Nuance needed: opioids and harm

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Overreliance on opioid dose as a predictor of problems needs to be addressed – and pharmacists may need help assessing other predictors

Problematic opioid behaviours in people with chronic pain, including opioid dependence, are associated with patient risk factors like younger age, substance dependence and mental health histories rather than simply higher opioid doses, says a new report.

In one of the largest and most detailed studies to date, researchers from the National Drug and Alcohol Research Centre (NDARC), UNSW Sydney, have analysed findings from a five-year cohort of 1,514 people who have been prescribed opioids for chronic non-cancer pain.

Lead author Dr Gabrielle Campbell, Senior Research Fellow at the University of the Sunshine Coast and adjunct at NDARC said: “This report suggests that risk for problematic opioid outcomes is related to a combination of patient characteristics and pre-existing factors rather than opioid dose alone.”

The report found that at cohort entry, participants had been prescribed an opioid for a median of four years.

At the five-year follow up, 85% remained on opioid medication, with 56% taking more than 50mg OME/per day.

Approximately 9% of the cohort met criteria for opioid dependence.

“Long-term opioid use for people living with chronic non-cancer pain is common. This has traditionally been associated with concerns of increased rates of adverse harms related to opioid use, particularly dependence and overdose,” said Dr Campbell.

The report comes in response to concerns that patients with chronic non-cancer pain have been exposed to abrupt and forced tapering and cessation of opioids simply for being on a high dose and concern that a higher dose is associated with problematic opioid behaviours.

“It is possible that this emphasis on dose comes from the ability to easily measure and respond to dose thresholds, compared with the relative complexity and time considerations of assessing other clinical factors that substantially contribute to opioid-related risk,” said Dr Campbell.

“There is a need for more nuanced assessment of risks and benefits experienced by patients, and an avoidance of overreliance on opioid dose as a predictor of these problems.”

Pharmacist and deputy director of the Monash Addiction Research Centre Suzanne Nielsen, who is a co-author of the report, told the AJP that the findings are particularly timely given recent changes to how opioids are accessed.

“We know that prescription monitoring and opioid policies have tended to focus on specific dose thresholds when identifying risk,” she said.

“This study highlights the importance of considering other patient factors such as substance use disorders and mental health.

“For pharmacists, information about dose might be more easily accessible, but there is a need to be able to consider other key clinical factors when working with patients who are prescribed opioids for chronic pain, as not all risk is associated with dose.

“There may be a need to support pharmacists in how to assess some of these other clinical aspects when working with patients who are prescribed opioids.

“This is work particularly relevant with the recent PBS changes around opioids,” Dr Nielsen said.

“Patients will need to be reassessed if opioids are being provided long term, and this highlights the need for more nuanced assessments that consider the range of important patient factors identified in this work to inform any risk-benefit assessment and decisions around deprescribing.”

Access the study results here.

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