Psychiatric comorbidities complicate treatment of patients with chronic pain and opioid use disorder, but the prevalence of specific comorbid psychiatric disorders in this population has not been ...systematically investigated.
170 consecutive participants entering a treatment research program for co-occurring chronic pain and opioid use disorder between March 2009 and July 2013 were evaluated with the Structured Clinical Interview for DSM-IV-TR Axis I Disorders (SCID-I/P) and the Diagnostic Interview for DSM-IV Personality Disorders (DIPD-IV).
The prevalence of any lifetime (and current) comorbid Axis I disorder was 91% (75%); 52% met criteria for lifetime anxiety disorder (48% current), 57% for lifetime mood disorder (48% current), and 78% for lifetime nonopioid substance use disorder (34% current). Common current anxiety diagnoses were posttraumatic stress disorder (21%), generalized anxiety disorder (16%), and panic disorder without agoraphobia (16%). Common current mood diagnoses were major depressive disorder (40%) and dysthymia (11%). A majority of patients had a personality disorder (52%).
High rates and persistence of co-occurring psychiatric disorders, including anxiety or mood disorders, may explain in part the difficulty providers have treating patients with co-occurring opioid use disorder and chronic pain and suggest possible targets for improving treatment.
ClinicalTrials.gov identifiers: buprenorphine/naloxone treatment (NCT00634803), opioid treatment program-based methadone maintenance treatment (NCT00727675).
Abstract Objective To determine the impact of cognitive behavioral therapy on outcomes in primary care, office-based buprenorphine/naloxone treatment of opioid dependence. Methods We conducted a ...24-week randomized clinical trial in 141 opioid-dependent patients in a primary care clinic. Patients were randomized to physician management or physician management plus cognitive behavioral therapy. Physician management was brief, manual guided, and medically focused; cognitive behavioral therapy was manual guided and provided for the first 12 weeks of treatment. The primary outcome measures were self-reported frequency of illicit opioid use and the maximum number of consecutive weeks of abstinence from illicit opioids, as documented by urine toxicology and self-report. Results The 2 treatments had similar effectiveness with respect to reduction in the mean self-reported frequency of opioid use, from 5.3 days per week (95% confidence interval, 5.1-5.5) at baseline to 0.4 (95% confidence interval, 0.1-0.6) for the second half of maintenance ( P <.001 for the comparisons of induction and maintenance with baseline), with no differences between the 2 groups ( P =. 96) or between the treatments over time ( P = .44). For the maximum consecutive weeks of opioid abstinence there was a significant main effect of time ( P <.001), but the interaction ( P = .11) and main effect of group ( P = .84) were not significant. No differences were observed on the basis of treatment assignment with respect to cocaine use or study completion. Conclusions Among patients receiving buprenorphine/naloxone in primary care for opioid dependence, the effectiveness of physician management did not differ significantly from that of physician management plus cognitive behavioral therapy.
Abstract A range of innovative computer-based interventions for psychiatric disorders have been developed and are promising for drug use disorders due to reduced cost and greater availability ...compared to traditional treatment. Electronic searches were conducted from 1966 to November 19, 2009, using MEDLINE, Psychlit, and EMBASE. Four hundred sixty-eight nonduplicate records were identified. Two reviewers classified abstracts for study inclusion, resulting in 12 studies of moderate quality. Eleven studies were pilot or full-scale trials compared to a control condition. Interventions showed high acceptability despite substantial variation in type and amount of treatment. Compared to treatment-as-usual, computer-based interventions led to less substance use and higher motivation to change, better retention, and greater knowledge of presented information. Computer-based interventions for drug use disorders have the potential to dramatically expand and alter the landscape of treatment. Evaluation of Internet- and telephone-based delivery that allows for treatment-on-demand in patients' own environment is needed.
IMPORTANCE: Prescription opioid dependence is increasing and creates a significant public health burden, but primary care physicians lack evidence-based guidelines to decide between tapering doses ...followed by discontinuation of buprenorphine hydrochloride and naloxone hydrochloride therapy (hereinafter referred to as buprenorphine therapy) or ongoing maintenance therapy. OBJECTIVE: To determine the efficacy of buprenorphine taper vs ongoing maintenance therapy in primary care–based treatment for prescription opioid dependence. DESIGN, SETTING, AND PARTICIPANTS: We conducted a 14-week randomized clinical trial that enrolled 113 patients with prescription opioid dependence from February 17, 2009, through February 1, 2013, in a single primary care site. INTERVENTIONS: Patients were randomized to buprenorphine taper (taper condition) or ongoing buprenorphine maintenance therapy (maintenance condition). The buprenorphine taper was initiated after 6 weeks of stabilization, lasted for 3 weeks, and included medications for opioid withdrawal, after which patients were offered naltrexone treatment. The maintenance group received ongoing buprenorphine therapy. All patients received physician and nurse support and drug counseling. MAIN OUTCOMES AND MEASURES: Illicit opioid use via results of urinanalysis and patient report, treatment retention, and reinitiation of buprenorphine therapy (taper group only). RESULTS: During the trial, the mean percentage of urine samples negative for opioids was lower for patients in the taper group (35.2% 95% CI, 26.2%-44.2%) compared with those in the maintenance group (53.2% 95% CI, 44.3%-62.0%). Patients in the taper group reported more days per week of illicit opioid use than those in the maintenance group once they were no longer receiving buprenorphine (mean use, 1.27 95% CI, 0.60-1.94 vs 0.47 95% CI, 0.19-0.74 days). Patients in the taper group had fewer maximum consecutive weeks of opioid abstinence compared with those in the maintenance group (mean abstinence, 2.70 95% CI, 1.72-3.75 vs 5.20 95% CI, 4.16-6.20 weeks). Patients in the taper group were less likely to complete the trial (6 of 57 11% vs 37 of 56 66%; P < .001). Sixteen patients in the taper group reinitiated buprenorphine treatment after the taper owing to relapse. CONCLUSIONS AND RELEVANCE: Tapering is less efficacious than ongoing maintenance treatment in patients with prescription opioid dependence who receive buprenorphine therapy in primary care. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00555425
Abstract To determine whether treatment outcomes differed for prescription opioid and heroin use disorder patients, we conducted a secondary analysis of a 24-week (N = 140) randomized trial of ...physician management (PM) or PM plus cognitive behavioral therapy (CBT) in primary care buprenorphine/naloxone treatment. Self-reported opioid use and urine toxicology analyses were obtained weekly. We examined baseline demographic differences between primary prescription opioid use patients (n = 49) and primary heroin use patients (n = 91) and evaluated whether treatment response differed by assigned condition. Compared to primary heroin use patients, primary prescription opioid use patients had marginally fewer years of opioid use, were less likely to have had a previous drug treatment or detoxification, and were less likely to report injection drug use. Although opioid abstinence only, and treatment retention did not differ by opioid use group, opioid category moderated the effect of CBT on urine samples negative for all drugs. Primary prescription opioid use patients assigned to PM-CBT had more than twice the mean number of weeks of abstinence for all drugs (7.6) than those assigned to PM only (3.6; p = .02), while primary heroin use patients did not differ by treatment. Findings suggest that examination of other factors that may predict response to behavioral interventions is warranted.
Chronic pain (CP) is independently associated with substance use disorders (SUD) and posttraumatic stress disorder (PTSD). However, little is known about factors associated with CP among patients ...with co-occurring PTSD and SUD. Patterns of hospital resource usage should also be explored further.
Using the 2019 National Inpatient Sample (NIS), we identified 216,125 hospital discharges with co-occurring diagnoses of PTSD and SUD in 2019 and examined their association with CP. Multivariable logistic regression models were used to identify factors associated with an increased likelihood of CP in this cohort.
Among those with co-occurring PTSD and SUD (
= 216,125), 35,450 had associated CP, a prevalence of 164.02 cases per 1,000 discharges (95% CI 160.54, 167.52). Individuals aged 55-64 with co-occurring PTSD and SUD were approximately 7.2 times more likely to experience CP, compared to those aged 16-24 (OR = 7.2; 95% CI 6.09, 8.60). Being in the CP group was associated with 50% increased odds of insomnia and obesity (OR = 1.5; 95% CI 1.12, 2.03 and OR = 1.5; 95% CI 1.38, 1.55, respectively), 30% increased odds of anxiety (OR = 1.3; 95% CI 1.24, 1.38), 20% increased odds of attention deficit disorder (ADD;OR = 1.2; 95% CI 1.12, 1.38) and 10% increased odds of depression (OR = 1.1; 95% CI 1.01, 1.14). Compared with females, being male was associated with slightly decreased odds of CP (OR = 0.9; 95% CI 0.84, 0.94).
Among hospitalized Americans with co-occurring PTSD and SUD, advanced age, being female, and the presence other mental health disorders were associated with an increased risk of CP. Providers treating co-occurring PTSD/SUD should evaluate for and consider evidence-based management of CP if present.
Aims
To estimate the influence of non‐medical use of prescription opioids (NMUPO) on heroin initiation among US veterans receiving medical care.
Design
Using a multivariable Cox regression model, we ...analyzed data from a prospective, multi‐site, observational study of HIV‐infected and an age/race/site‐matched control group of HIV‐uninfected veterans in care in the United States. Approximately annual behavioral assessments were conducted and contained self‐reported measures of NMUPO and heroin use.
Setting
Veterans Health Administration (VHA) infectious disease and primary care clinics in Atlanta, Baltimore, New York, Houston, Los Angeles, Pittsburgh and Washington, DC.
Participants
A total of 3396 HIV‐infected and uninfected patients enrolled into the Veterans Aging Cohort Study who reported no life‐time NMUPO or heroin use, had no opioid use disorder diagnoses at baseline and who were followed between 2002 and 2012.
Measurements
The primary outcome measure was self‐reported incident heroin use and the primary exposure of interest was new‐onset NMUPO. Our final model was adjusted for socio‐demographics, pain interference, prior diagnoses of post‐traumatic stress disorder and/or depression and self‐reported other substance use.
Findings
Using a multivariable Cox regression model, we found that non‐medical use of prescription opioids NMUPO was associated positively and independently with heroin initiation adjusted hazard ratio (AHR) = 5.43, 95% confidence interval (CI) = 4.01, 7.35.
Conclusions
New‐onset non‐medical use of prescription opioids (NMUPO) is a strong risk factor for heroin initiation among HIV‐infected and uninfected veterans in the United States who reported no previous history of NMUPO or illicit opioid use.
Despite the growing morbidity and mortality rates associated with opioid use disorder, a large gap still exists between treatment need and capacity. Low-threshold clinics utilizing medication for ...opioid use disorder (MOUD) treatment can increase treatment access but are understudied, and little is known about how patient demographic characteristics are associated with their social support and functioning in these settings.
We used multivariate regression to estimate associations between demographic characteristics and self-reported social support or functioning indicators among patients receiving MOUD in a low-threshold clinic using several validated instruments administered at intake: Behavior and Symptom Identification Scale, Brief Pain Inventory, and Life Events Checklist for DSM-5. Patients initiating MOUD treatment between April 1 and December 31, 2017, with complete surveys were included (N=582).
Patients were primarily male (62%), aged 34 or older (53%), non-Hispanic White (79%), separated or not married (86%), and unemployed (64%). Over 20% did not live in a house or apartment in the past month. Women were more likely to "get along" with people outside their family or in social situations and to identify their partner as their source of support. Women, non-White, and older patients were at higher risk of social functioning-disrupting events (physical/sexual assaults or experiencing chronic pain), while employment and housing were protective against exposure to these trauma-related events. However, employment and housing also decreased the odds of talking with others about substance use. The aforementioned results were obtained from multivariate logistic regression models and were significant to p<0.05.
Variation in support and functioning by demographic characteristics suggests that treatment facilities may benefit from adopting strategies that take baseline disparities in support and functioning into account.
OBJECTIVE:This study examined the cross-sectional associations among pain intensity, pain catastrophizing, and sleep disturbance among patients receiving methadone maintenance treatment (MMT) for ...opioid use disorder (OUD) and reporting co-occurring chronic pain.
MATERIALS AND METHODS:Participants were 89 individuals with OUD and chronic pain drawn from a larger cross-sectional study of 164 MMT patients who completed a battery of self-report measures. The authors conducted 6 mediation models to test all possible pathways (ie, each variable tested as an independent variable, mediator, or dependent variable).
RESULTS:The only significant mediation effect was an indirect effect of sleep disturbance on pain intensity through pain catastrophizing. That is, greater sleep disturbance was associated with greater pain catastrophizing, which in turn was associated with greater pain intensity.
DISCUSSION:Altogether, findings suggest that the sleep disturbance to pain catastrophizing to pain intensity pathway may be a key mechanistic pathway exacerbating pain issues among MMT patients with OUD and chronic pain. These results suggest that interventions targeting sleep disturbance may be warranted among MMT patients with OUD and chronic pain. Future work in this area with longitudinal data is warranted.
Office-based opioid treatment (OBOT) is an evidence-based treatment model for opioid use disorder (OUD) offered by both addiction and general primary care providers (PCPs). Calls exist for more PCPs ...to offer OBOT. Few studies have been conducted on the primary care characteristics of OBOT patients.
To characterize medical conditions, medications, and treatment outcomes among patients receiving OBOT with buprenorphine for OUD, and to describe differences among patients by age and by time in care.
This study is a retrospective review of medical records on or before 4/29/2019 at an outpatient primary care clinic within a nonprofit addiction treatment setting. Inclusion criterion was all clinic patients actively enrolled in the OBOT program. Patients not prescribed buprenorphine or with no OBOT visits were excluded.
Of 355 patients, 42.0% had another PCP. Common comorbid conditions included chronic pain and psychiatric diagnosis. Few patients had chronic viral hepatitis or HIV. Patients reported a median of 4 medications. Common medications were cardiovascular, antidepressant, and nonopioid pain agents. Older patients had a higher median number of medications. There was no significant difference in positive opioid urine toxicology (UT) based on age, chronic pain status, or psychoactive medications. Patients retained >1 year were less likely to have positive opioid UT.
Clinical needs of many patients receiving OBOT are similar to those of the general population, supporting calls for PCPs to provide OBOT.
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