Use of opioid medications for chronic noncancer pain syndromes in primary care
Rent the article at a discountRent now
* Final gross prices may vary according to local VAT.Get Access
OBJECTIVES: To define the spectrum of chronic noncancer pain treated with opioid medications in 2 primary care settings, and the prevalence of psychiatric comorbidity in this patient population. We also sought to determine the proportion of patients who manifested prescription opioid abuse behaviors and the factors associated with these behaviors.
DESIGN: A retrospective cohort study.
SETTING: A VA primary care clinic and an urban hospital-based primary care center (PCC) located in the northeastern United States.
PATIENTS: A random sample of VA patients (n=50) and all PCC patients (n=48) with chronic noncancer pain who received 6 or more months of opioid prescriptions during a 1-year period (April 1, 1997 through March 31, 1998) and were not on methadone maintenance.
MEASUREMENTS: Information regarding patients’ type of chronic pain disorder, demographic, medical, and psychiatric status, and the presence of prescription opioid abuse behaviors was obtained by medical record review.
MAIN RESULTS: Low back pain was the most common disorder accounting for 44% and 25% of all chronic pain diagnoses in the VA and PCC samples, respectively, followed by injury-related (10% and 13%), diabetic neuropathy (8% and 10%), degenerative joint disease (16% and 13%), spinal stenosis (10% and 4%), headache (4% and 13%) and other chronic pain disorders (8% and 22%). The median duration of pain was 10 years (range 3 to 50 years) in the VA and 13 years in the PCC sample (range 1 to 49 years). Among VA and PCC patients, the lifetime prevalence rates of psychiatric comorbidities were: depressive disorder (44% and 54%), anxiety disorder (20% and 21%), alcohol abuse/dependence (46% and 31%), and narcotic abuse/dependence (18% and 38%). Prescription opioid abusive behaviors were recorded for 24% of VA and 31% of PCC patients. A lifetime history of a substance use disorder (adjusted odds ratio [OR], 3.8; 95% confidence interval [CI], 1.4 to 10.8) and age (adjusted OR, 0.94; 95% CI, 0.89 to 0.99) were independent predictors of prescription opioid abuse behavior.
CONCLUSIONS: A broad spectrum of chronic noncancer pain disorders are treated with opioid medications in primary care settings. The lifetime prevalence of psychiatric comorbidity was substantial in our study population. A significant minority of patients manifested prescription opioid abusive behaviors, and a lifetime history of a substance use disorder and decreasing age were associated with prescription opioid abuse behavior. Prospective studies are needed to determine the potential benefits as well as risks associated with opioid use for chronic noncancer pain in primary care.
- Gureje O, Von Korff M, Simon GE, Gater R. Persistent pain and well being. A World Health Organization study in primary care. JAMA. 1998;280:147–51. CrossRef
- Donovan MI, Evers K, Jacobs P, Mandleblatt S. When there is no benchmark: designing a primary care-based chronic pain management program from the scientific basis up. J Pain Symptom Manage. 1999;18:38–48. CrossRef
- Becker N, Thomsen AB, Olsen AK, Sjogren P, Bech P, Eriksen J. Pain epidemiology and health related quality of life in chronic non-malignant pain patients referred to a Danish multidisciplinary pain center. Pain. 1997;73:393–400. CrossRef
- Gallagher RM. Primary care and pain medicine. A community solution to the public health problem of chronic pain. Med Clin N Amer. 1999;83:555–83. CrossRef
- Von Korff M, Wagner EH, Dworkin SF, Saunders KW. Chronic pain and use of ambulatory health care. Psychsom Med. 1991;53:61–79.
- Engel CC, Von Korff M, Katon WJ. Back pain in primary care: predictors of high health care costs. Pain. 1996;65:197–204. CrossRef
- Linton SJ, Hellsing AL, Hallden K. A population-based study of spinal pain among 35–45-year-old individuals. Prevalence, sick leave, and health care use. Spine. 1998;23:1457–63. CrossRef
- Rainville J, Sobel J, Hartigan C, Monlux G, Bean J. Decreasing disability in chronic back pain through aggressive spine rehabilitation. J Rehab Res Dev. 1997;34:383–93.
- NIH Technology Assessment Panel on Integration of Behavioral and Relaxation Approaches into the Treatment of Chronic Pain and Insomnia. Integration of behavioral and relaxation approaches into the treatment of chronic pain and insomnia. JAMA. 1996;276:313–8. CrossRef
- Morley S, Eccleston C, Williams A. Systematic review and meta-analysis of randomized controlled trials of cognitive behaviour therapy and behaviour therapy for chronic pain in adults, excluding headache. Pain. 1999;80:1–13. CrossRef
- Faas S. Exercises: which ones are worth trying, for which patients, and when? Spine. 1996;21:2874–8. CrossRef
- Schnitzer TJ. Non-NSAID pharmacologic treatment options for the management of chronic pain. Am J Med. 1998;105:45S-52S. CrossRef
- Merskey H. Pharmacological approaches other than opioids in chronic non-cancer pain management. Acta Anaesth Scand. 1997;41:187–90. CrossRef
- Onghena P, Van Houdenhove B. Antidepressant-induced analgesia in chronic non-malignant pain: a meta-analysis of 39 placebo-controlled studies. Pain. 1992;49:205–19. CrossRef
- McQuay H, Carroll D, Jadad AR, Moore A. Anticonvulsant drugs for management of pain: a systematic review. BMJ. 1995;311:1047–52.
- American Academy of Pain Medicine and American Pain Society. The use of opioids for the treatment of chronic pain. A Consensus Statement. Clin J Pain. 1997;13:6–8. CrossRef
- Krames ES. Interventional pain management. Appropriate when less invasive therapies fail to provide adequate analgesia. Med Clin N Amer. 1999;83:787–808. CrossRef
- Turk DC, Brody MC, Okifuji AE. Physicians’ attitudes and practices regarding the long-term prescribing of opioids in non-cancer pain. Pain. 1994;59:201–8. CrossRef
- Turk DC. Clinicians’ attitudes about prolonged use of opioids and the issue of patient heterogeneity. J Pain Symptom Manage. 1996;11:218–30. CrossRef
- Richards AH. The use of controlled-release morphine sulfate (MS Contin) in Queensland 1990–1993. Med J Aust. 1995;163:181–2.
- Bell JR. Australian trends in opioid prescribing for chronic noncancer pain, 1986–1996. Med J Aust. 1997;167:26–9.
- Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies. J Chronic Dis. 1987;40:373–83. CrossRef
- Wesson DR, Ling W, Smith DE. Precription of opioids for treatment of pain in patients with addictive disease. J Pain Symptom Manage. 1993;8:289–96. CrossRef
- Miotto K, Compton P, Ling W, Conolly M. Diagnosing addictive disease in chronic pain patients. Psychosomatics. 1996;37:223–35.
- Compton P, Darakjian K, Miotto K. Screening for addiction in patients with chronic pain and “problematic” substance use: evaluation of a pilot assessment tool. J Pain Symptom Manage. 1998;16:355–63. CrossRef
- Williams JW Jr, Kerber CA, Mulrow CD, Medina A, Aguilar C. Depressive disorders in primary care: prevalence, functional disability, and identification. J Gen Intern Med. 1995;10:7–12. CrossRef
- Katon W, Schulberg H. Epidemiology of depression in primary care. Gen Hosp Psychiatry. 1992;14:237–47. CrossRef
- Fifer SK, Mathias SD, Patrick DL, Mazonson PD, Lubeck DP, Buesching DP. Untreated anxiety among adult primary care patients in a health maintenance organization. Arch Gen Psychiatry. 1994;51:740–50.
- O’Connor PG, Samet JH. Prevalence and assessment of readiness for behavioral change of illicit drug use among primary care patients. J Gen Intern Med. 1996;11:53A.
- Reid MC, Fiellin DA, O’Connor PG. Hazardous and harmful alcohol consumption in primary care. Arch Intern Med. 1999;159:1681–9. CrossRef
- Fishbain DA, Goldberg M, Meagher BR, Steele R, Rosomoff H. Male and female chronic pain patients categorized by DSM-III psychiatric diagnostic criteria. Pain. 1986;26:181–97. CrossRef
- Katon W, Egan K, Miller D. Chronic pain: lifetime psychiatric diagnoses and family history. Am J Psychiatry. 1985;142:1156–60.
- Atkinson JH, Slater MA, Patterson TL, Grant I, Carfin SR. Prevalence, onset, and risk of psychiatric disorders in men with chronic low back pain: a controlled study. Pain. 1991;45:111–21. CrossRef
- Zenz M, Strumpf M, Tryba M. Long-term oral opioid therapy in patients with chronic nonmalignant pain. J Pain Symptom Manage. 1992;7:69–77. CrossRef
- Portenoy RK, Foley KM. Chronic use of opioid analgesics in nonmalignant pain: report of 38 cases. Pain. 1986;25:171–86. CrossRef
- Chabal C, Miklavz E, Jacobson L, Mariano A, Chaney E. Prescription opiate abuse in chronic pain patients: clinical criteria, incidence, and predictors. Clin J Pain. 1997;13:150–5. CrossRef
- Long DM. A comprehensive model for the study and therapy of pain: Johns Hopkins pain research and treatment program. In: Ng LKY, ed. New Approaches to Treatment of Chronic Pain: A Review of Multidisciplinary Pain Clinics and Pain Centers. NIDA Research Monograph Series. Rockville, Md: National Institute on Drug Abuse; 1981;36:66–75
- Weissman DE, Haddox JD. Opioid pseudoaddiction: an iatrogenic syndrome. Pain. 1989;36:363–6. CrossRef
- Taub A. Opioid analgesics in the treatment of chronic intractable pain of non-neoplastic origin. In: Kitahata LM, Collins D, eds. Narcotic Analgesics in Anesthesiology. Baltimore: Williams and Wilkins; 1982.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th Ed. Washington DC: American Psychiatric Press; 1994.
- Use of opioid medications for chronic noncancer pain syndromes in primary care
Journal of General Internal Medicine
Volume 17, Issue 3 , pp 173-179
- Cover Date
- Print ISSN
- Online ISSN
- Additional Links
- chronic pain
- opioid analgesic use
- primary care
- Industry Sectors
- Author Affiliations
- 1. VA Connecticut Healthcare System, Clinical Epidemiology Unit, 111/GIM, 950 Campbell Ave., 06516, West Haven, CT
- 2. the Department of Medicine, VA Connecticut Healthcare System, West Haven, Conn
- 3. the Department of Medicine, Yale University School of Medicine, USA
- 4. the Department of Pharmacy, Yale-New Haven Hospital, New Haven, Conn
- 5. the Department of Psychology, VA Connecticut Healthcare System, West Haven, Conn
- 6. the Department of Neurology, Yale University School of Medicine, USA
- 7. the Department of Psychiatry, Yale University School of Medicine, USA
- 8. the Department of Psychology, Yale University School of Medicine, USA