Symptom ResearchTrends in long-term opioid therapy for noncancer pain among persons with a history of depression
Introduction
Prescription opioids have become a common treatment strategy for chronic noncancer pain over the past two decades. Prescribing rates increased from 8% to 16% of all outpatient visits for musculoskeletal pain between 1980 and 2000 [1], and the prevalence of primary care physician visits in which opioids were prescribed increased from 41 per 1000 total visits in 1992–1993 to 59 per 1000 in 2000–2001 [2]. Rates of opioid use have continued to increase throughout the United States since 2000 (D Boudreau, Ph.D., unpublished data, March 2008) [3]. Despite increased rates of use, data are lacking on the efficacy and safety of longer-term opioid use for noncancer pain, particularly in patients with major depression or substance abuse who have generally been excluded from randomized opioid trials [4]. In a recent meta-analysis of randomized trials of opioid treatment for noncancer pain, the mean length of these trials was 5 weeks and the longest trial was 16 weeks [5]. The presence of a comorbid depressive disorder is common among individuals with chronic noncancer pain [6], [7], [8]. Prevalence rates have been reported to range from 3% to 28% in population-based samples [7], [8], [9], [10], as high as 46% in primary care patients with chronic pain [11] and as high as 100% in patients seen in pain specialty clinics [11]. Individuals with noncancer pain and depression report greater severity of both mental and physical symptoms [6], [12], [13] and may be more likely to be prescribed opioids [14], [15], [16]. These individuals, however, may also be at greater risk of prescription opioid abuse [17], [18]. An understanding of opioid-prescribing patterns in these patients, therefore, is important in order to better inform future clinical research and policy decisions.
CONSORT (CONsortium to Study Opioid Risks and Trends) was developed to improve understanding of trends in, and risks of, long-term opioid therapy for chronic noncancer pain in community practice and uses automated data from two health plans providing comprehensive health care to over 1% of the US population. In this study, we report trends and characteristics of long-term opioid therapy among patients with a depression diagnosis in a health care contact in the previous 2 years. Our primary objective was to describe and contrast trends in incident and prevalent long-term opioid use among individuals based on the presence of a depression diagnosis in the prior 2 years. A secondary objective was to present a profile of long-term opioid use, describing and contrasting use characteristics (e.g., dose, days supply) among individuals based on the presence of a depression diagnosis in the prior 2 years for the most recent year of data (2005).
Section snippets
Data source
Data were obtained from automated health plan records for Group Health Cooperative (GH) in Washington State and Kaiser Permanente of Northern California (KPNC) for the period January 1, 1997, through December 31, 2005. Data for opioid use were tracked through 2006. Both health plans serve employed persons, older populations enrolled in Medicare and lower-income persons insured by Medicaid and State health insurance programs for low-income populations. The health plans offer primary care as well
Opioid use trends
Table 1, Table 2 present age- and sex-adjusted rates of incident (Table 1) and prevalent (Table 2) long-term opioid use per 1000 persons, for GH (1997–2005) and KPNC (1999–2005) enrollees, stratified by presence of a depression diagnosis in the prior 2 years (“depressed” versus “nondepressed”). The decline in rates of long-term incident opioid use from 2004 to 2005 is likely due to the shorter time period available for identifying episodes which began in 2005 than episodes beginning in earlier
Discussion
This study found that patients in two large health plans in the Western United States who had received a depression diagnosis in the prior 2 years had approximately threefold higher rates of incident and prevalent long-term opioid therapy for noncancer pain compared to patients without a prior health care contact for depression. In addition, persons with a recent history of depression and with long-term opioid use were more likely to receive higher daily doses, greater days supply, more potent
Acknowledgment
This research was supported by NIDA Grant R01 DA022557. Dr. Braden is supported by a Ruth L. Kirschstein National Research Service Award (NRSA) Institutional Research Training Grant (T32).
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More than half of all outpatient visits are trigged by physical symptoms which, in turn, are not adequately explained by medical disorders at least half of the time. Further, the presence and severity of somatic symptoms often correlate more strongly with psychological, cognitive and behavioral factors than with physiological or biological findings. Finally, our understanding of the etiology, evaluation, and management of somatic symptoms and functional syndromes is less advanced than our knowledge of many defined medical and psychiatric disorders. This special section, edited by Kurt Kroenke, M.D., will highlight original studies that advance the science and clinical care of somatic symptoms.