Research · March 14, 2014
TAKE-HOME MESSAGE
- In this cohort study, 85% of over 14,000 patients who reported chronic nonmalignant pain did not use opioids. Occasional and persistent use was reported in 12% and 3% of patients, respectively. In addition, about 75% of patients who did use opioids reported that their pain was still strong or very strong.
- The authors conclude that many patients with chronic nonmalignant pain do not use opioids, and a majority of those who do use opioids do not experience pain relief.
Expert Comment
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Primary Care
The present study conducted in Norway attempted to answer several important questions including who is using opioids for pain, whether opioids seem to reduce incidence of severe pain, and which factors influence persistent use of opioids. Although a number of limitations are associated with doing these types of studies, most of the patients utilizing chronic opioid therapy had the most severe pain in spite of treatment. This brings up several questions, including whether these patients were adequately treated and whether they were continuing to receive benefit from treatment.
From a research perspective, this study points to the need for additional prospective trials using predictive models of comorbidities, genetics, activity level, and polypharmacy to determine how opioids may affect the end goal of improved function and quality of life with various treatments. Unfortunately we have minimal evidence to point us in the right direction and even less evidence to let us know when to reevaluate or de-prescribe. Some preliminary research does show that, in the right scenario, reducing opioid dose may actually reduce pain and depression and improve functional status. However, clinically, as with any chronic pain scenario, it is important to re-evaluate ongoing treatments to determine their benefit. Working with patients to attempt therapeutic trialswith reduction of therapies—especially passive therapies—can, in some cases, provide surprising results while helping to simplify the regimen for provider and patient.
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Primary Care
Pain and Opioid Use
Is it the pain or the person that drives the use of opioids? In this Norwegian database, which included over 14,000 patients with chronic nonmalignant pain, the majority of people (85%) do not take opioids. Of the remaining 15%, 12% take opioids occasionally and only 3% use opioids persistently. Even if you looked at the patients in the strong or very strong pain category, the majority still do not take opioids. But strangely, the 3% who take opioids persistently are the ones who still feel the most pain despite their opioid use. So, are the opioids really treating their pain or are these patients somehow different? Perhaps they are more pain sensitive or are more likely to become addicted.
This study also identified some key factors that make a person more likely to use opioids long-term. These factors include having had more than 100 doses of benzodiazepines, being physically inactive, having 8 or more medications and reporting strong pain intensity. Perhaps if we identify these patients before we prescribe, we can avoid creating more chronic opioid user.
ABSTRACT
In previous studies on prescription patterns of opioids accurate data on pain are missing, and previous epidemiological studies of pain lack accurate data on opioid use. The present linkage study which investigates the relationship between pain and opioid use is based on accurate individual data from the complete national Norwegian prescription database and the Nord-Trøndelag health study 3 which includes about 46 000 persons. Baseline data were collected in 2006 to 2008 and the cohort was followed for three years. Of 14 477 persons who reported chronic non-malignant pain 85% did not use opioids at all, while 3% used opioids persistently and 12% occasionally. Even in the group reporting severe or very severe chronic pain the number not using opioids (2680) was far higher than the number who used opioids persistently (304). However, three quarters of persons using opioids persistently reported strong or very strong pain in spite of the medication. Risk factors for persons with chronic pain who were not persistent opioid users at baseline, to use opioids persistently three years later were occasional use of opioids, prescription of >100 defined daily doses/year of benzodiazepines, physical inactivity, reports of “strong” pain intensity, and prescription of drugs from eight or more ATC groups. The study demonstrated that most persons having chronic non-malignant pain are not using opioids, even if the pain is strong or very strong. However, the vast majority of patients with persistent opioid use report strong or very strong pain in spite of opioid treatment.