Measuring opioid dependence in chronic pain patients: A comparison between addiction clinic and pain clinic patient populations

Authors

  • Mike McDonough, MBBS
  • Jacinta L. Johnson, PhD
  • Jason M. White, PhD
  • Femke T. A. Buisman-Pijlman, PhD

DOI:

https://doi.org/10.5055/jom.2019.0514

Keywords:

opioids, chronic non-cancer pain (CNCP), dependence, addiction, overdose

Abstract

Objective: To compare dependence characteristics between patients with chronic pain treated within an addiction medicine setting with those attending specialist pain clinics.

Setting and patients: Forty patients with chronic non-cancer pain taking opioid analgesics for >1 year were recruited from university-affiliated, tertiary teaching hospital clinics; 20 from an addiction medicine clinic (addiction clinic group) and 20 from specialist pain clinics (pain clinic group).

Design and main outcome measures: Data regarding demographics, past and current substance use, pain history and current daily opioid intake were collected. Patients completed three questionnaires: the Severity of Opioid Dependence Questionnaire, Leeds Dependence Questionnaire, and Pain Disability Index. A novel “Opioid Problem Checklist score” assessing drug-related problems was also determined for each patient.

Results: The addiction clinic group were younger, more likely to have experienced drug overdose and had a shorter duration of chronic pain. No significant differences in dependence questionnaire scores were found between groups. However, higher Pain Disability Index scores and higher Opioid Problem Checklist scores (indicating more drug-related problems) were found for the addiction clinic group.

Conclusions: Some degree of dependence was present across both addiction and pain clinic groups, supporting the notion a state of dependence can be identified among chronic pain patients taking opioids long term. Aberrant behaviors were not common in the pain clinic sample, suggesting these patients are unlikely to meet Diagnostic and Statistical Manual of Mental Disorders-V criteria for Substance Use Disorder. However, opioid dependence carries significant risks for relapse, chronicity, morbidity and mortality, warranting specific medical management. Management of such risks should be considered routine care in chronic pain patients taking opioids long term.

Author Biographies

Mike McDonough, MBBS

Clinical Director, Drug and Alcohol Services South Australia, SA Health, South Australia, Australia

Jacinta L. Johnson, PhD

Lecturer in Pharmacy, School of Pharmacy and Medical Sciences, University of South Australia, South Australia, Australia; Senior Pharmacist, Medication Safety, Flinders Medical Centre, SA Pharmacy, SA Health, South Australia, Australia

Jason M. White, PhD

Adjunct Professor, School of Pharmacy and Medical Sciences, University of South Australia, South Australia, Australia

Femke T. A. Buisman-Pijlman, PhD

Senior Lecturer in Addiction Studies, Adelaide Medical School, University of Adelaide, South Australia, Australia

References

Maxwell JC: The prescription drug epidemic in the United States: A perfect storm. Drug Alcohol Rev. 2011; 30: 264-270.

Hernandez SH, Nelson LS: Prescription drug abuse: Insight into the epidemic. Clin Pharmacol Ther. 2010; 88: 307-317.

Dhalla IA, Persaud N, Juurlink DN: Facing up to the prescription opioid crisis. BMJ. 2011; 343: d5142.

Manchikanti L, Helm S 2nd, Fellows B, et al.: Opioid epidemic in the United States. Pain Physician. 2012; 15: ES9-ES38.

Kuehn BM: Opioid prescriptions soar: Increase in legitimate use as well as abuse. JAMA. 2007; 297: 249-251.

Leong M, Murnion B, Haber PS: Examination of opioid prescribing in Australia from 1992 to 2007. Intern Med J. 2009; 39: 676-681.

Rintoul AC, Dobbin MD, Drummer OH, et al.: Increasing deaths involving oxycodone, Victoria, Australia, 2000-09. Inj Prev. 2011; 17: 254-259.

Blanch B, Pearson SA, Haber PS: An overview of the patterns of prescription opioid use, costs and related harms in Australia. Br J Clin Pharmacol. 2014; 78: 1159-1166.

Giraudon I, Lowitz K, Dargan PI, et al.: Prescription opioid abuse in the UK. Br J Clin Pharmacol. 2013; 76: 823-824.

Sullivan MD, Edlund MJ, Fan MY, et al.: Risks for possible and probable opioid misuse among recipients of chronic opioid therapy in commercial and medicaid insurance plans: The TROUP Study. Pain. 2010; 150: 332-339.

Chou R, Fanciullo GJ, Fine PG, et al.: Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009; 10: 113-130.

Katz NP, Adams EH, Benneyan JC, et al.: Foundations of opioid risk management. Clin J Pain. 2007; 23: 103-118.

Hall WD, Farrell MP: Minimising the misuse of oxycodone and other pharmaceutical opioids in Australia. Med J Aust. 2011; 195: 248-249.

Volkow ND, McLellan TA: Curtailing diversion and abuse of opioid analgesics without jeopardizing pain treatment. JAMA. 2011; 305: 1346-1347.

Sehgal N, Manchikanti L, Smith HS: Prescription opioid abuse in chronic pain: A review of opioid abuse predictors and strategies to curb opioid abuse. Pain Physician. 2012; 15: ES67-ES92.

Gourlay DL, Heit HA: Pain and addiction: Managing risk through comprehensive care. J Addict Dis. 2008; 27: 23-30.

Volkow ND, McLellan AT: Opioid abuse in chronic pain—Misconceptions and mitigation strategies. N Engl J Med. 2016; 374: 1253-1263.

Hojsted J, Sjogren P: Addiction to opioids in chronic pain patients: A literature review. Eur J Pain. 2007; 11: 490-518.

Vowles KE, McEntee ML, Julnes PS, et al.: Rates of opioid misuse, abuse, and addiction in chronic pain: A systematic review and data synthesis. Pain. 2015; 156: 569-576.

Ballantyne JC, LaForge KS: Opioid dependence and addiction during opioid treatment of chronic pain. Pain. 2007; 129: 235-255.

Ballantyne JC: Assessing the prevalence of opioid misuse, abuse, and addiction in chronic pain. Pain. 2015; 156: 567-568.

Minozzi S, Amato L, Davoli M: Development of dependence following treatment with opioid analgesics for pain relief: A systematic review. Addiction. 2013; 108: 688-698.

Portenoy RK: Chronic opioid therapy in nonmalignant pain. J Pain Symptom Manage. 1990; 5: S46-S62.

Juurlink DN, Dhalla IA: Dependence and addiction during chronic opioid therapy. J Med Toxicol. 2012; 8: 393-399.

Fishbain DA, Cole B, Lewis J, et al.: What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuse/addiction and/or aberrant drug-related behaviors? A structured evidence-based review. Pain Med. 2008; 9: 444-459.

Gourlay DL, Heit HA, Almahrezi A: Universal precautions in pain medicine: A rational approach to the treatment of chronic pain. Pain Med. 2005; 6: 107-112.

Kahan M, Srivastava A, Wilson L, et al.: Misuse of and dependence on opioids: Study of chronic pain patients. Can Fam Physician. 2006; 52: 1081-1087.

National Institute on Drug Abuse: The Neurobiology of Drug Addiction. 2007 [cited June 8, 2018]. Available at https://www.drugabuse.gov/publications/teaching-packets/neurobiologydrug-addiction/section-iii-action-heroin-morphine/8-definition-dependence. Accessed June 8, 2018.

Ballantyne J, Sullivan MD, Kolodny A: Opioid dependence vs addiction: A distinction without a difference? Arch Intern Med. 2012; 127: 1342-1343.

World Health Organisation: Dependence Syndrome. [cited June 8, 2018]. Available at http://www.who.int/substance_abuse/terminology/definition1/en/. Accessed June 8, 2018.

World Health Organisation: International Classification of Diseases (ICD-10). 1990 [cited July 1, 2017]. Available at http://apps.who.int/classifications/icd10/browse/2016/en. Accessed July 1, 2017.

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders: DSM-V. 5th ed. Washington, DC: American Psychiatric Association, 2013.

Analgesic Expert Group: Therapeutic Guidelines: Analgesic. Version 5. Melbourne: Therapeutic Guidelines Ltd., 2007.

Sutherland G, Edwards G, Taylor C, et al.: The measurement of opiate dependence. Br J Addict. 1986; 81: 485-494.

Phillips GT, Gossop MR, Edwards G, et al.: The application of the SODQ to the measurement of the severity of opiate dependence in a British sample. Severity of alcohol dependence questionnaire. Br J Addict. 1987; 82: 691-699.

Burgess PM, Stripp AM, Pead J, et al.: Severity of opiate dependence in an Australian sample: Further validation of the SODQ. Br J Addict. 1989; 84: 1451-1459.

Sutherland G, Edwards G, Taylor C, et al.: The opiate dependence syndrome: Replication study using the SODQ in a New York clinic. Br J Addict. 1988; 83: 755-760.

Dawe S, Loxton NJ, Hides L, et al.: Review of Diagnostic Screening Instruments for Alcohol and Other Drug Use and Other Psychiatric Disorders. 2nd ed. Monograph Series, No. 48 (The National Drug Strategy). Canberra, ACT: Commonwealth Department of Health and Ageing, Publications Production Unit, 2002.

Raistrick D, Bradshaw J, Tober G, et al.: Development of the Leeds Dependence Questionnaire (LDQ): A questionnaire to measure alcohol and opiate dependence in the context of a treatment evaluation package. Addiction. 1994; 89: 563-572.

Ford P: An evaluation of the Dartmouth Assessment of Lifestyle Inventory and the Leeds Dependence Questionnaire for use among detained psychiatric inpatients. Addiction. 2003; 98: 111-118.

Chibnall JT, Tait RC: The Pain Disability Index: Factor structure and normative data. Arch Phys Med Rehabil. 1994; 75: 1082-1086.

Tait RC, Pollard CA, Margolis RB, et al.: The Pain Disability Index: Psychometric and validity data. Arch Phys Med Rehabil. 1987; 68: 438-441.

Anagnostis C, Gatchel RJ, Mayer TG: The pain disability questionnaire: A new psychometrically sound measure for chronic musculoskeletal disorders. Spine (Phila Pa 1976). 2004; 29: 2290-2302; discussion 2303.

Boscarino JA, Rukstalis MR, Hoffman SN, et al.: Prevalence of prescription opioid-use disorder among chronic pain patients: Comparison of the DSM-5 vs. DSM-4 diagnostic criteria. J Addict Dis. 2011; 30: 185-194.

Engel GL: Psychogenic pain and pain-prone patient. Am J Med. 1959; 26: 899-918.

Adler RH, Zlot S, Hurny C, et al.: Engel’s “Psychogenic pain and the pain-prone patient:” A retrospective, controlled clinical study. Psychosom Med. 1989; 51: 87-101.

Fishbain DA, Rosomoff HL, Rosomoff RS: Drug abuse, dependence, and addiction in chronic pain patients. Clin J Pain. 1992; 8: 77-85.

Fishbain DA, Cutler B, Rosomoff H, et al.: Comorbidity between psychiatric disorders and chronic pain. Curr Pain Headache Rep. 1998; 2: 1-10.

Scarinci IC, McDonald-Haile J, Bradley LA, et al.: Altered pain perception and psychosocial features among women with gastrointestinal disorders and history of abuse: A preliminary model. Am J Med. 1994; 97: 108-118.

Moore M, Jones T, Browder JH, et al.: A comparison of common screening methods for predicting aberrant drug-related behavior among patients receiving opioids for chronic pain management. Pain Med. 2009; 10: 1426-1433.

Michna E, Ross EL, Hynes WL, et al.: Predicting aberrant drug behavior in patients treated for chronic pain: Importance of abuse history. J Pain Symptom Manage. 2004; 28: 250-258.

Von Korff M, Shortreed SM, LeResche L, et al.: A longitudinal study of depression among middle-aged and senior patients initiating chronic opioid therapy. J Affect Disord. 2017; 211: 136-143.

Sullivan MD, Edlund MJ, Zhang B, et al.: Association between mental health disorders, problem drug use, and regular prescription opioid use. Arch Intern Med. 2006; 166: 2087-2093.

Wasan AD, Butler SF, Budman SH, et al.: Psychiatric history and psychologic adjustment as risk factors for aberrant drug-related behaviour among patients with chronic pain. Clin J Pain. 2007; 23: 307-315.

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR. 4th ed (text revision). Washington, DC: American Psychiatric Association, 2000.

Gomes T, Mamdani MM, Dhalla IA, et al.: Opioid dose and drug-related mortality in patients with nonmalignant pain. Arch Intern Med. 2011; 171: 686-691.

Chou R, Turner JA, Devine EB, et al.: The effectiveness and risks of long-term opioid therapy for chronic pain: A systematic review for a National Institutes of Health Pathways to Prevention Workshop. Ann Intern Med. 2015; 162: 276-286.

Fischer B, Jones W, Rehm J: High correlations between levels of consumption and mortality related to strong prescription opioid analgesics in British Columbia and Ontario, 2005-2009. Pharmacoepidemiol Drug Saf. 2013; 22: 438-442.

Published

07/01/2019

How to Cite

McDonough, MBBS, M., J. L. Johnson, PhD, J. M. White, PhD, and F. T. A. Buisman-Pijlman, PhD. “Measuring Opioid Dependence in Chronic Pain Patients: A Comparison Between Addiction Clinic and Pain Clinic Patient Populations”. Journal of Opioid Management, vol. 15, no. 4, July 2019, pp. 285-93, doi:10.5055/jom.2019.0514.