Low Risk of Opioid Use Disorder in Primary Care

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 – March 2017

This study shows what pain patients have been saying all along: prescribing opioids for patients with chronic pain very rarely causes problems of drug 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.

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.

This is an exceptionally rigorous study with a good number of subjects and an unusually long period of follow-up.

Also, it refutes the uninformed belief that “opioids don’t work for long-term chronic pain”.

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.

This shows that some depression and anxiety are perfectly normal when a person is suffering from chronic pain and this distress is not “catastrophizing”.

Less than 5% of our study population revealed any evidence of substance use disorder.

Even this low percentage only “revealed any evidence of SUD”, which is a far cry from full-blown addiction.

And remember, “revealed evidence of” can be any use of opioids not precisely as prescribed, including taking less or adjusting doses to personal pain levels as they fluctuate over time.

Under the strict classification of SUD I definitely “abuse” my opioids.

For simplicity, my prescription label says to take up to two tablets/capsules in the morning and again in the evening or the ubiquitous “one to two tablets every 4-6 hours”, but I don’t take my pain medication at regular times in regular quantities. I may take a little more or less at various times of the day as my pain dictates but, over the month, I can usually get by with a little less than prescribed.

However, my irregular use of my prescribed opioids could still be classified as “drug abuse”, qualifying me for a diagnosis of “substance use disorder”. That’s just nuts.

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 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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