A recent meta-analysis of 148 studies suggests that 9.3 percent of patients prescribed opioids for chronic pain develop “dependence” or “opioid use disorder” (D&OUD). The study, conducted by Kyla Thomas and six other researchers at Bristol Medical School in England, also found prevalence rates for “signs and symptoms” of D&OUD (29.6 percent), “aberrant behavior” (22 percent), and those considered “at risk” of D&OUD (12.4 percent). The authors conclude that “problematic pharmaceutical opioid use is common in chronic pain patients treated with opioid analgesics, with nearly one in 10 experiencing dependence and opioid use disorder, one in three showing signs and symptoms of dependence and opioid use disorder, and one in five displaying aberrant behavior.”
Thomas et al. believe opioids are overprescribed and suggest that their results support this claim. However, these numbers are less alarming than they appear, and they do not necessarily support the authors’ implied link between medical opioid use and increasing drug-related deaths.
The study, published in the journal Addiction on Wednesday, is the largest meta-analysis on this topic to date. However, Thomas et al. caution that the “high heterogeneity” of results from the underlying studies, most of which (115) were conducted in the United States, means that the findings should be interpreted carefully.
Stefan Kertesz, a pain and addiction specialist at the University of Alabama at Birmingham, views the study as “not bad” but emphasizes the importance of understanding its implications. He points out that most studies in the meta-analysis focus on “prevalence” rather than “new-onset incidence,” which may overestimate the likelihood of new problems arising after opioid prescriptions. Kertesz also raises concerns about the application of diagnostic criteria in the underlying studies, noting inconsistencies in how these criteria were used across different studies.
The studies included in the meta-analysis, which excluded cancer patients and those using opioids for acute pain, defined “D&OUD” in various ways based on different diagnostic criteria. Despite potential limitations, Kertesz acknowledges that the estimate of 9.3 percent of chronic pain patients on opioids fitting a D&OUD label is consistent with other high-quality prevalence studies.
Kertesz further questions whether prevalence estimates from older studies accurately reflect the current situation of more regulated opioid prescribing practices. He notes that actual U.S. opioid prescribing rates have decreased significantly in recent years, suggesting that prevalence estimates based on data from high-prescribing periods may not accurately represent the current landscape.
Thomas et al. cast a wide net in defining “problematic pharmaceutical opioid use,” capturing behaviors that fall short of meeting the criteria for “dependence” or “opioid use disorder.” This approach aligns with their concerns about the use of opioids for chronic pain management.
The authors’ critique of opioid use for chronic non-cancer pain (CNCP), which affects a significant portion of the population, highlights the ongoing challenges in managing this condition. Despite limited evidence of long-term benefits and guidelines advising against opioid use for many pain conditions, opioids continue to be widely prescribed for CNCP, prompting Thomas et al. to advocate for broader measures to address problematic opioid use.
While the calculated rates may seem alarming, they align with previous findings by experts such as Nora Volkow and A. Thomas McLellan, who noted in a 2016 New England Journal of Medicine article that addiction to opioids occurs in only a small percentage of exposed individuals. Rates of misuse, abuse, and addiction-related behaviors may be higher, but the prevalence of diagnosed addiction remains relatively low.
Thomas et al. present their similar numbers as indicative of a problem that “appears to be common,” but this assertion is more a result of spin rather than new information uncovered by the meta-analysis. The issue of “confusion in definition” highlighted by Volkow and McLellan persists as a challenge. For instance, DSM-5 consolidated the labels of “substance dependence” and “substance abuse” into the broader category of “substance use disorder” (SUD), contributing to the difficulty in accurately assessing the severity of the problems identified in Thomas et al.’s findings.
The inclusion of various categories such as “aberrant behavior,” “signs and symptoms,” and “at risk of D&OUD” further complicates the evaluation of the prevalence of problematic opioid use. Definitions like “tolerance” and “withdrawal” may not be suitable for chronic pain patients, leading to discrepancies in the assessment of opioid-related issues. Additionally, the alarm raised by Thomas et al. regarding the widespread prescription of opioids for chronic pain is not entirely supported by scientific evidence or guidelines, as indicated by the low percentage of opioid-related deaths involving prescribed medications.
Furthermore, the portrayal of the opioid epidemic in the US and Canada as primarily involving prescribed opioids is misleading, as data from the CDC show that the majority of opioid-related deaths in 2022 were linked to illicit fentanyl. The focus on prescription opioids as a significant contributor to overdose deaths overlooks the complexities of the issue and may lead to unwarranted concerns about the use of these medications for legitimate pain management. One reason for doctors to exercise caution when prescribing opioids is the rise in opioid-related fatalities. According to Kertesz, the decision to prescribe chronic opioids for pain comes with the risk of inducing dependency, with the hope of therapeutic benefits. He emphasizes the importance of informing patients about the risks of misuse, as there is a non-trivial likelihood of triggering a new addiction or problematic behavior. However, connecting pain treatment to “the increase in opioid-related fatalities,” as suggested by Thomas et al., may lead to an exaggeration of the risks involved. This can create a different kind of danger for patients, as seen in the experiences of individuals nationwide over the past decade.
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