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Spinal Cord Injury: Patient Characteristics May Inform Future Opioid Misuse

February 17, 2017
Spinal cord injury patients with depression, impulsivity, and anxiety were found at higher risk for future pain medication misuse. Current smokers, including of cigarette and cannabis, were also significantly at increased risk for abuse.

Interview with Jillian Clark, MA

Pain can be a particularly steep challenge for clinicians who treat patients with a spinal cord injury (SCI). While doctors are not remiss of the risks associated with pain medications, up to this point, it has been difficult to clearly define specific patient factors that may predict the possibility of medication misuse.

Now, researchers have identified personality traits, such as depression, impulsivity, and anxiety, that may increase a person's risk of abuse.1 In a study of patients with a SCI, those that  showed signs of depression, impulsivity, and anxiety were far more at risk for pain medication misuse (PMM). Many behavioral traits also appeared linked to pain medication misuse, like smoking cannabis and cigarettes, and drinking alcohol.

Certain factors may predispose patients with a spinal cord injuries to misuse pain medications.

The study, published in the Journal of Pain,1 is the first of its kind to examine a large sample of patients who have suffered a traumatic SCI in an attempt to identify possible traits that might help identify their susceptibility to prescription overuse or abuse, including demographics, injury types, experience with and management of pain, personality traits, and diagnosis of depression.

"Our article provides an initial exploration of a variety of predictors (e.g., demographic, substance use, psychological) of risk of PMM within this specific population, which will be useful for prescribers who work with patients with SCI," Jillian Clark, MA, lead author, from the Medical University of South Carolina in Charleston, South Carolina, told Practical Pain Management.

"A noteworthy finding was that interference of pain on functioning was related to risk of PMM, whereas pain severity was not. These findings may suggest that misuse behaviors are associated with attempts to cope with functional limitations due to pain, rather than alleviating the pain, itself."

Sorting Out Risk Factors for Misusing Pain Medications

The study examined 1,619 patients, using both clinical and population-based cohorts to do a longitudinal analysis. All of the patients had reported at least 1 painful condition related to their SCI with frequency of pain as a common complaint, averaging 14.14 (SD = 11.35) in the previous month, with an intensity of 5.7 (SD = 2.2) out of 10.

The researchers found nearly a third of patients (29.6%) had scores of ≥ 25 on the Pain Medication Questionnaire (PMQ), which was indicative of medication misuse. A sizeable subset of the patients (17.6%) scored ≥ 30 on the PMQ, which researchers used to define the presence of PMM.  

The researchers found strong correlations between certain patient factors and the risk of PMM. In a logistic regression analysis, personality traits such as anxiety, impulsiveness, sensation-seeking, and depression increased the likelihood of PMM. In fact, people who scored positive for depressive symptoms appeared 1.61 times more likely be at risk of PMM as compared to those with minimal depressive symptoms.

Another subset of patients who presented at elevated risk were smokers, who appeared 2.05 times more at risk for PMM than nonsmokers; similarly, occasional and frequent cannabis users also appeared 2.66 and 1.79 times at risk, respectively. when compared to nonusers.

"Identifying these particular associations is important given recent state laws regarding cannabis and medicinal cannabis," Ms. Clark noted.

"The relationship between personality traits and medication misuse identified in our article may actually be an extension of lifelong patterns of sensation-seeking and medication misuse that predate the onset of SCI," Ms. Clark explained. "Our article, while not implying causation, suggests that these personality traits are important to consider when prescribing pain medications within this population."

Demographics and Daily Use Offer Critical Insights

Indeed, the study may guide clinicians not only about the behavioral traits of patients at risk of PMM but also the way in which medications are taken daily, something that could be monitored in a clinical setting. In fact, most patients (65.7%) reported using pain medications daily to relieve their pain were the same individuals who most often were at a 96% increased risk of misusing their medications.

According to the authors, such findings could illustrate numerous patient characteristics that clinicians may find useful in monitoring when prescribing pain medications. However, it should be noted that not every aspect of the study syncs with previous research on the topic.

Indeed, Ms. Clark and her colleagues found that pain severity was not related to the risk of PMM, something that directly contrasts with prior research.2 Granted, previous research examining SCI patients did find a significant association between pain severity and PMM, based on a much smaller sample size and a lesser cutoff on the PMQ scale (≥ 25) to define PMM,3 the authors explained.

The age of the patient also provided some interesting findings, such that it was not significantly associated with PMM once substance use and psychological factors were factored into the analysis.1

In fact, many aspects of the study’s findings did contrast with past studies that have looked specifically at PMM risk. On the subject of race, while past studies reported that white, non-Hispanic patients exhibited greater opioid misuse,4,5 this study found black, non-Hispanic participants showed a higher risk, instead.1

Yet, the study findings identified traits that might alert pain practitioners to consider assessing these factors for increased susceptibility for misuse of pain medications in some patients

According to the authors, this could account for about 18% of patients who have a SCI and struggle with at least one painful condition. The hope is that as more studies are conducted, a better understanding of the characteristics in patients that flag them as susceptible to misuse their medications.

“Further research should continue to examine the risk of PMM in relation to limited functioning and pain severity within individuals with SCI,” the authors stated.

This research supported by a grant from the US Department of Health and Human Services Administration for Community Living. The authors declared no conflicts of interest.

Last updated on: February 17, 2017
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