Special Topics in Pain: Opioids

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Problematic Use of Prescription Opioids and Medicinal Cannabis Among Patients Suffering from Chronic Pain.

Author(s): Feingold D, et al.
Journal: Pain Med. 2017;18:294-306. 62 references.
Reprint: Daniel Feingold, PhD, Addiction Medicine and Dual Diagnosis Services, Department of Psychiatry, Sheba Medical Center, Tel Hashomer, Israel. Email: d.y.feingold@gmail.com
Faculty Disclosure: Please see original article for disclosures. Abstracted by N Walea, who has nothing to disclose.
Objective: Review and evaluate the latest advances and newest information in the area of Opioids; Review and evaluate the latest advances and newest information in the area of Forms of Psychotherapy; Review and evaluate the latest advances and newest information in the area of Legal considerations


Editor’s Note: When I first read this article, I was struck by the variation in estimates of misuse of both opioids and cannabis (and their combined therapeutic use) using various scales. Better validation of scales is needed, e.g. 17% versus 52.6% using different scales. The degree of concern is obviously different although any misuse is a concern. Generalized anxiety disorder is understandably prevalent in opioid misuse (74.5%) and medical cannabis (41.9%).. Other substances play a significant role. Interestingly, individuals born outside of Israel had lower levels of misuse than Israeli born individuals perhaps due to lifelong stress (my surmise, not the authors). One wonders how these statistics translate to Unites States standards.

Class: Pharmacology: Opioid and cannabis misuse; Scales for abuse

There is increasing concern regarding opioid use due to the alarming increase in emergency room visits associated with adverse effect of opioid use, substance abuse-treatment admissions, and death from overdose. In the past two decades, medical cannabis (MC) has been used widely for pain control in the United States and in several countries worldwide. Research regarding prevalence of use and potential problematic use of MC is lacking.

The study sample included chronic pain patients (N = 888) in the two largest pain centers in Israel. The study ran from November 2014 to April 2015. Data collection was anonymous in order to increase reliability of respondents' replies.

Problematic use of prescription opioids was assessed using the Alcohol Use Disorder and Associated Disabilities Interview Schedule Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (AUDADIS-IV) items based on Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV) criteria for opioid dependence, The Portenoy's Criteria (PC; 10-item self-report questionnaire) and the Current Opioid Misuse Measure (COMM; 17-item self report questionnaire tracking current aberrant medication-related behaviors during opioid treatment).

Problematic use of cannabis was assessed using the cannabis dependence criteria from AUDADIS-IV and modified PC (due to lack of specific tools for measuring cannabis in contest with chronic pain, the word Medicinal Cannabis was substituted for opioid). Psychiatric comorbidities were assessed using the depression module of the Patient Health Questionnaire (PHQ-9) and the generalized anxiety disorder scale (GAD-7). Additional sociodemographic and clinical correlates of problematic use were also used.

Among individuals who were currently treated with opioids (with or without current use of MC [N = 551]), the prevalence of problematic use of opioids was 52.6% (DSM-IV criteria), 17.1% (PC), and 28.7% (COMM questionnaire). Among individuals currently treated with MC (with or without use of prescription opioids [N = 406]), prevalence of problematic use of cannabis was 21.2% by DSM-IV criteria and 10.6% when using the modified PC. No significant differences were found in rates of problematic use of opioids and cannabis between the two medical centers.

Problematic use of opioids according to PC was inversely associate with age (individuals 65 years and older had significantly lower odds of receiving a diagnosis of problematic use compared with individuals whose age was between 18 and 64). Individuals residing in rural areas had significantly lower odds of receiving a diagnosis of problematic use compared to those residing in urban areas. Individuals who reported a lifetime diagnosis of depression had significantly higher odds of receiving a diagnosis of problematic use when compared to those without the diagnosis. The individuals with problematic use of opioids reported significantly higher average and maximum levels of pain compared with those without problematic use.

GAD was prevalent among 74.5% of individuals with problematic use of opioids and 41.9% of those with problematic use of cannabis.

Increased prevalence of problematic use of cannabis according to PC was significantly associated with country of birth (individuals born outside Israel had lower odds of receiving a diagnosis of problematic use compared with individuals born in Israel). Individuals with a partner for spouse had significantly greater odds of receiving a diagnosis of problematic use compared with individuals without a partner. Individuals who reported a lifetime diagnosis of depression had significantly greater odds of receiving a diagnosis of problematic use compared with those without depression. Use of MC for 5 years or more was associated with higher rates of problematic use of cannabis.  

Apart from MC, the most commonly used substances from individuals treated with prescription opioids were alcohol (32%), nonprescription cannabis (19%), LSD (1.1%), and synthetic cannabinoids (0.7%). The most commonly used substances among those treated with MC, apart from prescription opioids, were alcohol (36.9%), Ecstasy (1.1%), and LSD (0.5%). Heroin was used by 0.5% of those receiving MC. Specific questions pertaining to use of non-prescribed opioids among MC users were not included in the questionnaires so these data are not available.

Important Points:
Problematic use of opioids is common among chronic pain patients treated with prescription opioids and is more prevalent than problematic use of cannabis among those receiving MC. Problematic use of prescription opioids or MC or both was found to be associated with more severe pain, concurrent use of alcohol and drugs, and higher levels of depression and anxiety. Pain patients should be screened for risk factors for problematic use before initiating long-term treatment for pain-control. Given the increasing popularity of MC use, more accurate tools for assessing problematic use of cannabis among pain patients are required.

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