The missing ‘P’ in pain management: how the current opioid epidemic highlights the need for psychiatric services in chronic pain care

Howe, Catherine Q.; Sullivan, Mark D.

doi:10.1016/j.genhosppsych.2013.10.003

Cited by 100 publications

(79 citation statements)

References 100 publications

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“…15 Research on the efficacy of opioids in depression treatment, limited by small samples, short follow-up time, and lack of control groups, does not support opioids as effective long-term treatments for depression. 31 This evidence, combined with the finding from the present study, supports the conclusion that opioids may cause short-term improvement in mood, but longterm use is associated with risk of new-onset depression.…”

Section: Discussionsupporting

confidence: 88%

“…Patients with chronic noncancer pain and depression are more likely than those without depression to receive opioids, 3 have a longer duration of use, 4,5 take them at higher morphine equivalent doses (MEDs), 6 and misuse and or abuse opioids. 7,8 A review of psychopathology in pain 9 suggests the opioid epidemic in the United States reflects underdetected and undertreated mental illness in patients with chronic pain.…”

Section: Introductionmentioning

confidence: 99%

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Prescription Opioid Duration, Dose, and Increased Risk of Depression in 3 Large Patient Populations

Scherrer

Salas

Copeland

et al. 2016

The Annals of Family Medicine

194

173

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PURPOSE Recent results suggests the risk of a new onset of depression increases with longer duration of opioid analgesic use. It is unclear whether new-onset depression related to opioid analgesic use is a function of the dose prescribed or the duration of use or both.METHODS Using a retrospective cohort design, we collected patient data from 2000 to 2012 from the Veterans Health Administration (VHA), and from 2003 to 2012 from both Baylor Scott & White Health (BSWH) and the Henry Ford Health System (HFHS). Patients (70,997 VHA patients,13,777 BSWH patients,and 22,981 HFHS patients) were new opioid users, aged 18 to 80 years, without a diagnosis of depression at baseline. Opioid analgesic use duration was defined as 1 to 30, 31 to 90, and more than 90 days, and morphine equivalent dose (MED) was defined as 1 to 50 mg/d, 51 to 100 mg/d, and greater than 100 mg/d of analgesic. Pain and other potential confounders were controlled for by inverse probability of treatment-weighted propensity scores.RESULTS New-onset depression after opioid analgesic use occurred in 12% of the VHA sample, 9% of the BSWH sample, and 11% of the HFHS sample. Compared with 1-to 30-day users, new-onset depression increased in those with longer opioid analgesic use. Risk of new-onset depression with 31 to 90 days of opioid analgesic use ranged from hazard ratio [HR] = 1.18 (95% CI, 1.10-1.25) in VHA to HR = 1.33 (95% CI, 1.16-1.52) in HFHS; in opioid analgesic use of more than 90 days, it ranged from HR = 1.35 (95% CI, 1.26-1.44) in VHA to HR = 2.05 (95% CI, 1.75-2.40) in HFHS. Dose was not significantly associated with a new onset of depression.CONCLUSIONS Opioid-related new onset of depression is associated with longer duration of use but not dose. Patients and practitioners should be aware that opioid analgesic use of longer than 30 days imposes risk of new-onset depression. Opioid analgesic use, not just pain, should be considered a potential source when patients report depressed mood. Ann Fam Med 2016;14:54-62. doi: 10.1370/afm.1885. INTRODUCTIOND epression co-occurs with chronic noncancer pain 1,2 and is known to be associated with opioid use. Patients with chronic noncancer pain and depression are more likely than those without depression to receive opioids, 3 have a longer duration of use, 4,5 take them at higher morphine equivalent doses (MEDs), 6 and misuse and or abuse opioids. 7,8 A review of psychopathology in pain 9 suggests the opioid epidemic in the United States reflects underdetected and undertreated mental illness in patients with chronic pain.Every year more than 200 million prescriptions for opioids are written in the United States. 10 Known consequences of this opioid epidemic include abuse and accidental overdose.11-13 A less understood adverse outcome and emerging line of inquiry is the association between opioid use and risk of depression. In a study of nearly 50,000 Veterans Health Administration (VHA) patients, opioid analgesic use of longer than 180 14 In a prospective study of chronic pain patients, thos...

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Section: Discussionsupporting

confidence: 88%

Section: Introductionmentioning

confidence: 99%

Prescription Opioid Duration, Dose, and Increased Risk of Depression in 3 Large Patient Populations

Scherrer

Salas

Copeland

et al. 2016

The Annals of Family Medicine

194

173

View full text Add to dashboard Cite

show abstract

“…Importantly, in some cases, opioid use during pregnancy leads to neonatal opioid withdrawal syndrome (142). Patients with mental health comorbidities and patients with histories of substance use disorders might be at higher risk than other patients for opioid use disorder (62,143,144). Recent analyses found that depressed patients were at higher risk for drug overdose than patients without depression, particularly at higher opioid dosages, although investigators were unable to distinguish unintentional overdose from suicide attempts (145).…”

Section: Benefits and Harms Of Opioid Therapymentioning

confidence: 99%

“…The SNRI duloxetine is FDA-approved for the treatment of diabetic neuropathy and fibromyalgia. Because patients with chronic pain often suffer from concurrent depression (144), and depression can exacerbate physical symptoms including pain (177), patients with co-occurring pain and depression are especially likely to benefit from antidepressant medication (see Recommendation 8). Nonopioid pharmacologic therapies…”

Section: Recommendationsmentioning

confidence: 99%

CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016

Haegerich²,

2016

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“…18 Unfortunately, psychiatric care is lacking in the management of many chronic pain patients. 19 Calcaterra and colleagues reported that opioids plus benzodiazepines were the most common cause of polysubstance overdose deaths in a national study from 1999 to 2009, and increased the risk of drug overdose associated with opioids. 1 In our cohort, benzodiazepines significantly increased the risk of overdose but did not disproportionately affect persons with mental health disorders.…”

Section: Discussionmentioning

confidence: 99%

Drug Overdose in a Retrospective Cohort with Non-Cancer Pain Treated with Opioids, Antidepressants, and/or Sedative-Hypnotics: Interactions with Mental Health Disorders

Turner

Liang

2015

J GEN INTERN MED

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The missing ‘P’ in pain management: how the current opioid epidemic highlights the need for psychiatric services in chronic pain care

Cited by 100 publications

References 100 publications

Prescription Opioid Duration, Dose, and Increased Risk of Depression in 3 Large Patient Populations

Prescription Opioid Duration, Dose, and Increased Risk of Depression in 3 Large Patient Populations

CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016

Drug Overdose in a Retrospective Cohort with Non-Cancer Pain Treated with Opioids, Antidepressants, and/or Sedative-Hypnotics: Interactions with Mental Health Disorders

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