High-Risk Patients More Likely to Receive Long-Term Opioid Therapy

New epidemiological evidence suggests that patients at greater risk of opioid abuse and misuse could be the same patients who are more likely to receive prescriptions for pain for an extended period of time.

Interview with Patrick D. Quinn, PhD, and Robert J. Gatchel, PhD, ABPP

With a rising rate of opioid prescribing among patients who at greatest risk for adverse outcomes, a team of researchers examined commercial health care claims in search of patterns of those with and without a diagnosed psychiatric or behavioral disorder.¹

Referred to as “adverse selection,”² patients with a history of substance use disorder (SUD), especially opioid use disorder (OUD), are often more likely to have received prescribed opioid medications. The researchers concluded that some patients taking opioids also had a history of various psychiatric conditions and were at greater risk for opioid misuse, abuse, and possibly suicide.

In analyzing over 10 million health insurance claims, researchers identified patients with a history of psychiatric conditions who also received a prescription for an opioid medication as more likely to having their opioid prescriptions turn into long-term opioid regimens.

The study,  published in Pain, is one of the largest epidemiological studies to examine opioid prescribing patterns in the US. According to Patrick D. Quinn, PhD, lead author and visiting research scientist in the department of psychological and brain sciences at Indiana University in Bloomington, it may be difficult to infer why patients with high-risk predictors for opioid misuse and abuse would still be prescribed opioids in the clinical setting, even if such clinical decisions do go against opioid treatment guidelines.^3,4

“It’s important to keep in mind that this study cannot really tell us much about why some patients, such as those with psychiatric conditions, are more likely to transition to long-term opioid therapy,” Dr. Quinn told Practical Pain Management. “That’s because we do not know from the data we analyzed what occurred in encounters between patients and providers that led to opioid prescriptions being filled.”

Psychiatric Conditions: A Predictor for Opioid Use

The study used data from health insurance claims of opioid recipients, logged from 2003 to 2013, and followed these patients from the index-date of their initial opioid prescription to the end of their continuous enrollment [an average of 1.55 years (interquartile range: 0.63-3.22)]. Patients were at least 13 years of age and had no cancer diagnoses in the year before or 1.5 years after the index-date for their prescription opioid.

Researchers took patients with psychiatric diagnoses who had filled at least 1 opioid prescription and matched them to controls. The investigators found depressive disorders were the most common condition among patients with psychiatric diagnoses (8.5% of cases). However, across all mental health categories, a prior psychiatric diagnosis showed a consistent pattern of long-term opioid use.

In fact, patients who had been diagnosed with a prior OUD or nonopioid-related SUD were more like to be prescribed a opioid prescription—16% (OUD) and 11% (SUD)—relative with patients who had no psychiatric conditions.

Researchers similarly found psychoactive medications were dispensed more often to patients prior to an opioid prescription, with at least 12.5% of patients having at least 1 selective serotonin reuptake inhibitor (SSRI) prescribed before an initial opioid prescription was written. In fact, patients with any prior psychoactive medication were more likely to seek and receive an opioid medication at some later point.

This was true even for patients receiving benzodiazepine; these patients had a 52% greater odds of receiving an opioid prescription in comparison to patients not taking this class of drugs.

Risks Greater in Psychiatric Patients on Long-Term Opioids

Patients who had a prior diagnosis of a psychiatric condition were more likely to continue with opioid therapy once it was initiated. These same patients had greater rates of suicide attempts, self-injury, and motor vehicle crashes, which were predictors of long-term reliance on opioid medications. According to Dr. Quinn, it is unclear what clinical inferences can be made from these troublesome associations.

There are a number of explanations for clinicians to continue prescribing opioids to these patients in light of these disconcerting patient patterns. For example, some clinicians may not be aware of their patient’s prior psychiatric diagnosis, an issue that has led to increased advocacy for the use of mental health screening prior to opioid initiation.

“As others have argued, mental health screening or integrated mental health care might help providers and their patients make informed decisions regarding the best [pain] treatment options,” Dr. Quinn told Practical Pain Management.

Perhaps of more concern, patients with a history of a prior suicide attempt or self-injury received long-term opioid therapy 2.55 times the rate of those with no prior history of such events. According to Dr. Quinn, it appears long-term opioid use and an increased suicide risk may be attributed to a prior diagnosis of some form of depressive disorder.

“It might be, for example, that patients with depression or other psychiatric conditions were more likely to engage in this behavior and were also more likely to receive long-term opioid therapy, meaning that the link between prior self-injury and opioids could be expected based on pre-existing psychiatric conditions,” Dr. Quinn explained.

“Overall, this investigation again highlights the significant epidemic of opioid misuse in the US,” said Robert J. Gatchel, PhD, ABPP, from the University of Texas at Arlington. “With chronic pain as a major health problem in the US, coupled with the fact of high rates of opioid prescriptions for it, more clinical research is needed to address methods to better manage this economic and human suffering ‘dual threat.'”

Research continues to look for danger signs for opioid use among patients with self-injurious tendencies, especially among minors.⁵ Even if this pattern could be explained by prior psychiatric diagnoses, Dr. Quinn finds it worrisome that such patients would be granted extended opioid therapy, especially given the evidence of a higher incidence of suicide mortality among individuals taking higher doses of opioids.⁶

“If our findings on self-injury are replicated, we hope that it can help spur greater attention to screening for self-injurious behavior,” said Dr. Quinn.

View Sources

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2. Sullivan MD. Who gets high-dose opioid therapy for chronic non-cancer pain? PAIN. 2010;151:567-568.
3. Howe CQ, Sullivan MD. The missing ‘P’ in pain management: How the current opioid epidemic highlights the need for psychiatric services in chronic pain care.Gen Hosp Psychiatry. 2014;36:99-104.
4. Sullivan MD, Howe CQ. Opioid therapy for chronic pain in the United States: Promises and perils.PAIN. 2013;154:S94-S100.
5. Gaither JR, Leventhal JM, Ryan SA, et al. National trends in hospitalizations for opioid poisonings among children and adolescents, 1997 to 2012.JAMA Pediatric 2016;170(12):1195-1201.
6. Ilgen MA, Bohnert AS, Ganoczy D, et al. Opioid dose and risk of suicide.PAIN. 2016;157(5):1079-1084.