Volatility and change in chronic pain severity predict outcomes of treatment for prescription opioid addiction

Abstract

Background and aims Buprenorphine-naloxone (BUP-NLX) can be used to manage prescription opioid addiction among persons with chronic pain, but post-treatment relapse is common and difficult to predict. This study estimated whether changes in pain over time and pain volatility during BUP-NLX maintenance would predict opioid use during the taper BUP-NLX taper. Design Secondary analysis of a multisite clinical trial for prescription opioid addiction, using data obtained during a 12-week BUP-NLX stabilization and 4-week BUP-NLX taper. Setting Community clinics affiliated with a national clinical trials network in 10 U.S. cities. Participants Subjects with chronic pain who entered the BUP-NLX taper phase (N = 125) with enrollment occurring from June, 2006 to July 2009 (52% male, 88% Caucasian, 31% married). Measurements Outcomes were weekly biologically-verified and self-reported opioid use from the 4-week taper phase. Predictors were estimates of baseline severity, rate of change, and volatility in pain from weekly self-reports during the 12-week maintenance phase. Findings Controlling for baseline pain and treatment condition, increased pain (OR = 2.38, p = .02) and greater pain volatility (OR = 2.43, p = .04) predicted greater odds of positive opioid urine screen during BUP-NLX taper. Increased pain (IRR = 1.40, p = .04) and greater pain volatility (IRR = 1.66, p = .009) also predicted greater frequency of self-reported opioid use. Conclusions Adults with chronic pain receiving outpatient treatment with buprenorphine-naloxone (BUP-NLX) for prescription opioid addiction have elevated risk for opioid use when tapering off of maintenance treatment. Those with relative persistence in pain over time and greater volatility in pain during treatment are less likely to sustain abstinence during BUP-NLX taper.

<p>Greater Pain Severity is Associated with Inability to Access Addiction Treatment Among a Cohort of People Who Use Drugs</p>

“…While there is a paucity of other literature on the role of pain in accessing addiction treatment, other studies have found that pain is a significant concern among individuals seeking addiction treatment, 5 , 15 – 18 and that persistent pain among individuals enrolled in addiction treatment is associated with increased likelihood of substance use severity and frequency, positive urine drug screens, shorter treatment duration, hospitalization, and relapse; decreased likelihood of abstinence; and higher costs associated with health service utilization (ie, inpatient, medical, psychiatric, and other service costs). 5 , 19 – 21 Pain may present a significant challenge to accessing addiction treatment due to the scarcity of evidence-based guidelines for pain management among individuals in addiction treatment—particularly for individuals on opioid agonist treatment who have concurrent pain and may require significantly higher doses compared to individuals without concurrent pain. 22 – 25 Other possible reasons why pain may be associated with inability to access addiction treatment may include clinic policies that may prohibit the treatment of non-addiction related health concerns; physical mobility or geographic barriers that may limit the ability of individuals experiencing pain to access treatment services; stigma or past negative health-care experiences related to pain or substance use; or long wait times that may be difficult for a person experiencing pain to endure.…”

Psycho-physiological response to pain among individuals with comorbid pain and opioid use disorder: Implications for patients with prolonged abstinence

“…This escalated psycho-physiological response to a pain trigger appears to represent a key, previously unidentified, intervention point for COAP patients. In a study that examined self-reported pain volatility and severity among co-morbid OUD and chronic pain patients on MOUD, self-reported greater pain volatility and severity is strongly related to greater non-prescription opioid use (38).…”

Pain Therapy Guided by Purpose and Perspective in Light of the Opioid Epidemic

“…This result suggests that the abuse liability of opioids in the chronic pain state is not directly motivated by analgesia-seeking and intensifies when the drug is no longer available yet drug-associated cues and environmental stimuli are present. Together, these preclinical findings suggests that chronic pain produces a vulnerability to addiction-like behavior, bearing a similarity to the behavior of opioid addicts in chronic pain who are more likely to relapse once tapering off a maintenance buprenorphine naloxone treatment ( 97 ).…”

“…Buprenorphine, an opioid partial agonist, has analgesic effects and can be used to treat co-occurring chronic pain and OUD. While outcomes for OUD treatment with buprenorphine are similar for patients with and without chronic pain ( 99 ), poorly controlled pain during buprenorphine treatment is a risk for opioid relapse ( 97 , 100 , 101 ). Buprenorphine combined with naloxone, an opioid antagonist added to reduce diversion of buprenorphine for intravenous abuse, is FDA approved for OUD (e.g., Suboxone ® ), while a transdermal formulation (Butrans ® ) and a buccal film (Belbuca ® ), both without added naloxone, are approved for chronic pain.…”