With all the concern recently about misuse of prescription opioids in pain patients, this study offers additional information about risk factor evaluation when considering one's approach. The study also adds further to the large body of knowledge concerning different patterns and reasons for using intoxicants between men and women. There's an old adage about this: Men go to the bar, women go to the doctor.
Risk Factors for Opioid Misuse Among Pain Patients Differ by Sex
May 4, 2010 — A new study published in the April issue of theJournal of Pain reveals men and women with chronic pain who misuse opioid medications — including taking these medications at a dose frequency unsanctioned by treating physicians — do so for different reasons.
Women with chronic pain are more likely to misuse opioids because of emotional issues and psychological distress, whereas men who do the same are more likely to report social and behavioral problems, such as associating with friends who use drugs or alcohol, having a bad temper, or having legal difficulties.
"We found from our analysis that women tend to misuse pain medications for mood problems — when they are anxious or depressed — while men misuse them for euphoric or behavioral reasons that are less associated with mood," lead researcher Robert Jamison, PhD, associate professor in the Department of Anesthesia and Psychiatry at Brigham and Women's Hospital, Boston, Massachusetts, told Medscape Psychiatry.
"So these may be important markers for clinicians that can help identify patients who might have trouble with opioid misuse — and it's important to provide these patients with interventions that might be helpful. For women, the characteristics to look for are whether they are depressed or anxious, and for men, past history would be a marker," Dr. Jamison added.
Pain Severity Similar Between Sexes
In the study, 662 patients with chronic noncancer pain who take opioid medications were recruited from medical centers in 5 states and surveyed with pain assessment questionnaires to examine rates and characteristics of problematic opioid use.
The investigators also examined predictive associations between risk factors for abuse and misuse by patients of their prescription medications. At baseline, patients completed a series of questionnaires, including the revised Screener and Opioid Assessment for Pain Patients and the Brief Pain Inventory, a multidimensional pain questionnaire.
After 5 months, they underwent a structured prescription drug use interview with a clinician, the Prescription Drug Use Questionnaire (PDUQ), and their clinicians completed the Physician Opioid Therapy Questionnaire (POTQ) — an 11-item scale used to assess misuse of opioids.
Patients were asked to undergo a urine toxicology screen and were classified by the Aberrant Drug Behavior Index (ADBI) concerning their opioid medication abuse based on a combination of self-report in the PDUQ, the physician-reported POTQ, and urine toxicology results. Because some patients had missing data on 2 or more variables, they were excluded from the final analyses — leaving a total of 455 patients or 74.2% of those who began the study.
Results indicated that there was little difference between men and women in the severity of their pain or their rate of opioid misuse — the ADBI indicated prescription opioid misuse in 31% of males and 36.7% of females in the final analysis, a difference that was not statistically significant.
Yet results from both patient self-reports and clinician evaluations indicated that women who misused their opioid medications were more likely to report a history of physical and sexual abuse, psychiatric diagnoses, or a history of psychiatric illness and family concerns. Counting pain pills was also predictive of opioid misuse among women.
High Rate of Misuse
By contrast, men who misused opioids were more likely to have close friends who used alcohol or drugs, to have a bad temper, to have legal problems, and to have a history of drug and/or alcohol abuse.
Other research by Dr. Jamison and colleagues, based on satisfaction questionnaires of chronic pain patients who misuse prescription medications, have suggested that women may benefit most from clinical interventions such as antidepressant and individual and group cognitive or behavioral therapy that addresses the psychological risk factors for misuse. Education about avoiding the use of opioids as a way of dealing with anxiety or sleep disturbances due to stress may also be helpful, he said.
Yet, men may benefit more from monthly urine screens, pill counts, and compliance monitoring to reduce opioid misuse, as well as behavioral consequences of misuse such as more frequent dosing and clinic visits, he added.
Certainly, the study calls attention to the problem of opioid misuse among chronic pain patients. And although only a small percentage of these patients actually develop dependence or addiction, clinicians at the pain management center of Brigham and Women's Hospital have found through urine screens that up to 42% of pain patients misuse their medications, he said.
"These folks have terrible pain as well as clinical history issues that make them very difficult to manage. It really is very challenging to treat these patients, and the idea of the study was to help piece together the puzzle of how to best help them," he said.
"Opioid misuse is a growing concern for chronic pain patients," commented Larissa Mooney, MD, assistant professor of psychiatry at the University of California–Los Angeles. "The vast majority of patients with chronic pain don't develop a problem, but there are vulnerable subgroups," she said.
"This study adds to an emerging literature on gender differences in addiction — how men and women are different in terms of etiology, consequences, and the mechanisms of drug misuse," she said.
Dr. Mooney cautioned that the study's conclusions may not be applicable to all patients with chronic pain. Many of the patients in the study were older (older than 50 years), had long-standing chronic pain, and were often disabled by their pain conditions. "It would be interesting to see if these findings apply to younger patients with less chronic pain history," she said.
She noted that counseling, as well as careful monitoring, for pain patients who misuse prescription opioids or have risk factors for prescription abuse may be helpful for both men and women, she said.
"I don't think that these treatment recommendations are applicable only to men or women," she added.
The study was supported by grants from the National Institute on Drug Abuse and the Arthritis Foundation. Dr. Jamison reported research support from Inflexxion Inc. Dr. Mooney has disclosed no relevant financial relationships.
J Pain. 2010;11:312-320