Special Topics in Pain: Opioids

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Opioid Overdose History, Risk Behaviors, and Knowledge in Patients Taking Prescribed Opioids for Chronic Pain

Author(s): Dunn, K et al.
Journal: Pain Medicine. 2017; 18: 1505-1515. 75 references.
Reprint: Kelly E. Dunn, PhD, 5510 Nathan Shock Drive, Baltimore, MD 21224. E-mail: kdunn9@jhmi.edu
Faculty Disclosure: Abstracted by N Walea, who has nothAbstracted by N Walea, who has nothing to disclose.ing 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 Risk and prognostic scales

Editor’s Note: Opioid misuse is common amongst chronic pain patients, and it is up to the vigilant pain physician to monitor these patients appropriately and limit opioid therapy for only good candidates.  Interestingly, nearly 20% of patients reported a prior overdose on opioids, and in general, they were unlikely to have been trained to use naloxone.  The SOAPP-R score of greater than or equal to 7 (which is still considered a “low risk” patient by the scoring system used for that scale where values <9 are low risk) was found to be correlated with a lifetime risk of overdose of 85%.  While this study was performed via an optional survey and therefore could be subject to response bias, it nonetheless is an interesting study that shows relatively high risks of opioid overdoses with relatively low patient knowledge on potential agents to reverse an overdose (naloxone) – an important mismatch.

Classification: Opioids; Risk scales for opioid misuse; Addiction

Information is lacking about the experience of overdose among patients being treated for chronic pain (CP) with a prescription opioid since current opioid overdose prevention efforts almost exclusively target illicit opioid users.

For this study, chronic pain patients were recruited online during March 2015 using crowdsourcing technology. The survey was restricted to participants who lived within the United States and participants were required to complete a brief introductory survey to assess their eligibility for this study. All questions were administered as self-report surveys, and completed on line through the questionnaire manager Qualtrics. There were 502 individuals who qualified and completed the survey questionnaires.

The Diagnostic and Statistical Manual (DSM)-5 checklist was used to identify symptoms of opioid use disorder (OUD) with participants answering questions regarding history of opioid overdose (personally or witnessing an overdose), and past 30-day engagement in behaviors that incur increased risk of overdose. Participants also completed a self-report survey to assess their knowledge of opioids, opioid overdose and naloxone. The Brief Pain Inventory (BPI) characterized pain severity and functional interference with daily activities. The Screener and Opioid Assessment for Patients with Pain (SOAPP-R) was designed to assess risk of a patient developing problematic opioid use. The Current Opioid Misuse Measure (COMM) was designed to assess aberrant medication-related behaviors among participants who have been maintained chronically on opioids for pain.

The results of the analysis of this data indicate that nearly one in five patients, who have experienced chronic pain for 3 months or more and are receiving a prescription opioid for pain management, report having experienced at least one nonfatal opioid-related overdose during their lifetime. CP participants who reported engaging in behavior that could increase their risk of experiencing an overdose were unlikely to have received and/or been trained to administer naloxone and had poor response rates to the overdose knowledge items queried.

Nine percent of CP participants reported experiencing an overdose in the past 30 days, 53.8% reported using opioids by themselves in the past 30 days, and 37.5% reported combining opioids with alcohol. These are all known risk factors for experiencing a fatal overdose. Only 19.3% of participants correctly identified combining sedatives and opioids as a risk factor for experiencing an opioid overdose on the knowledge questions. Further, 38.7% of CP participants had witnessed an overdose, which has itself been associated with an increased risk for experiencing a future overdose. Finally, the majority of CP participants reported not having received and/or been trained to administer naloxone, and fewer than 50% of participants answered knowledge questions correctly for each of the items asked.

Both the SOAPP-R, a measure of risk for developing problematic opioid use, and the number of DSM OUD criteria endorsed were significantly associated with lifetime history of and number of lifetime over doses. Overall, these data suggest that there is value in educating all CP patients about the risk of opioid-related overdose and that scores on the SOAPP-R and DSM-5 checklist may provide an easy method to quickly assess a patient's likelihood for experiencing an overdose and to potentially implement a brief intervention in clinical settings.

 Important Points:
This study demonstrates that nearly one in five individuals with CP report having experience an opioid-related overdose and that this group is largely uninformed about behaviors that increase their risk of overdose. Established SOAPP-R and DSM thresholds provide an opportunity to identify participants at elevated risk for having experienced an opioid overdose. This study supports development of additional concentrated efforts to prevent overdose among chronic pain patients.

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