Generalized Anxiety and Depression Among Chronic Pain Patients on Opiod Therapy are Associated with Higher Pain Impairment Increased Service Utilization and Poorer Health BOSCARINO
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Generalized Anxiety and Depression Among Chronic Pain Patients on Opiod Therapy are Associated with Higher Pain Impairment Increased Service Utilization and Poorer Health BOSCARINO

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  • 1. Anxiety & Depression among Pain Patients are Associated withHigher Pain Impairment, Increased Utilization and Poorer Health Joseph A. Boscarino, PhD, MPH, Center Health Research Stuart N. Hoffman, DO, Department of Neurology Glenn S. Gerhard, MD, Weis Center John J. Han, MD, Department of Anesthesiology Margaret R. Rukstalis, MD, Center for Health Research Porat M. Erlich, PhD, MPH Center for Health Research Walter F. Stewart, PhD, MPH, Center for Health Research Geisinger Clinic Danville, PA 18th HMORN Conference May 1, 2012 (Session B7) HMORN Presentation 4-24-12.ppt
  • 2. Funding Study funding for this research was provided by the Geisinger Clinic Research Fund (Grant No. TRA-015). Joseph A. Boscarino, PhD, MPH was the study PI. There are no conflicts of interest associated with his research.
  • 3. Past Month Nonmedical Use of Psychotherapeutic Drugs among Persons Aged 12 or Older in US: 2002-2010 National Survey on Drug Use and Health, SAMHSA, 2011.
  • 4. Specific Drug Associated with Initiation of Illicit Drug Use among Illicit Drug Initiates Aged 12 or Older in US in the Past Year National Survey on Drug Use and Health, SAMHSA, 2011.
  • 5. Objective Research on opioid dependence is difficult, given challenges to subject recruitment & measurement. We tested a research design by studying prescription opioid use among outpatients at Geisinger Clinic, Danville, PA. Objective was to assess the risk of addiction among outpatients in a medical setting.
  • 6. Method Cross-sectional study implemented among Geisinger Clinic’s outpatients. Patients selected for diagnostic interviews if had 5+ prescription opioid orders for non-cancer pain in prior 12 months. Opioid dependence was based on the Diagnostic and Statistical Manual of Mental Disorder - IV (DSM-IV).
  • 7. DSM-IV Criteria Opioid-related disorders: 305.50 - Abuse 304.00 - Dependence 292.84 - Induced mood disorder 292.11 - Induced psychotic disorder, with delusions 292.12 - Induced psychotic disorder, with hallucinations 292.89 - Intoxication 292.81 - Intoxication delirium 292.9 - Related disorder NOS 292.0 - WithdrawalDSM-IV Definition of Drug Dependence: Psychological and/or physical dependenceon a drug resulting from the use of that drug on a periodic or continuous basis. Thisdependence is characterized by tolerance, withdrawal, and loss of control symptomsrelated to drug taking and by psychosocial impairments. The individual who uses thedrug feels unable to function without the drug.
  • 8. Method (cont’d) A Composite International Diagnostic Interview (CIDI) was used to obtain data on addiction & mental health status; also used other DSM-IV scales. Data collected on exposure to psychological trauma, post-traumatic stress disorder (PTSD) & other disorders. 705 patients completed the survey; 505 of patients (72%) provided DNA for genotyping and completed the NEO Five-Factor Inventory. Data also gathered on demographics factors. EHR data also obtained.
  • 9. Study Assessments Prescription opioid dependence (POD) Major depression (MD) Generalized anxiety disorder (GAD) Post-traumatic stress disorder (PTSD) Alcohol dependence (AD) Illicit drug dependence/abuse Childhood abuse/neglect Antisocial personality Trauma exposure history
  • 10. Sample design2459 adult patients– 9 primary care & 3 specialty clinics– ≥4 prescriptions 86 not contacted (study quota met)– not cancer-related– July 2006 – June 2007 983 not reachable or not qualified – Institutionalized (nursing home, correctional facility, mental institution, etc.) – Incapable of answering questions – Language barrier 2373 attempted contact (mail/phone) – Denied taking medications – Deceased – Disconnected phone – Busy signal/answering machine – Business/wrong number1390 actually contacted (8/07–11/08) 685 Not interested/declined study705 consented & completed interview The mean age of patients was 55 years of age (SD=13.4) and 60.9% (95% C.I. = 55.9-65.7) were female. 505 genotyped
  • 11. World Health Organization Composite InternationalDiagnostic Interview (CIDI) Staff Certification and Training are Important
  • 12. Prevalence of Opioid Dependence* Lifetime Drug No LifetimeDependence Measures Total Sample Dependence Dependence Percent 95% C.I. (N) Percent 95% C.I. (N) Percent (N)Lifetime Opioid Depend. % Yes 35.1 30.6-39.8 (251) 100.0 --- (251) --- --- % No --- --- --- 100.0 (454) 64.9 60.3-69.4 (454)Current Opioid Depend. % Yes 72.4 67.3-77.0 (181) 0.0 (0) 25.4 21.7-29.5 (181) % No 27.6 23.0-32.7 (70) 100.0 (454) 74.6 70.5-78.3 (524) *Based on DSM-IV criteria. Boscarino, et al. Risk factors for drug dependence among outpatients on opioid therapy in a large US healthcare system. Addiction. 2010; 105 (10): 1776-1782.
  • 13. Lifetime DSM-5 Opioid-use Disorder vs. Lifetime DSM-4 Opioid Dependence(tolerance & withdrawal dropped, craving added, abuse added, except legal probs) DSM-5 Opioid-use DSM-5 Opioid-use Total DSM-4 Opioid Disorder not Present Disorder Present Dependence Diagnostic Criteria Used* % 95% CI (n) % 95% CI (n) % 95% CI (n) DSM-4 Opioid Depend not Pres. 94.9 92.2-96.7 (436) 7.7 4.3- 13.4 (18) 64.5 59.8-68.9 (454) DSM-4 Opioid Depend Pres. 5.1 3.3-7.8 (23) 92.3 86.6-95.7 (228) 35.5 31.1-40.2 (251) Total DSM-5 Opioid-use Disorder 65.1 60.5-69.5 (459) 34.9 30.5-39.5 (246) 100.0 -- -- (705) *Kappa = 0.873, p < 0.0001 for DSM-4 vs. DSM-5. Boscarino et al. Prevalence of prescription opioid-use disorder among chronic pain patients: Comparison of the DSM-5 vs. DSM-4 criteria. J Addict Dis. 2011; 30: 185-194.
  • 14. Why are DSM-4 and DSM-5 Results the Same? 1. Cases that would have been excluded under DSM-5 by elimination of withdrawal and tolerance are now included by addition of the drug abuse and craving. 2. Also due to the retention of “loss of control” symptoms in DSM-5, because those with withdrawal and tolerance under DSM-4 also have loss of control symptoms.Boscarino et al. Prevalence of prescription opioid-use disorder among chronic painpatients: Comparison of the DSM-5 vs. DSM-4 criteria. J Addict Dis. 2011; 30: 185-194.
  • 15. Opioid Dependence by Select Predictors Lifetime No Lifetime Total Sample Drug Drug Study Predictors Percent (N) Dependence Dependence Percent (N) Percent (N) Lifetime Opioid Drug Abuse % Yes 12.3 (88) 31.8 (79) 1.9 (9)*** % No 87.7 (617) 98.1 (445) 68.3 (172) Severity Opioid Dependence % High 15.1 (108) 30.4 (77) 6.8 (31)*** % Not High 84.9 (597) 93.2 (423) 69.6 (174) Lifetime Alcohol Dependence % Yes 9.7 (68) 14.3 (36) 7.1 (32)** % No 90.3 (637) 92.9 (442) 85.7 (215) Lifetime Tobacco Dependence % Yes 36.3 (251) 41.8 (103) 33.4 (148)*** % No 63.7 (454) 66.6 (306) 58.2 (148) Lifetime Posttraumatic Stress ** p<0.01 % Yes 13.1 (97) 8.7 (42)*** 21.3 (55) *** p<0.001** p<0.01 % No 86.9 (608) 91.3 (412) 78.7 (196)*** p<0.001
  • 16. Opioid Dependence by Select Predictors (cont’d) Lifetime No Lifetime Drug Study Predictors Total Sample Drug Dependence Dependence Percent (N) Percent (N) Percent (N) History Childhood Neglect % High 24.6 (178) 33.0 (84) 20.1 (94)** % Not High 75.4 (527) 79.9 (360) 67.0 (167) History Exposure to Psych Trauma % High 22.5 (161) 31.8 (80) 17.5 (81)*** % Not High 77.5 (544) 82.5 (373) 68.2 (171) History Illicit Drug Use % Yes 38.1 (273) 50.3 (127) 31.5 (146)*** % No 61.9 (432) 68.5 (308) 49.7 (124) History Substance Abuse Treat. % Yes 21.8 (153) 36.4 (90) 13.9 (63)*** % No 78.2 (552) 86.1 (391) 63.6 (161) ** p<0.01 History Anti-Social Personality % Yes 23.3 (167) 32.7 (83) 18.3 (84)*** % No 76.7 (538) 81.7 (370)** p<0.01 67.3 (168) (N =) (705) (251) (454)*** p<0.001
  • 17. Pain & Prescription Opioid Dependence are Associated Current pain scores on Brief Pain Inventory correlated with opioid dependence symptoms (r ~ 0.20) (p<0.001) 32% of those with current opioid dependence report high 7-day pain levels vs. 18% w/o dependence (p<0.001) 73% of those with current opioid dependence report high pain functional impairment vs. 55% w/o dependence (p<0.001)
  • 18. Logistic Regression Results Predicting Drug Dependence* Model 1: Model 2: Lifetime Opioid Dependence Current Opioid DependenceBest Predictor Variables OR 95% CI p-value OR 95% CI p-valueLess than 65 Years Old 2.70 1.76-4.15 <0.001 2.24 1.37-3.64 0.004Reported Pain Interferes with Life/work 2.20 1.50-3.23 0.001 1.74 1.13-2.66 0.016History of Opioid Abuse 14.84 6.29-34.99 <0.001 3.90 1.46-10.40 0.011History of High Addiction Severity 2.61 1.56-4.37 0.002 1.93 1.40-2.66 0.001High Number Opioid Orders in past 3 Yrs 1.89 1.34-2.66 0.002 _ _ _History of Major Depression -- -- -- 1.37 1.16-1.63 0.002Currently on Psychotropic Medications -- -- -- 1.61 1.11-2.34 0.017 *Boscarino, et al. Risk factors for drug dependence among outpatients on opioid therapy in a large US healthcare system. Addiction. 2010; 105 (10): 1776-1782.
  • 19. Lifetime Prevalence of Mental Disorders in Study POD = 37% (95% CI = 33-41%) PTSD = 15% (95% CI = 12-18%) GAD = 13% (95% CI = 11-17%) MD = 38% (95% CI = 34-42%)POD = Prescription opioid dependence; PTSD = Posttraumaticstress disorder; GAD = Generalized anxiety disorder; MD =Major depression.
  • 20. Patient Health Statistics 20+ outpatient visits past year = 16% 5+ hospitalizations past 5 years = 17% Rate health status poor = 19% Current pain interferes with life = 21% Ever treated for substance abuse = 22% Ever suicidal thoughts = 26% History of childhood neglect = 25% Ever used illicit drugs = 38%
  • 21. Anxiety Associated with* Higher pain impairment (OR=2.0, p=0.01) Higher service utilization (OR=3.4, p< 0.001) History suicidal thoughts, (OR=2.5, p=0.002) Poorer reported health (OR= 2.1, p=0.01) *Logistic regression controlling for other mental disorders & health risk factors
  • 22. Depression Associated with* Higher hospitalizations (OR=2.2, p=0.002) History suicidal thoughts (OR=8.3, p<0.001) History substance abuse treatment (OR=1.8, p=0.01) *Logistic regression controlling for other mental disorders & health risk factors
  • 23. Rx Opioid Dependence Associated with* Higher pain impairment (OR=1.7, p = 0.007) History addiction treatment OR=2.3, p< 0.001) Poorer reported health (OR=1.8, p = 0.005) *Logistic regression controlling for other mental disorders & health risk factors
  • 24. Study limitations• Patients selected based on Rx in EHR• Cross-sectional study design• DSM-IV criteria in transition• Sample size limited (N= 705)• Population 96% White• Mostly rural & non-urban region
  • 25. Conclusion Chronic pain patients receiving opioids have historyof mental health disorders, including POD, GAD & MD These comorbidities are associated with painimpairment, service utilization, suicidal thoughts, andpoor health status, potentially complicating patient care. PTSD was not associated with comorbidity, onceother variables were controlled. Study suggests that chronic pain patients on opioidtherapy may benefit by integration of mental healthservices into primary and specialty care.
  • 26. ReferencesBoscarino JA, Rukstalis M, Hoffman SN, et al. Risk factors for drugdependence among outpatients on opioid therapy in a large UShealthcare system. Addiction. 2010; 105(10):1776-1782.Erlich PM, Hoffman SN, Rukstalis M, Han JJ, Chu X, KaoWHL, Gerhard GS, Stewart WF, Boscarino JA. Nicotinicacetylcholine receptor genes on chromosome 15q25.1 areassociated with nicotine and opioid dependence severity. HumGenet. 2010; 128: 491-499.Boscarino JA, Rukstalis, MR, Hoffman SN, Han JJ, Erlich PM, RossS, Gerhard GS, Stewart WF. Prevalence of prescription opioid-usedisorder among chronic pain patients: Comparison of the DSM-5 vs.DSM-4 diagnostic criteria. J Addict Dis. 2011; 30: 185-194.Boscarino JA, Erlich PM, Hoffman SN, Rukstalis M, Stewart WF.Association of FKBP5, COMT and CHRNA5 polymorphisms withPTSD among outpatients at risk for PTSD. Psychiatry Res. 2011;188: 173-174.