In the JournalsPerspective

Patients with mental illness account for more than half of all opioid prescriptions

More than half of the opioids distributed in the United States annually are prescribed to adults with psychological conditions such as depression and anxiety, according to research recently published in the Journal of the American Board of Family Medicine.

The most recent data from the CDC indicate that more than six out of 10 drug overdose deaths involve opioids, and 91 Americans die every day from opioid overdose.

“Despite the increase in the prevalence of mental health disorders and the importance of tracking use of prescription opioids nationally, the extent to which U.S. adults with mental health disorders use prescription opioids has not been thoroughly examined,” Matthew A. Davis, MPH, PhD, department of psychiatry, University of Michigan, and colleagues wrote. “Furthermore, identification of the specific factors that may underpin the association would help clarify the complex relationship between mental health and pain.”

Researchers used the Medical Expenditure Panel Survey to assess the relationship between patients with mental illness and prescription opioid use. Patients with mental illness were identified by ICD codes of 300 (anxiety, dissociative and somatoform disorders), 311 (depressive disorder), and 296 (episodic mood disorders). Opioid use was defined as those who received at least two opioid prescriptions in the past calendar year. The final analytic sample consisted of 51,891 patients aged 18 years and older.

Davis and colleagues wrote that among the U.S. population of 239.4 million adults, an estimated 38.6 million had a mental health disorder. Of the adults with mental health disorders, 18.7% were opioid users, compared with only 5% of U.S. adults without mental health disorders. The researchers also found that of the approximately 115 million opioid prescriptions distributed each year in the U.S., 51.4% were received by adults who have a mental health disorder.

In addition, researchers found that in unadjusted analyses the odds of opioid use was four times higher among adults with mental health disorders than among those without (OR = 4.34; 95% CI, 3.93–4.77). After adjusting for sociodemographic characteristics, health status, and use of selected health services, although attenuated, the association persisted: adults with mental health disorders had more than twice the odds of being anopioid user (OR = 2.08; 95% CI, 1.83–2.35). Other factors in the fully adjusted model associated with opioid use included having undergone inpatient surgery (OR = 3.58); having severe self-reported pain (OR = 3.15), having had outpatient surgery (OR = 2.73), and having a substance abuse diagnosis (OR = 2.42), having moderate self-reported pain (OR = 2.15), indicating a physical limitation (OR = 1.84), and having a usual source of care (OR = 1.67).

Further, Davis and colleagues noted that 19.3% of patients with pain and mood disorders initiated opioid use, compared with 17.2% of patients with pain without mood disorders. “Evidence indicating an increased risk of depressive symptoms in patients receiving chronic opioids may raise concerns regarding reverse causality,” they wrote. “The relationship between mental health disorders and pain is also likely bidirectional, with improvements in pain leading to improvements in mental health symptoms and vice versa.”

Researchers also indicated that there is some evidence that suggests optimizing pain treatment and depression can improve outcomes in primary care, and that having a mental health disorder is associated with increased opioid use even after controlling

for a wide array of other demographic and clinical risk factors, such as substance abuse.

“Our findings that patients with mental illness are more likely to receive opioid prescriptions across all different levels of pain suggests that there may be additional patient- and provider-related factors specific to those with mental illness that increase the likelihood of receiving prescription opioids,” Davis and colleagues wrote. “Such a relationship is particularly concerning because mental illness is also a prominent risk factor for overdose and other adverse opioid-related outcomes. Thus, the expectation would be that physicians would be more conservative with their prescribing behaviors in the setting of mental illness and favor nonopioid alternatives.”

“Urgent attention [is warranted] to determine if the risks associated with such prescribing are balanced with therapeutic benefits,” Brian Sites, MD, MS, anesthesiologist at Dartmouth-Hitchcock Medical Center, said in a press release.

A study that recently appeared in MMWR suggested that the risk for chronic opioid use can be triggered in as little as 3 days. Those researchers also suggested that treatment of acute pain with opioids should be for the shortest duration possible, which is consistent with CDC’s guidelines for opioid use.

A speaker at the this year’s AANP conference suggested that successfully treating patients with chronic pain and opioid use disorder must involve the patient being actively engaged in self-management of their condition, while other research recently identified six potential ‘building blocks’ that could lead to better outcomes in chronic opioid management, including calculating progress toward achieving clinic objectives and pinpointing resources for complex patients. – by Janel Miller

Disclosure: The researchers report no relevant financial disclosures.

More than half of the opioids distributed in the United States annually are prescribed to adults with psychological conditions such as depression and anxiety, according to research recently published in the Journal of the American Board of Family Medicine.

The most recent data from the CDC indicate that more than six out of 10 drug overdose deaths involve opioids, and 91 Americans die every day from opioid overdose.

“Despite the increase in the prevalence of mental health disorders and the importance of tracking use of prescription opioids nationally, the extent to which U.S. adults with mental health disorders use prescription opioids has not been thoroughly examined,” Matthew A. Davis, MPH, PhD, department of psychiatry, University of Michigan, and colleagues wrote. “Furthermore, identification of the specific factors that may underpin the association would help clarify the complex relationship between mental health and pain.”

Researchers used the Medical Expenditure Panel Survey to assess the relationship between patients with mental illness and prescription opioid use. Patients with mental illness were identified by ICD codes of 300 (anxiety, dissociative and somatoform disorders), 311 (depressive disorder), and 296 (episodic mood disorders). Opioid use was defined as those who received at least two opioid prescriptions in the past calendar year. The final analytic sample consisted of 51,891 patients aged 18 years and older.

Davis and colleagues wrote that among the U.S. population of 239.4 million adults, an estimated 38.6 million had a mental health disorder. Of the adults with mental health disorders, 18.7% were opioid users, compared with only 5% of U.S. adults without mental health disorders. The researchers also found that of the approximately 115 million opioid prescriptions distributed each year in the U.S., 51.4% were received by adults who have a mental health disorder.

In addition, researchers found that in unadjusted analyses the odds of opioid use was four times higher among adults with mental health disorders than among those without (OR = 4.34; 95% CI, 3.93–4.77). After adjusting for sociodemographic characteristics, health status, and use of selected health services, although attenuated, the association persisted: adults with mental health disorders had more than twice the odds of being anopioid user (OR = 2.08; 95% CI, 1.83–2.35). Other factors in the fully adjusted model associated with opioid use included having undergone inpatient surgery (OR = 3.58); having severe self-reported pain (OR = 3.15), having had outpatient surgery (OR = 2.73), and having a substance abuse diagnosis (OR = 2.42), having moderate self-reported pain (OR = 2.15), indicating a physical limitation (OR = 1.84), and having a usual source of care (OR = 1.67).

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Further, Davis and colleagues noted that 19.3% of patients with pain and mood disorders initiated opioid use, compared with 17.2% of patients with pain without mood disorders. “Evidence indicating an increased risk of depressive symptoms in patients receiving chronic opioids may raise concerns regarding reverse causality,” they wrote. “The relationship between mental health disorders and pain is also likely bidirectional, with improvements in pain leading to improvements in mental health symptoms and vice versa.”

Researchers also indicated that there is some evidence that suggests optimizing pain treatment and depression can improve outcomes in primary care, and that having a mental health disorder is associated with increased opioid use even after controlling

for a wide array of other demographic and clinical risk factors, such as substance abuse.

“Our findings that patients with mental illness are more likely to receive opioid prescriptions across all different levels of pain suggests that there may be additional patient- and provider-related factors specific to those with mental illness that increase the likelihood of receiving prescription opioids,” Davis and colleagues wrote. “Such a relationship is particularly concerning because mental illness is also a prominent risk factor for overdose and other adverse opioid-related outcomes. Thus, the expectation would be that physicians would be more conservative with their prescribing behaviors in the setting of mental illness and favor nonopioid alternatives.”

“Urgent attention [is warranted] to determine if the risks associated with such prescribing are balanced with therapeutic benefits,” Brian Sites, MD, MS, anesthesiologist at Dartmouth-Hitchcock Medical Center, said in a press release.

A study that recently appeared in MMWR suggested that the risk for chronic opioid use can be triggered in as little as 3 days. Those researchers also suggested that treatment of acute pain with opioids should be for the shortest duration possible, which is consistent with CDC’s guidelines for opioid use.

A speaker at the this year’s AANP conference suggested that successfully treating patients with chronic pain and opioid use disorder must involve the patient being actively engaged in self-management of their condition, while other research recently identified six potential ‘building blocks’ that could lead to better outcomes in chronic opioid management, including calculating progress toward achieving clinic objectives and pinpointing resources for complex patients. – by Janel Miller

Disclosure: The researchers report no relevant financial disclosures.

    Perspective
    Lawrence Greenblatt

    Lawrence Greenblatt

    This meticulously done epidemiologic research by Matthew Davis, et al., confirms out a correlation that many primary care clinicians have observed in their clinical practice-that those thought to be at higher risk for opioid misuse due to mental illness are more likely to receive chronic opioid therapy.  However, the degree to which opioid therapy is concentrated into the individuals suffering from mental illness was truly striking and well beyond the level most would have predicted.  One might imagine that individuals suffering from depression, anxiety, or other significant mental health disorders would be less able to cope with chronic pain or to effectively manage their pain through non-opioid strategies such as physical therapy, exercise, or relaxation strategies.  However, it is also possible that opioids have a therapeutic effect on anxiety and/or depression much like the improvement in symptoms from schizophrenia among individuals who use nicotine.  Given that roughly half of individuals with depression or anxiety under treatment do not achieve adequate remission of these conditions, one can envision individuals reluctant to stop their opioid therapy if it mitigates other symptoms. 

    Primary care clinicians prescribe nearly half of all opioids in the U.S. and the majority of chronic opioid therapy.  We must be cautious of prescribing these medications for individuals with co-morbid mental illness as they are more likely to remain on long-term therapy with its inherent risks and likely limited benefits on pain and function.

    • Lawrence Greenblatt, MD, FACP
    • Professor of Medicine, Professor of Community and Family Medicine, Duke University School of Medicine

    Disclosures: Greenblatt reports no relevant financial disclosures.