Opioid use, abuse behaviors fluctuate over time in patients with chronic noncancer pain
Patients who use opioids for chronic noncancer pain occasionally demonstrated problematic extra-medical opioid use behaviors, but these behaviors fluctuated considerably over time, according to survey data in JAMA Network Open.
“Past research has tended to find the mean of opioid behaviors across cohorts, which is useful in characterizing their prevalence in a population, but uninformative about individual trajectories of opioid use over time,” Louisa Degenhardt, PhD, of the University of New South Wales, in Sydney, told Healio Rheumatology. “I wanted to know if the population prevalence of indicators of problematic opioid use reflects a persistent pattern of behavior by the same individuals, or whether behavior varies by different individuals over time.”
To analyze prevalence, incidence, persistence and cessation for various opioid behaviors, including indicators of extra-medical use and harm, in people with opioid prescriptions, Degenhardt and colleagues conducted a 5-year prospective cohort study in communities across Australia. Participants included 1,514 adults with an opioid prescription for chronic noncancer pain, recruited through community pharmacies. Chronic pain was defined as lasting longer than 3 months. Inclusion was limited to patients receiving a Schedule 8 opioid — a classification that includes morphine, oxycodone, buprenorphine, methadone and hydromorphone — for more than 6 weeks.
Researchers conducted telephone or face-to-face interviews with each participant at baseline and 3 months, with annual interviews thereafter for 5 years. Each interview lasted approximately 60 to 90 minutes, and participants were compensated AUD $40 to $50 for each session. In addition to the interviews, a 7-day medication diary collected frequency and dose information on all pain, psychiatric and sleep medications. From recruitment to follow-up, the study stretched from August 2012 to December 2018. For their analysis, Degenhardt and colleagues used data from the baseline and five annual follow-up interviews.
The main outcomes were high-dose opioid use, defined as 200 oral morphine equivalent (OME) mg per day or more; requesting an increase in opioid dose; requesting an early prescription renewal; tampering with opioid medication; diversion of medication to others; and opioid dependence, based on the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision. The researchers also analyzed opioid cessation.
According to the researchers, approximately one in eight people were taking more than 200 OME mg per day at each annual interview — with a range of 10.98% (95% CI, 10.33% to 11.63%) to 14.73% (95% CI, 13.98% to 15.48%) at any given interview. Meanwhile, the percentage of participants who had requested an increased dose in the previous 3 months ranged from 8.46% (95% CI, 7.89% to 9.03%) to 23.77% (95% CI, 22.82% to 24.73%) in each interview. Comparatively fewer people — ranging from 4.61% (95% CI, 4.19% to 5.03%) to 13.97% (95% CI, 13.24% to 14.70%) in any given interview — asked for an early renewal.
Between 8.28% (95% CI, 7.71% to 8.84%) and 13.06% (95% CI, 12.35% to 13.77%) of participants at each interview met criteria for opioid dependence. Meanwhile, between 3.06% (95% CI, 2.72% to 3.40%) and 7.86% (95% CI, 7.31% to 8.41%) in any given interview reported tampering with their opioid medication, and between 0.47% (95% CI, 0.33% to 0.60%) and 1.39% (95% CI, 1.16% to 1.62%) reported diverting them to others.
However, opioid cessation increased across interviews, from year 9.15% (95% CI, 8.55% to 9.74%) in year 1 to 20.02% (95% CI, 19.14% to 20.89%) in year 5.
In addition, there were considerable changes in the incidence and cessation of all behaviors from one interview to the next. For example, those who engaged in any of the above behaviors did so at only one interview, the researchers wrote. Specifically for opioid dependence, between 55.26% (95% CI, 53.81% to 56.71%) and 64.44% (95% CI, 62.87% to 66.00%) of cases in one interview failed meet the dependence criteria in the following interview.
“The findings challenge a common view that the risk of opioid-related behaviors is static and that risk assessment at the start of opioid treatment can predict which patients will develop opioid use disorder,” Degenhardt said. “Even among a cohort of people with long standing chronic noncancer pain, long term opioid use, and multiple physical, mental health and substance use disorder comorbidities, indicators of problematic opioid use are dynamic and time-limited — not chronic and recurring.”
“Individuals who engage in opioid-related behaviors change over time, which also suggests that opioid behaviors of concern need not persist,” she added. “Patient monitoring needs to be ongoing, as extra-medical use or concerns may sometimes occur. Monitoring tools to predict risk may be improved by considering dynamic factors, such as fluctuations in pain severity and interference, pain self-efficacy, depression and anxiety.”
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