Pain Level is a Predictor for Opioid Addiction
Many factors can make a patient more susceptible to addiction. For patients taking prescription opioids, one of the most important factors may seem the most obvious—pain.
Patients who suffer from moderate or severe pain were 41% more likely to develop prescription opioid use disorder (OUD), according to the results of a recent study conducted by researchers at the Columbia University Medical Center, New York, NY. The research is the latest insight into the driving factors behind opioid addiction.1
"These findings indicate that adults who report moderate or more severe pain are at increased risk of becoming addicted to prescription opioids," said Mark Olfson, MD, MPH, a professor of psychiatry at Columbia University Medical Center, and senior author of the study.
In 2014, approximately 1.9 million Americans reported substance use disorder involving prescription opioid pain relievers,2 and over 259 million prescriptions were written for opioid medications, enough for every adult American to have their own bottle of pills.3
"In light of the national opioid abuse epidemic, these new results underscore the importance of developing effective, multimodal approaches to managing common painful medical conditions," said Dr. Olfson, and while it may be difficult to determine which patients will respond best to a particular combination of therapies, developing more personalized pain management plan for patients could help stem overreliance on opioid-based therapies.
"Several nondrug interventions such as message, exercise, and mindfullness, as well as non-opioid medications including nonsteroidal antiinflammatory drugs (NSAIDs), antidepressants, and anticonvulsants can often play useful roles in the overall approach to pain management." Unfortunately, insurance companies do not consistently reimburse patients for these nondrug therapies, a barrier that may be holding back more incorporation of multimodal approaches into chronic pain management, Dr. Olfson told Practical Pain Management.
A Real Relationship Between Pain and Addiction
Using data supplied through the National Epidemiologic Survey on Alcohol and Related Conditions, Dr. Olfson and his colleagues were able to calculate the relationship between pain and OUD. They performed an analysis on 2 separate “waves” involving approximately 34,000 patients—the first wave from 2001 to 2002 and the second from 2004 to 2005.
To measure pain, the investigators used a 5-point scale based on pain interference with daily activities, as well as a dichotomized scale: “no pain” representing no or very little interference, and “pain” representing moderate to extreme interference. To assess patients for OUD, researchers used the Alcohol Use Disorder and Associated Disabilities Interview Schedule (DSM-IV).
Dr. Olfson and his colleagues found pain and OUD were “significantly associated” with one another both at baseline and at the 3-year follow-up, independent of the various other demographic and clinical characteristics, like age, sex, anxiety or mood disorders, and family history of drug, alcohol, and behavioral problems.
However, those characteristics did reveal some other interesting associations. For instance, patients who reported pain and OUD were also more likely to report recent substance use issues, mood or anxiety disorders, or a family history of alcohol use disorder. Researchers also found males and younger adults showed an increased risk for OUD, while females and older adults were more likely to report pain.
Interestingly, while pain at baseline was significantly associated with OUD at follow-up, OUD at baseline was not associated with pain at follow-up. This indicates that pain likely leads to reliance on opioids, not the other way around, the researchers reported.
Addiction: A Liability in Acute and Chronic Pain Care
The findings fall in line with other recent studies investigating the antecedents of opioid abuse. One study found over a fifth of patients on long-term opioid regimens for chronic noncancer pain met criteria for moderate OUD, and nearly 15% had severe OUD.4 But even in palliative patients with severe pain at the end of life, especially cancer pain these populations, there is a substantial risk of opioid abuse,5 leading more doctors to recommend the incorporation of the Opioid Risk Tool into patient assessments, as well as more adjunctive treatments to reduce opioid requirements and adverse events.6
Doctors are continuing to learn more about how OUD occurs, and oftentimes, the risk factors of opioid addiction are rarely static, instead changing dynamically based not only on pain intensity, but on disease progression, tolerance, drug interactions, as well as changes in mental health and patient lifestyle.7 Because of this, doctors should be mindful of known addiction risk factors for opioid abuse and maintain careful monitoring of patient behavior, said Dr. Olfson.
"For the foreseeable future, opioids will continue to play an important role in the management of chronic noncancer pain. Given the risks of abuse, however, it is imporate that physicians remain alert to addiction risk factors such as personal or family history of drug abuse. It is also important for clinicians to monitior their patients carefully for emerging signs of opioid abuse and dependence," Dr. Olfson told Practical Pain Management. Researchers also have suggested caution should be extended to patients prescribed opioids for acute pain, given opioid naïve patients taking opioids after an elective surgery can be at risk of prolonged postoperative opioid use.8 Even the use of prescribed opioids in patients before the 12th grade have been independently associated with future opioid misuse.9
However, Dr. Olfson also stressed that the utility of opioid medications should not be undermined because of their risks for addiction or misuse. "At the same time, the study results should not be interpreted as supporting an overly restrictive posture towards opioid therapy for pain management. The findings suggest that moderate or more severe pain that persists because it is not effectively treated also puts patients at risk for opioid addiction."
The study authors reported no conflicts of interest.