Low Risk of OUD in Primary Care Opioid Prescribing

Low Risk of Producing an Opioid Use Disorder in Primary Care by Prescribing Opioids to Prescreened Patients with Chronic Noncancer Pain | Pain Medicine | Oxford Academic – Pain Medicine, Volume 19, Issue 4, 1 April 2018

This longitudinal and prospective study seems to be of high quality and shows what we’ve known all along: among pain patients, in general, there is only a small chance of developing problems with opioid abuse.

Objective: To examine the risk of developing aberrant behaviors that might lead to a substance use disorder (addiction) when prescribing opioids for the relief of chronic noncancer pain in primary care settings.

Design: Longitudinal, prospective, descriptive design with repeated measures.  

Setting: Private community-based internal medicine and family medicine clinics.

Subjects: Patients with chronic musculoskeletal pain.

I’m glad this study is using “real life” situations: a patient with widespread musculoskeletal pain (like from EDS and Fibromyalgia) goes to their primary care provider and, after trying many other treatments, is finally prescribed opioids.

A patient seeking opioids only for relief from their physical pain knows exactly how precious these effective medications are. We quickly discover that we’ll probably need opioids for a very, very long time and are thus very concerned about tolerance right from the beginning.

Many of us take our opioids as sparingly as possible, often taking less than needed, and try to ration ourselves to at least slow down our inevitable tolerance to the drug.

When opioids are our last resort because nothing else worked for us, we feel very “dependent” on this medication and on the doctor prescribing it. If our doctor threatens us with discontinuation of the opioids, as so plainly stated in those awful “pain contracts”, we understandably become resentful.

Methods:

Standardized measures of patient status (pain, functional impairment, psychiatric disorders, family history) and treatments provided, urine drug monitoring, and medical chart audits (presence of aberrant drug-related behaviors) were obtained in a cohort of 180 patients at the time of initiating opioids for chronic noncancer pain and at three, six, and 12 months thereafter.

Results

Over the 12-month follow-up period, subjects demonstrated

  • stable, mild to moderate levels of depression (PHQ-9 scores ranging from 9.43 to 10.92),
  • mild anxiety (BAI scores ranging from 11.80 to 14.67),
  • minimal aberrant drug-related behaviors as assessed by chart reviews, and
  • a low percentage of illicit drug use as revealed by results of urine drug monitoring.
  • Less than 5% of our study population revealed any evidence of substance use disorder.

Conclusions

This prospective study suggests that patients without a recent or prior history of substance use disorder who were prescribed primarily short-acting opioids in low doses for chronic noncancer pain have a low risk for developing a substance use disorder.

This is a plain statement of fact, but it probably won’t make the news because it runs counter to the prevailing myths about opioids.

By now, thanks to the media, most Americans believe opioids are virtually poisonous, that taking “just a few” will instantly make them addicts and lead to shooting up street drugs and eventual death.

Americans have been led to believe that opioids “cause” addiction in everyone. If a patient has been taking opioids for months/years, they are considered to be addicted in our culture and, sadly, even among doctors nowadays.

That’s why so many “pain management” programs and clinics are actually drug-abstinence programs. This is a classic “bait and switch”, holding out the promise of treating a patient’s chronic pain but instead taking away their opioids.

Many doctors have internalized the PROPaganda and believe that these medications are actually the source of our problems rather than the intractable pain for which we’re taking them.

So many studies these days look at the dosages of opioids and show negative results corresponding to the dose, but they never even mention that we are taking these medications for intractable pain.

When their use for effective pain relief is not considered, then opioid doses seem like the cause of our problems. See Opioids Blamed for Side-Effects of Chronic Pain.

This finding supports the importance of prescreening patients being considered for opioid therapy and that prescription of opioids for noncancer pain may carry a lower risk of abuse in selected populations such as in private, community-based practices.

 

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