Psychiatry and Primary Care1The missing ‘P’ in pain management: how the current opioid epidemic highlights the need for psychiatric services 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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2021, International Journal of Drug PolicyCitation Excerpt :We found depression diagnosed in 19.0% to 25.6% of the sample and anxiety disorders were diagnosed in 20.3% to 35.9%. SUDs were not common except in the group receiving >200 MME. While the prevalence of comorbid psychiatric disorders is consistent with prior studies of opioid use, (Davis, Lin, Liu, & Sites, 2017; Han et al., 2017; Howe, & M.D., 2014; Scherrer et al., 2015; Sullivan Zhang, Unutzer, & Wells, 2006) the prevalence of psychiatric disorders is much lower than the prevalence of benzodiazepine prescriptions. Benzodiazepine prescriptions in patients on opioids are generally used to reduce insomnia and anxiety.
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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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Recent epidemiologic studies have found that most patients with mental illness are seen exclusively in primary care medicine. These patients often present with medically unexplained somatic symptoms and utilize at least twice as many health care visits as controls. There has been an exponential growth in studies in this interface between primary care and psychiatry in the last 10 years. This special section, edited by Jürgen Unutzer, M.D., will publish informative research articles that address primary care-psychiatric issues.