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.
chronic pain opioid analgesic use primary care
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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.PubMedCrossRefGoogle Scholar
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.PubMedCrossRefGoogle Scholar
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.PubMedCrossRefGoogle Scholar
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.PubMedCrossRefGoogle Scholar
Von Korff M, Wagner EH, Dworkin SF, Saunders KW. Chronic pain and use of ambulatory health care. Psychsom Med. 1991;53:61–79.Google Scholar
Engel CC, Von Korff M, Katon WJ. Back pain in primary care: predictors of high health care costs. Pain. 1996;65:197–204.PubMedCrossRefGoogle Scholar
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.PubMedCrossRefGoogle Scholar
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.Google Scholar
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.CrossRefGoogle Scholar
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.PubMedCrossRefGoogle Scholar
Schnitzer TJ. Non-NSAID pharmacologic treatment options for the management of chronic pain. Am J Med. 1998;105:45S-52S.PubMedCrossRefGoogle Scholar
Merskey H. Pharmacological approaches other than opioids in chronic non-cancer pain management. Acta Anaesth Scand. 1997;41:187–90.PubMedCrossRefGoogle Scholar
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.PubMedCrossRefGoogle Scholar
McQuay H, Carroll D, Jadad AR, Moore A. Anticonvulsant drugs for management of pain: a systematic review. BMJ. 1995;311:1047–52.PubMedGoogle Scholar
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.CrossRefGoogle Scholar
Krames ES. Interventional pain management. Appropriate when less invasive therapies fail to provide adequate analgesia. Med Clin N Amer. 1999;83:787–808.PubMedCrossRefGoogle Scholar
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.PubMedCrossRefGoogle Scholar
Turk DC. Clinicians’ attitudes about prolonged use of opioids and the issue of patient heterogeneity. J Pain Symptom Manage. 1996;11:218–30.PubMedCrossRefGoogle Scholar
Richards AH. The use of controlled-release morphine sulfate (MS Contin) in Queensland 1990–1993. Med J Aust. 1995;163:181–2.PubMedGoogle Scholar
Bell JR. Australian trends in opioid prescribing for chronic noncancer pain, 1986–1996. Med J Aust. 1997;167:26–9.PubMedGoogle Scholar
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.PubMedCrossRefGoogle Scholar
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.PubMedCrossRefGoogle Scholar
Miotto K, Compton P, Ling W, Conolly M. Diagnosing addictive disease in chronic pain patients. Psychosomatics. 1996;37:223–35.PubMedGoogle Scholar
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.PubMedCrossRefGoogle Scholar
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.PubMedCrossRefGoogle Scholar
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.PubMedGoogle Scholar
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.Google Scholar
Reid MC, Fiellin DA, O’Connor PG. Hazardous and harmful alcohol consumption in primary care. Arch Intern Med. 1999;159:1681–9.PubMedCrossRefGoogle Scholar
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.PubMedCrossRefGoogle Scholar
Katon W, Egan K, Miller D. Chronic pain: lifetime psychiatric diagnoses and family history. Am J Psychiatry. 1985;142:1156–60.PubMedGoogle Scholar
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.PubMedCrossRefGoogle Scholar
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.PubMedCrossRefGoogle Scholar
Portenoy RK, Foley KM. Chronic use of opioid analgesics in nonmalignant pain: report of 38 cases. Pain. 1986;25:171–86.PubMedCrossRefGoogle Scholar
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.PubMedCrossRefGoogle Scholar
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;36:66–75Google Scholar
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.Google Scholar
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th Ed. Washington DC: American Psychiatric Press; 1994.Google Scholar