- Email: [email protected]
Hyperalgesia in pain patients at elevated risk for opioid misuse
Abstracts
S45
(276) Characteristics of patients prescribed high doses of opioid medications to treat non-cancer pain
(278) Hyperalgesia in pain patients at elevated risk for opioid misuse
B Morasco, J Duckart, T Carr, R Deyo, and S Dobscha; Oregon Health & Science University, Portland, OR
R Edwards, A Wasan, and R Jamison; Brigham & Women’s Hospital, Boston, MA
Despite increased opioid use, little is known about patients receiving high doses of opioids. In this study we describe the prevalence of high dose opioid use, as well as demographic and clinical characteristics, in VA patients with chronic non-cancer pain. Veterans with chronic pain prescribed high doses of opioids (>=180 mg/day morphine equivalent) for 901 consecutive days were identified (n=478) from electronic medical records and compared to two chronic pain groups: Traditional Dose group (5-179 mg/day; n=500) or No Opioid group (n=500). The average participant was male (90.7%), 55.1 years (SD=12.6), Caucasian (70.8%), and married (49.3%). The only significant demographic difference among groups was race/ethnicity, as African-Americans were less likely to be in the High Dose group. The most common diagnoses were joint pain (75.0%), low back pain (67.9%), or rheumatism/arthritis (60.9%). High dose opioid use occurred in 2.4% of chronic pain patients and 3.4% of pain patients taking opioids. The average dose in the High Dose group was 324.9 (SD=285.1) mg/day. The Traditional Dose group averaged 32.4 (SD=20.1) mg/day. In a logistic regression analysis, factors associated with an increased likelihood of being prescribed high doses of opioids included diagnoses of neuropathy (OR=1.73, 95% CI=1.14-2.61), low back pain (OR=1.69, 95% CI=1.18-2.42), or rheumatism/arthritis (OR=1.49, 95% CI=1.09-2.04), pain specialty clinic visits (OR=1.88, 95% CI=1.08-3.29), and higher frequency of primary care appointments (OR=1.52, 1.01-2.30). Conversely, African-American race/ ethnicity (OR=0.35, 95% CI=0.18-0.68) and diagnosis of hypertension (OR=0.67, 95% CI=0.48-0.93) were associated with decreased likelihood of being in the High Dose group. High dose opioid use occurs in 2-3% of VA chronic non-cancer pain patients and is associated with several pain diagnoses and higher medical utilization. Further study is needed to identify better predictors of high dose usage, as well as the efficacy and safety of such dosing.
One of the mainstays of pain treatment is therapy with oral opioid medications, but increasing evidence links prescription opioids with a variety of adverse outcomes, including medication misuse and opioid-induced hyperalgesia. Unfortunately, we currently know relatively little about the characteristics of low-risk and high-risk phenotypes. The present study employed quantitative sensory testing to evaluate pain responses in low-risk and highrisk chronic pain patients who were either taking or not taking prescription opioids. Out of the 119 chronic pain patients tested, approximately 60% were taking opioids. The Screener and Opioid Assessment for Patients with Pain (SOAPP-R; a 24-item self-report measure of risk for opioid misuse) was used to classify patients as either low- or high-risk using a previously-validated cutoff score (18); roughly half of the patients were classified into each category. Groups were compared on measures of mechanical and thermal pain responses. There were main effects of risk classification on each pain measure. The high-risk group reported higher levels of clinical pain, had lower pressure and heat pain thresholds, had lower heat pain tolerance, and rated repetitive mechanical stimuli as more painful relative to the low-risk group (p< .05). On measures of thermal pain thresholds, there was a main effect of opioid status, with the group of patients taking opioids showing less sensitivity to thermal pain (p< .05). In general, the other pain response measures did not differ significantly across opioid groups, though for each pain response, the low-risk, onopioids group was the least pain-sensitive. Collectively, unlike some previous studies, we did not observe opioid-induced hyperalgesia. Rather, regardless of opioid status, the high-risk group was hyperalgesic relative to the low-risk group. Future opioid treatment studies may benefit from the classification of opioid risk, and the examination of pain sensitivity and other factors that differentiate high- and low-risk groups.
(277) Sleep disordered breathing in patients taking opiates for chronic pain
(279) A nationally representative survey of clinicians attitudes and behaviors regarding long-tem use of opioids
C Jungquist, M Smith, and M Perlis; University of Rochester, Rochester, NY
H Wilson, C Kemp, B Theodore, M Kim, J Robinson, and D Turk; University of Washington, Seattle, WA
The overall aim of this study was to examine the relationships among chronic pain, opioids, respiration, and sleep in a sample of subjects referred for assessment of sleep disorders. A descriptive study was conducted. Independent variables were risk factors for sleep disordered breathing, pain intensity, opioid dose. Dependent Variables included were measures of sleep disordered breathing, sleep architecture, and sleep continuity. Regression models were used for statistical analysis. Data was collected on a total of 419 subjects (no pain [n = 171], pain – opioid Tx [n = 187], and pain 1 opioid Tx [n = 61]). Sample demographic (mean 1/- SD): age 50 yr 1/- 12.; 51% male; BMI 33.8 1/- 7; Epworth Sleepiness Scale 10.3 1/- 5; pain intensity 3.8 1/- 2 (0-10 scale); morphine equivalent dose 152 1/- 195 mg. There was a positive dose response relationship between amount of opioid and frequency of central apneic events and percent of stage 3/4 sleep; the [no pain vs. pain] group comparison revealed that subjects with pain had a lower percent of stage 1 sleep, and the [pain minus opioid vs. pain plus opioid]) group comparison revealed that subjects treated with opioids had significantly more central apneic events, more stage 2 sleep and less REM sleep; greater pain intensity was associated with more frequent central apneic events and fewer obstructive apneic events. These data suggest that the management of chronic pain with opioids is not likely to exacerbate obstructive sleep apnea at stable opioid doses; however; central sleep apnea may be worsened. The magnitude of the effect is modest, and the clinical relevance of the effect is unknown. Thus, the potential for marginal respiratory disturbance (an increase of 2.8 central events for every 100 mg. morphine equivalent opioid dose) must be weighed against the therapeutic value of opioids.
Despite their long history and known effectiveness, controversy surrounds the long-term use of opioids for chronic pain. Paradoxically, while the number of prescriptions has increased rapidly, prescriber concerns related to efficacy, short-term and long-term adverse effects, misuse and abuse, morbidity and mortality, and scrutiny by regulatory agencies have been increasing. In addition, major changes have occurred over the past 15 years, including new opioid formulations, evolving marketing practices, and increased regulation. Given these developments, a comprehensive, national survey focusing on prescriber beliefs and practices surrounding opioids for chronic non-cancer pain stratified by specialty and region of the country is timely. The primary objective of the current study is to examine current attitudes and behaviors of physicians about opioid medication. To accomplish this, a new standardized assessment measure, Clinicians Attitudes About Opioids (CAOS) scale, including questions regarding beliefs about efficacy, impediments to use, and regulatory issues, will be administered to a national representative sample of opioid prescribers. The initial phases of this project involve development of CAOS. Focus groups with physicians are being conducted for content development. CAOS will first be administered to a representative sample of 250 physicians, stratified by specialty and region. After refinement, CAOS will be administered to a representative sample of 2000 physicians. The stability of attitudes and behaviors will be evaluated through test re-test on a random sample of 100 completers within 2 weeks of their initial assessment. Completion of a national survey with a carefully developed measure will permit in-depth understanding of providers’ current attitudes and behaviors associated with opioid prescribing and, importantly, will also permit repeated assessment to investigate how evolving legislation, marketing landscapes, and product formulations alter beliefs and practices. This study is currently underway and results will be presented. (Supported by Ortho-McNeil Janssen Scientific Affairs, LLC.)
S45
(276) Characteristics of patients prescribed high doses of opioid medications to treat non-cancer pain
(278) Hyperalgesia in pain patients at elevated risk for opioid misuse
B Morasco, J Duckart, T Carr, R Deyo, and S Dobscha; Oregon Health & Science University, Portland, OR
R Edwards, A Wasan, and R Jamison; Brigham & Women’s Hospital, Boston, MA
Despite increased opioid use, little is known about patients receiving high doses of opioids. In this study we describe the prevalence of high dose opioid use, as well as demographic and clinical characteristics, in VA patients with chronic non-cancer pain. Veterans with chronic pain prescribed high doses of opioids (>=180 mg/day morphine equivalent) for 901 consecutive days were identified (n=478) from electronic medical records and compared to two chronic pain groups: Traditional Dose group (5-179 mg/day; n=500) or No Opioid group (n=500). The average participant was male (90.7%), 55.1 years (SD=12.6), Caucasian (70.8%), and married (49.3%). The only significant demographic difference among groups was race/ethnicity, as African-Americans were less likely to be in the High Dose group. The most common diagnoses were joint pain (75.0%), low back pain (67.9%), or rheumatism/arthritis (60.9%). High dose opioid use occurred in 2.4% of chronic pain patients and 3.4% of pain patients taking opioids. The average dose in the High Dose group was 324.9 (SD=285.1) mg/day. The Traditional Dose group averaged 32.4 (SD=20.1) mg/day. In a logistic regression analysis, factors associated with an increased likelihood of being prescribed high doses of opioids included diagnoses of neuropathy (OR=1.73, 95% CI=1.14-2.61), low back pain (OR=1.69, 95% CI=1.18-2.42), or rheumatism/arthritis (OR=1.49, 95% CI=1.09-2.04), pain specialty clinic visits (OR=1.88, 95% CI=1.08-3.29), and higher frequency of primary care appointments (OR=1.52, 1.01-2.30). Conversely, African-American race/ ethnicity (OR=0.35, 95% CI=0.18-0.68) and diagnosis of hypertension (OR=0.67, 95% CI=0.48-0.93) were associated with decreased likelihood of being in the High Dose group. High dose opioid use occurs in 2-3% of VA chronic non-cancer pain patients and is associated with several pain diagnoses and higher medical utilization. Further study is needed to identify better predictors of high dose usage, as well as the efficacy and safety of such dosing.
One of the mainstays of pain treatment is therapy with oral opioid medications, but increasing evidence links prescription opioids with a variety of adverse outcomes, including medication misuse and opioid-induced hyperalgesia. Unfortunately, we currently know relatively little about the characteristics of low-risk and high-risk phenotypes. The present study employed quantitative sensory testing to evaluate pain responses in low-risk and highrisk chronic pain patients who were either taking or not taking prescription opioids. Out of the 119 chronic pain patients tested, approximately 60% were taking opioids. The Screener and Opioid Assessment for Patients with Pain (SOAPP-R; a 24-item self-report measure of risk for opioid misuse) was used to classify patients as either low- or high-risk using a previously-validated cutoff score (18); roughly half of the patients were classified into each category. Groups were compared on measures of mechanical and thermal pain responses. There were main effects of risk classification on each pain measure. The high-risk group reported higher levels of clinical pain, had lower pressure and heat pain thresholds, had lower heat pain tolerance, and rated repetitive mechanical stimuli as more painful relative to the low-risk group (p< .05). On measures of thermal pain thresholds, there was a main effect of opioid status, with the group of patients taking opioids showing less sensitivity to thermal pain (p< .05). In general, the other pain response measures did not differ significantly across opioid groups, though for each pain response, the low-risk, onopioids group was the least pain-sensitive. Collectively, unlike some previous studies, we did not observe opioid-induced hyperalgesia. Rather, regardless of opioid status, the high-risk group was hyperalgesic relative to the low-risk group. Future opioid treatment studies may benefit from the classification of opioid risk, and the examination of pain sensitivity and other factors that differentiate high- and low-risk groups.
(277) Sleep disordered breathing in patients taking opiates for chronic pain
(279) A nationally representative survey of clinicians attitudes and behaviors regarding long-tem use of opioids
C Jungquist, M Smith, and M Perlis; University of Rochester, Rochester, NY
H Wilson, C Kemp, B Theodore, M Kim, J Robinson, and D Turk; University of Washington, Seattle, WA
The overall aim of this study was to examine the relationships among chronic pain, opioids, respiration, and sleep in a sample of subjects referred for assessment of sleep disorders. A descriptive study was conducted. Independent variables were risk factors for sleep disordered breathing, pain intensity, opioid dose. Dependent Variables included were measures of sleep disordered breathing, sleep architecture, and sleep continuity. Regression models were used for statistical analysis. Data was collected on a total of 419 subjects (no pain [n = 171], pain – opioid Tx [n = 187], and pain 1 opioid Tx [n = 61]). Sample demographic (mean 1/- SD): age 50 yr 1/- 12.; 51% male; BMI 33.8 1/- 7; Epworth Sleepiness Scale 10.3 1/- 5; pain intensity 3.8 1/- 2 (0-10 scale); morphine equivalent dose 152 1/- 195 mg. There was a positive dose response relationship between amount of opioid and frequency of central apneic events and percent of stage 3/4 sleep; the [no pain vs. pain] group comparison revealed that subjects with pain had a lower percent of stage 1 sleep, and the [pain minus opioid vs. pain plus opioid]) group comparison revealed that subjects treated with opioids had significantly more central apneic events, more stage 2 sleep and less REM sleep; greater pain intensity was associated with more frequent central apneic events and fewer obstructive apneic events. These data suggest that the management of chronic pain with opioids is not likely to exacerbate obstructive sleep apnea at stable opioid doses; however; central sleep apnea may be worsened. The magnitude of the effect is modest, and the clinical relevance of the effect is unknown. Thus, the potential for marginal respiratory disturbance (an increase of 2.8 central events for every 100 mg. morphine equivalent opioid dose) must be weighed against the therapeutic value of opioids.
Despite their long history and known effectiveness, controversy surrounds the long-term use of opioids for chronic pain. Paradoxically, while the number of prescriptions has increased rapidly, prescriber concerns related to efficacy, short-term and long-term adverse effects, misuse and abuse, morbidity and mortality, and scrutiny by regulatory agencies have been increasing. In addition, major changes have occurred over the past 15 years, including new opioid formulations, evolving marketing practices, and increased regulation. Given these developments, a comprehensive, national survey focusing on prescriber beliefs and practices surrounding opioids for chronic non-cancer pain stratified by specialty and region of the country is timely. The primary objective of the current study is to examine current attitudes and behaviors of physicians about opioid medication. To accomplish this, a new standardized assessment measure, Clinicians Attitudes About Opioids (CAOS) scale, including questions regarding beliefs about efficacy, impediments to use, and regulatory issues, will be administered to a national representative sample of opioid prescribers. The initial phases of this project involve development of CAOS. Focus groups with physicians are being conducted for content development. CAOS will first be administered to a representative sample of 250 physicians, stratified by specialty and region. After refinement, CAOS will be administered to a representative sample of 2000 physicians. The stability of attitudes and behaviors will be evaluated through test re-test on a random sample of 100 completers within 2 weeks of their initial assessment. Completion of a national survey with a carefully developed measure will permit in-depth understanding of providers’ current attitudes and behaviors associated with opioid prescribing and, importantly, will also permit repeated assessment to investigate how evolving legislation, marketing landscapes, and product formulations alter beliefs and practices. This study is currently underway and results will be presented. (Supported by Ortho-McNeil Janssen Scientific Affairs, LLC.)