Journal Article Annotations
2016, 4th Quarter
Annotations by Thomas Penders, MD, FAPM; Alex Sidelnik, MD; and Diana Robinson, MD
Consultation Psychiatrists are daily confronted with dilemmas resulting from the now well-described epidemic of opioid use disorders. Our group reports on two new studies and one review published that can enhance our understanding of the psychiatric antecedents and consequences of patients maintained on opioid analgesics for management of chronic painful medical and surgical conditions.
The finding: In patients receiving opioid analgesia, risk factors for overdose include total opioid dosage, concurrent use of sedative-hypnotics, use of extended-release/long-acting opioids, and presence of substance use or other mental health disorders.
Strengths and weaknesses: This is a systematic review of recently published literature including a total of 15 observation studies with data drawn prospectively from administrative and surveillance data. The individual studies were fairly heterogeneous with varying definitions of overdose, differing inclusion criteria, and varying degrees to which confounding was addressed. Despite their heterogeneity when the studies are combined in whole, they provide a comprehensive examination of risk factors associated with overdose in opioid analgesia.
Relevance: Given the significant increase of fatal opioid overdose in the United States over the past decade, the study provides a valuable review of risk factors associated with overdose in patients receiving opioid analgesia. Clinicians may find the information helpful in identifying high-risk individuals for risk-reduction interventions and guide clinical practice. For further review of treatment guidelines in opioid analgesia, see the CDC Guideline for Prescribing Opioids for Chronic Pain published in 2016.
The finding: This study of patients admitted to the hospital for opioid use disorder or unintentional opioid overdose found low rates of outpatient substance use disorder treatment engagement after discharge. They found that patients with behavioral health providers prior to hospitalization were more likely to engage in follow-up care while those less likely to engage in follow-up care were age 55-64, had left against medical advice, were admitted from an emergency department, or admitted for an unintentional opioid overdose.
Strengths and weaknesses: This is a retrospective analysis of a large database of insurance claims for approximately 50 million employees and dependents. This yielded a large sample size of 36,719 individuals meeting inclusion criteria. Interestingly, the rate of outpatient substance use treatment engagement post-hospitalization was lower than in other similar previous studies likely due to more stringent treatment engagement definitions (i.e. two outpatient SUD visits rather than 1 within 30 days of hospital discharge). A limitation of the study is that it utilized data collected from commercially insured patients which may skew the socioeconomic status, psychosocial measures such as family support, and severity of illness which are important factors predicting patient engagement in post-discharge SUD treatment.
Relevance: Given that engagement with outpatient services after inpatient admission reduces the risk of re-admission and is associated with positive treatment outcomes, encouraging successful transition from inpatient care to outpatient services is critical. This study provides additional information on patients that are at higher risk of failing to engage in outpatient services that may benefit from more proactive disposition planning, referrals, scheduling appointments, motivational interviewing, transportation services, or case management services.
The finding: This report reviews the results of a study of a sample of patients from two orthopedic and one neurosurgical clinic at an academic medical center. A convenience sample of patients attending follow-up visits for surgical procedures were approached to participate by completing questionnaires designed to measure pain severity, depression, and anxiety as well as levels of non-medical use of prescription opioids. The primary conclusion of the study confirmed the author’s hypothesis that high levels of depression were associated with greater misuse of opioids. Analysis also revealed that absence of depression was somewhat protective against non-medical use of pain relievers. The findings held true across varying levels of pain severity.
Strengths and weaknesses: 86% of patients approached agreed to participate in completion of the study instruments. Comparison of the three sampling sites showed no significant differences on several demographic variables.
This convenience sample included patients in specialty surgical clinics. The patient population sampled had a much higher level of non-medical use of opioids than previously reported among patients with chronic pain limiting the generalizability of the findings.
Relevance: This study adds to the evidence suggesting that the presence of depression is an important part of the experience of chronic pain. Consultation psychiatrists frequently encounter such patients in both inpatient and outpatient settings. The authors suggest that this data confirms the recommendation in screening for depressive disorders among patients with chronic pain. Effective treatment of depressive disorders may decrease the risk for misuse and addictive use of opioids leading to decreased morbidity and mortality among patients with chronic painful surgical conditions.