A proportion of chronic pain patients on prescribed opioids took chances with their medications over time, such as seeking early refills or giving pills to others — but such behaviors were intermittent, not persistent, according to data from the Australian POINT study.
In a group of about 1,500 people with chronic noncancer pain surveyed every year for 5 years, the prevalence of opioid use, problematic opioid use, and harmful behaviors was fairly consistent at each interview. This consistency masked changes in individuals who engaged in each behavior, reported Louisa Degenhardt, PhD, of the National Drug and Alcohol Research Center at University of New South Wales in Sydney, and co-authors in JAMA Network Open.
“The findings challenge a common view that the risk of opioid-related behaviors is static and that risk assessment at the start of opioid treatment can predict which patients will develop opioid use disorder,” Degenhardt told MedPage Today.
“Despite concerns about harms related to long-term prescribed opioid use for people with chronic noncancer pain, there has been no prior research into whether these patients engage in consistent patterns of risk,” she noted.
“Patient monitoring needs to be ongoing,” Degenhardt added. “Monitoring tools to predict risk may be improved by considering dynamic factors such as fluctuations in pain severity and interference, pain self-efficacy, depression, and anxiety.”
In the prospective POINT study, risky patterns were defined as high-dose opioid use of at least 200 oral morphine equivalent (OME) mg/day, requesting an increase in opioid dose, requesting early prescription renewal, tampering with opioids, diverting opioids to others, and meeting clinical criteria for opioid dependence.
Researchers followed 1,514 people in communities throughout Australia who were prescribed opioids for chronic noncancer pain from August 2012 to December 2018. Participants were assessed at baseline and then annually for 5 years. The first annual evaluation included a self-completed questionnaire; the other assessments were conducted in 60- to 90-minute sessions by trained interviewers. Opioid consumption was self-reported.
More than half (55.6%) of participants were women. Mean age was 58, and 48.7% were unemployed. Participants reported living with a pain condition for a median of 10 years and had a median of two pain conditions in the past 12 months. Back and neck problems were most common (80%), followed by arthritis (67%).
At any given interview, about 11% to 15% of participants reported taking 200 OME mg/day or more. The percent that requested a higher dose in the previous 3 months ranged from 8.5% to 23.8%. Fewer people asked for an early prescription renewal (4.6% to 14%).
Between 3% and 8% reported tampering with opioids at any given interview. Between 0.5% and 1.4% reported diversion to others. At each interview, 8.3% to 13.1% met criteria for opioid dependence, but more than half of those cases did not meet dependence criteria in the following interview.
Behaviors were not stable within individuals over time and typically occurred at only one or two points over 5 years of follow-up, Degenhardt pointed out. “This suggests that even among a cohort of people with long-standing chronic noncancer pain, long-term opioid use, and multiple physical, mental health, and substance use disorder comorbidities, indicators of problematic opioid use are dynamic and time-limited, not chronic and recurring,” she said.
Across the years, the percentage of people who stopped opioid treatment increased from 9.2% in year 1 to 20% in year 5. This changed throughout interviews as some people stopped and restarted prescription opioids the next year. People who stopped treatment were less likely to express concern about its adverse effects on their lives and functioning and reported having a greater capacity to cope with pain, Degenhardt observed.
The study had limitations, the researchers noted. Data were self-reported and some behaviors assessed in the study are associated with stigma, which may have led to underreporting. Whether changes in behavior reflected changes in medication regimens was unclear. The study was based on chronic pain patients in Australia and results may not apply to others.
The POINT study received funding from the Australian National Health and Medical Research Council (NHMRC).
Researchers reported relationships with the NHMRC, the National Institutes of Health, Indivior, Mundipharma, Seqirus, and Chiesi.