific body part (e.g., grip strength for arthritis patients) [7], rather than more meaningful measures of role function, overall quality of life and psychosocial functioning. Pain relief itself may or may not lead to

Opioid treatment of mental health disorders

Because of its euphoric, sedating and anxiolytic effect, opium was widely used in the late 19th century and early 20th century to treat melancholia, mania and other forms of psychological distress [82]. However, the use of opioids to treat psychiatric disorders gradually became obsolete when nonaddictive antidepressants became available in the 1950s [83]. Opioids primarily act through binding to the opioid receptors, which produce both analgesic and hedonic effects. Recently, opioid medications

Discussion

Evidence reviewed in this paper underscores the phenomenon of adverse selection in chronic pain management where high-risk patients are more likely to end up on high-risk opioid regimens, and shows the important ways in which psychiatric comorbidities contribute to these high-risk levels. Psychiatric disorders, especially substance abuse, depression and PTSD, are highly prevalent in patients with CNCP. Patients with these substance use and mental health diagnoses are more likely to receive

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    Disclosures: Dr. Howe reports no competing interests. Dr. Sullivan has received educational grants from Pfizer, Covidien and Endo.

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