Risk factors for clinically recognized opioid abuse and dependence among veterans using opioids for chronic non-cancer pain

In determining the appropriate role of opioids, two public health crises must be balanced: the opioid abuse epidemic and the “silent” crisis of unrelieved chronic pain. Opioids can be used safely and effectively in selected patients; however, clinicians must be aware of their abuse liability and individual risk factors for opioid misuse. A number of opioids are approved for use in the United States, and although there are class effects, there can be great variability among patients with regard to opioid response. In addition to the medication, prescribers must also determine the most appropriate dose and route of administration. Considerations must be made for special population, such as the renally impaired, those with hepatic dysfunction, and pediatric and elderly patients. Another factor is abuse-deterrent properties. Of particular interest as an opioid agent is buprenorphine, which is available in various routes of administration and because of its unique pharmacokinetics may be administered to renally compromised and elderly patients without dosing restrictions. Buprenorphine is also associated with a lower abuse liability than other opioids. Patients suffering moderate to severe pain syndromes should not be denied access to effective pain control, which in some cases may appropriately include opioid therapy. Key words: Buprenorphine, Chronic Pain, Opioid, Opioid Abuse, Opioid Prescribing, Risk Factors for Opioid Abuse

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Predicting Persistent Opioid Use, Abuse, and Toxicity Among Cancer Survivors

JNCI Journal of the National Cancer Institute ◽

10.1093/jnci/djz200 ◽

2019 ◽

Vol 112 (7) ◽

pp. 720-727 ◽

Cited By ~ 6

Author(s):

Lucas K Vitzthum ◽

Paul Riviere ◽

Paige Sheridan ◽

Vinit Nalawade ◽

Rishi Deka ◽

...

Keyword(s):

Risk Factors ◽

At Risk ◽

Cancer Survivors ◽

Critical Role ◽

Multivariable Analysis ◽

Area Under The Curve ◽

Opioid Abuse ◽

Opioid Use ◽

Multivariable Logistic Regression Model ◽

Patients At Risk

Abstract Background Although opioids play a critical role in the management of cancer pain, the ongoing opioid epidemic has raised concerns regarding their persistent use and abuse. We lack data-driven tools in oncology to understand the risk of adverse opioid-related outcomes. This project seeks to identify clinical risk factors and create a risk score to help identify patients at risk of persistent opioid use and abuse. Methods Within a cohort of 106 732 military veteran cancer survivors diagnosed between 2000 and 2015, we determined rates of persistent posttreatment opioid use, diagnoses of opioid abuse or dependence, and admissions for opioid toxicity. A multivariable logistic regression model was used to identify patient, cancer, and treatment risk factors associated with adverse opioid-related outcomes. Predictive risk models were developed and validated using a least absolute shrinkage and selection operator regression technique. Results The rate of persistent opioid use in cancer survivors was 8.3% (95% CI = 8.1% to 8.4%); the rate of opioid abuse or dependence was 2.9% (95% CI = 2.8% to 3.0%); and the rate of opioid-related admissions was 2.1% (95% CI = 2.0% to 2.2%). On multivariable analysis, several patient, demographic, and cancer and treatment factors were associated with risk of persistent opioid use. Predictive models showed a high level of discrimination when identifying individuals at risk of adverse opioid-related outcomes including persistent opioid use (area under the curve [AUC] = 0.85), future diagnoses of opioid abuse or dependence (AUC = 0.87), and admission for opioid abuse or toxicity (AUC = 0.78). Conclusion This study demonstrates the potential to predict adverse opioid-related outcomes among cancer survivors. With further validation, personalized risk-stratification approaches could guide management when prescribing opioids in cancer patients.

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Long-term opioid users with chronic noncancer pain: Assessment of opioid abuse risk and relationship with healthcare resource use

Journal of Opioid Management ◽

10.5055/jom.2018.0440 ◽

2018 ◽

Vol 14 (2) ◽

pp. 131 ◽

Cited By ~ 6

Author(s):

Anna D. Coutinho, BPharm, PhD ◽

Kavita Gandhi, BPharm, MS ◽

Rupali M. Fuldeore, BAMS, MS ◽

Pamela B. Landsman-Blumberg, MPH, DrPH ◽

Sanjay Gandhi, PhD

Keyword(s):

Risk Factors ◽

At Risk ◽

Opioid Abuse ◽

Low Risk ◽

Chronic Noncancer Pain ◽

Cart Analysis ◽

Risk Patients ◽

Noncancer Pain ◽

Abuse Risk

Objective: Identify opioid abuse risk factors among chronic noncancer pain (CNCP) patients receiving long-term opioid therapy and assess healthcare resource use (HRU) among patients at elevated abuse risk.Design: Data were obtained from an integrated administrative claims database. Classification and Regression Tree (CART) analysis identified risk factors potentially predictive of opioid abuse, which were used to classify the overall population into cohorts defined by levels of abuse risk. Multivariable logistic regression compared HRU across risk cohorts.Setting: Retrospective cohort study.Patients, participants: 21,072 patients aged ≥18 years diagnosed with ≥1 of 5 types of CNCP and a prescription for Schedule II or III/IV opioid medication used long-term (≥90 days).Main outcome measures: (1) Opioid abuse risk factors; (2) HRU differences between risk cohorts.Results: CART analysis identified four groups at elevated opioid abuse risk defined by three factors (age, daily opioid dose, and total days’ supply of opioids); sensitivity: 70.3 percent, specificity: 74.1 percent, and positive predictive value: 5.6 percent. The analysis results were used to classify patients into low-risk (72.5 percent), at-risk (25.4 percent), and opioid-abuser (2.2 percent) cohorts. In multivariable analysis, emergency department (ED) use was higher among at-risk vs low-risk patients (odds ratio [OR]: 1.14; p < 0.05); hospitalization and ED visits were higher for opioid-abusers vs low-risk patients (OR: 2.33 and 2.14, respectively; p < 0.05).Conclusions: This study identifies a subpopulation of CNCP patients at risk of opioid abuse. However, limited sensitivity and specificity of criteria defining this subpopulation reinforce the importance of physician discretion in patient-level treatment decisions.

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The Role of Opioid Prescription in Incident Opioid Abuse and Dependence Among Individuals with Chronic Non-cancer Pain

Clinical Journal of Pain ◽

10.1097/ajp.0000000000000021 ◽

2013 ◽

pp. 1 ◽

Cited By ~ 33

Author(s):

Mark J. Edlund ◽

Bradley C. Martin ◽

Joan E. Russo ◽

Andrea Devries ◽

Jennifer Brennan Braden ◽

...

Keyword(s):

Cancer Pain ◽

Opioid Abuse ◽

Opioid Prescription

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Pluri Psychopathology and Risk of Opioid Use Disorder

Journal of Clinical Review & Case Reports ◽

10.33140/jcrc/03/07/00004 ◽

2018 ◽

Vol 3 (7) ◽

Keyword(s):

Risk Factors ◽

Chronic Pain ◽

Risk Factor ◽

Cancer Pain ◽

Gender Dysphoria ◽

Psychiatric Comorbidity ◽

Opioid Use Disorder ◽

Opioid Use ◽

Transdermal Fentanyl ◽

Case Presentation

Background: Psychiatric comorbidty is an important risk factor when predicting risk of opioid use disorder in chronic non-cancer pain. We present a case with gender dysphoria, in wich psychiatric comorbidity was not taken into account for de prescription of pharmacological treatment for pain. Case presentation: We report the case of a 51-year-old man with gender dysphoria, personality disorder, chronic pain disorder and opioid use disorder. For the last 9 years he has taken continuousy transdermal fentanyl prescribed by chronic non-cancer pain. Despite of presenting a pluripathology that discouraged the use of opioids in this patient, throughout his evolution, he has gone to different non-psychiatrists and has shown himself with a querulous, confictive and demanding attitude, so that he managed to keep on raising his dose of prescribed opioids. Conclusions: This case shows the importance of knowing the risk factors of consumption due to the use of opioids patients with chronic non-cancer pain, the importance of psychiatric comorbidity associated with prognosis and the neeed to know exactly how opioids are managed by some prescribers, as well as to carry out an interdisciplinary therapeutic plan to avoid risks.

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Risk factors for opioid abuse/dependence in hospitalized cancer patients in the United States.

Journal of Clinical Oncology ◽

10.1200/jco.2019.37.15_suppl.11589 ◽

2019 ◽

Vol 37 (15_suppl) ◽

pp. 11589-11589

Author(s):

Veli Bakalov ◽

Amy Tang ◽

Amulya Yellala ◽

Laila Babar ◽

Rupin Shah ◽

...

Keyword(s):

Risk Factors ◽

Liver Cancer ◽

Cancer Patients ◽

Mental Disease ◽

The United States ◽

Opioid Abuse ◽

Screening Tools ◽

Inhospital Mortality ◽

Cancer Type ◽

Increased Risk

11589 Background: Opioid medications are the mainstay for treating cancer pain. Goal of this study was to identify risk factors for opioid abuse/dependence in patients hospitalized with cancer, explore whether risk of opioid abuse/dependence varies by cancer type and to assess whether opioid abuse/dependence in cancer patients effects the outcomes of hospitalization. Methods: The Nationwide Inpatient Sample for the years of 2011-2015 was queried for the analysis. We used ICD-9-CM codes of solid tumors as a primary diagnosis for hospitalization, and opioid abuse/dependence as a secondary diagnosis of the hospitalization. We performed univariate and multivariate logistic regression analyses to examine the association between risk factors and opioid abuse/dependence. Data were analyzed using SAS v9.4 (SAS Institute, Cary, NC). Results: Total of 524,624 patients were included in our cohort. Rate of opioid abuse/dependence was highest in patients with liver cancer (1.77%). Opioid abuse/dependence was less associated with age (>65 years old: OR 0.29, 95% CI 0.21-0.39). Patients with Medicaid insurance associated with increased risk of opioid abuse/dependence comparing to other insurances (OR 5.29, 95% CI 4.78-5.86). Strongest association with opioid abuse/dependence were in patients with liver cancer (OR 6.07, 95% CI 5.11-7.20) followed by head and neck cancer (OR 3.20, 95% CI 2.67-3.84). Substance abuse (OR 9.9, 95% CI 9.04-10.84), mental disease (OR-2.87, 95% CI 2.64-3.13) and nutrition deficiency (OR-2.09, 95% CI 1.90-2.31) were highly associated with opioid abuse dependence. Inhospital mortality rate, total cost of hospitalization, and length of stay were significantly higher in patients with opioid abuse/dependence (Table). Conclusions: We identified risk factors for opioid abuse/dependence in hospitalized patients with cancer and demonstrated that risk of opioid abuse varies by cancer type, and opioid abuse/dependence affects the outcomes of hospitalization. Findings of our study can be used for development of the screening tools with higher sensitivity and specificity for predicting the risk of opioid abuse/dependence in cancer patients.[Table: see text]

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Opioid Therapy for Chronic Noncancer Pain: Safe, Effective, Appropriate?

10.2310/pm.15027 ◽

2016 ◽

Author(s):

Joseph V. Pergolizzi Jr ◽

Robert B. Raffa ◽

Robert Taylor ◽

Jo Ann LeQuang

Keyword(s):

Risk Factors ◽

Chronic Pain ◽

Elderly Patients ◽

The United States ◽

Opioid Therapy ◽

Abuse Liability ◽

Opioid Abuse ◽

Individual Risk ◽

Chronic Noncancer Pain ◽

Routes Of Administration

In determining the appropriate role of opioids, two public health crises must be balanced: the opioid abuse epidemic and the “silent” crisis of unrelieved chronic pain. Opioids can be used safely and effectively in selected patients; however, clinicians must be aware of their abuse liability and individual risk factors for opioid misuse. A number of opioids are approved for use in the United States, and although there are class effects, there can be great variability among patients with regard to opioid response. In addition to the medication, prescribers must also determine the most appropriate dose and route of administration. Considerations must be made for special population, such as the renally impaired, those with hepatic dysfunction, and pediatric and elderly patients. Another factor is abuse-deterrent properties. Of particular interest as an opioid agent is buprenorphine, which is available in various routes of administration and because of its unique pharmacokinetics may be administered to renally compromised and elderly patients without dosing restrictions. Buprenorphine is also associated with a lower abuse liability than other opioids. Patients suffering moderate to severe pain syndromes should not be denied access to effective pain control, which in some cases may appropriately include opioid therapy. Key words: Buprenorphine, Chronic Pain, Opioid, Opioid Abuse, Opioid Prescribing, Risk Factors for Opioid Abuse

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Therapeutic Use, Abuse, and Nonmedical Use of Opioids: A Ten-Year Perspective

January 2018 - Pain Physician ◽

10.36076/ppj.2010/13/401 ◽

2010 ◽

Vol 5;13 (5;9) ◽

pp. 401-435

Author(s):

Laxmaiah Manchikanti

Keyword(s):

Drug Abuse ◽

Cancer Pain ◽

Prescription Drugs ◽

Scientific Evidence ◽

Therapeutic Use ◽

Emergency Department Visits ◽

Opioid Abuse ◽

Opioid Use ◽

Controlled Drugs ◽

Nonmedical Use

The treatment of chronic pain, therapeutic opioid use and abuse, and the nonmedical use of prescription drugs have been topics of intense focus and debate. After the liberalization of laws governing opioid prescribing for the treatment of chronic non-cancer pain by state medical boards in the late 1990s, and with the introduction of new pain management standards implemented by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in 2000, opioids, in general, and the most potent forms of opioids including Schedule II drugs, in particular, have dramatically increased. Despite the escalating use and abuse of therapeutic opioids, nearly 15 to 20 years later the scientific evidence for the effectiveness of opioids for chronic non-cancer pain remains unclear. Concerns continue regarding efficacy; problematic physiologic effects such as hyperalgesia, hypogonadism and sexual dysfunction; and adverse side effects – especially the potential for misuse and abuse – and the increase in opioid-related deaths. Americans, constituting only 4.6% of the world’s population, have been consuming 80% of the global opioid supply, and 99% of the global hydrocodone supply, as well as two-thirds of the world’s illegal drugs. Retail sales of commonly used opioid medications (including methadone, oxycodone, fentanyl base, hydromorphone, hydrocodone, morphine, meperidine, and codeine) have increased from a total of 50.7 million grams in 1997 to 126.5 million grams in 2007. This is an overall increase of 149% with increases ranging from 222% for morphine, 280% for hydrocodone, 319% for hydromorphone, 525% for fentanyl base, 866% for oxycodone, to 1,293% for methadone. Average sales of opioids per person have increased from 74 milligrams in 1997 to 369 milligrams in 2007, a 402% increase. Surveys of nonprescription drug abuse, emergency department visits for prescription controlled drugs, unintentional deaths due to prescription controlled substances, therapeutic use of opioids, and opioid abuse have been steadily rising. This manuscript provides an updated 10-year perspective on therapeutic use, abuse, and nonmedical use of opioids and their consequences. Key words: Controlled prescription drug abuse, opioid abuse, opioid misuse, nonmedical use of psychotherapeutic drugs, nonmedical use of opioids, National Survey on Drug Use and Health, National Center on Addiction and Substance Abuse at Columbia University

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