Associations between multiple medication use and medication-related problems among people with chronic non-cancer pain who are prescribed opioids

Chronic non-cancer pain (CNCP) affects one in five people in Australia. Guidelines for CNCP treatment usually recommend paracetamol followed by opioids, NSAIDs, antidepressants or antiepileptics depending on the type of CNCP. However, many people do not experience adequate analgesia from a single medication. Consequently, many people use multiple medications which increases the potential for medication-related problems (MRPs). MRPs with opioids have been documented. However, there has been limited research assessing MRPs with multiple medication use. This dissertation investigated MRPs using an Australian cohort of people with CNCP prescribed opioids. Medication use was quantified using a self-report, seven-day diary. The dissertation aimed to: 1) describe medication use; 2) assess whether multiple medication use is associated with overdose and adverse effects; 3) assess the correlates of paracetamol use above recommended maximum daily doses; 4) assess whether the use of multiple sedative medications are associated with sleep problems and 5) assess whether different types of medication use are associated with pain severity and functioning. This dissertation had five major findings. Firstly, the majority of people used paracetamol in addition to opioids as well as an antidepressant, benzodiazepine or antiepileptic. Secondly, multiple medication use was associated with a higher number of adverse effects but not overdose. Thirdly, paracetamol use above recommended maximum daily doses was associated with higher opioid doses and using paracetamol/opioid combination products. Fourthly, multiple sedative medication use was associated with greater sleep problems with the exception of people with comorbid mental disorders, who tended to have less sleep disturbance. Lastly, NSAID and high dose opioid use were associated with higher pain severity and interference with functioning. The dissertation reported that multiple medication use is the norm and not the exception, and that the majority of people were experiencing at least one adverse effect that impacted daily functioning. In addition, higher medication use was associated with a greater number of adverse effects and more severe sleep problems. Moreover, despite the use of multiple medications, people were likely to remain in pain and have considerable deficits in function. This dissertation highlights the need for GP training and support in identifying and addressing MRPs

Diversion of prescribed opioids by people living with chronic pain: Results from an Australian community sample

Introduction and Aims There has been an increase in prescription of opioids for chronic non‐cancer pain, and concern exists over possible diversion of prescription opioids to the illicit marketplace. Recent media coverage suggests that elderly patients sell their prescribed opioids for additional income. This study investigated the extent to which an Australian community sample of chronic pain patients prescribed opioids reported supplying their prescribed opioids to others. Design and Methods Participants living with chronic non‐cancer pain and prescribed opioids for their pain (n = 952) were recruited across Australia via advertisements at pharmacies. A telephone interview included questions about their pain condition and opioid medication. Results Participants had been living with pain for a mean of 14.2 years; most common conditions included chronic back/neck problems and arthritis/rheumatism. Around half (43%) were currently prescribed one opioid, and 55% had been prescribed 2-5 opioids; the most common was oxycodone. Forty‐two participants (4%) reported ever supplying prescribed opioids to another person; one participant reported receiving payment. Participants who supplied opioids to others were younger (odds ratio 0.97, 95% confidence interval 0.95-0.99) and engaged in a greater number of aberrant behaviours relating to their opioid medication (odds ratio 1.77, 95% confidence interval 1.45-2.17), including tampering with doses, taking opioids by alternative routes, seeing doctors to obtain extra opioids and refilling prescriptions early. Discussion and Conclusion Few people with chronic non‐cancer pain divert their opioids to others. Media reports of elderly patients selling their opioids to supplement their income may be reflective of exceptional cases. Future studies may investigate the extent to which other patient groups divert prescription opioids to the illicit marketplace

Comparing opioids: a guide to estimating oral morphine equivalents (OME) in research.

The growing research into pharmaceutical opioid use has led to a need to develop clear ways to represent and compare opioid use. One way is through the application of oral morphine equivalents (OMEs). This technical report aids researchers to convert opioids into OMEs

Children in social research: do higher payments encourage participation in riskier studies?

The MESSI (Managing Ethical Studies on Sensitive Issues) study used hypothetical scenarios, presented via a brief online survey, to explore whether payment amounts influenced Australian children and young people to participate in social research of different sensitivity. They were more likely to participate in the lower sensitivity study than in the higher at all payment levels (A$200 prize draw, no payment,$30, or $100). Offering payments to children and young people increased the likelihood that they would agree to participate in the studies and, in general, the higher the payments, the higher the likelihood of their participating. No evidence of undue influence was detected: payments can be used to increase the participation of children and young people in research without concerns of undue influence on their behavior in the face of relatively risky research. When considering the level of payment, however, the overriding consideration should be the level of risk to the children and young people

The use of paracetamol (acetaminophen) among a community sample of people with chronic non‐cancer pain prescribed opioids

Background The regular use of simple analgesics in addition to opioids such as paracetamol (or acetaminophen) is recommended for persistent pain to enhance analgesia. Few studies have examined the frequency and doses of paracetamol among people with chronic non‐cancer pain including use above the recommended maximum daily dose. Aims To assess (i) the prevalence of paracetamol use among people with chronic non‐cancer pain prescribed opioids, (ii) assess the prevalence of paracetamol use above the recommended maximum daily dose and (iii) assess correlates of people who used paracetamol above the recommended maximum daily dose including: age, gender, income, education, pain severity and interference, use of paracetamol/opioid combination analgesics, total opioid dose, depression, anxiety, pain self‐efficacy or comorbid substance use, among people prescribed opioids for chronic non‐cancer pain. Methods This study draws on baseline data collected for the Pain and Opioids IN Treatment (POINT) study and utilises data from 962 interviews and medication diaries. The POINT study is national prospective cohort of people with chronic non‐cancer pain prescribed opioids. Participants were recruited from randomly selected pharmacies across Australia. Results Sixty‐three per cent of the participants had used paracetamol in the past week (95% CI = 59.7–65.8). Among the paracetamol users 22% (95% CI = 19.3–24.6) had used paracetamol/opioid combination analgesics and 4.8% (95% CI = 3.6–6.3) had used paracetamol above the recommended maximum daily dose (i.e. \u3e 4000 mg/day). Following binomial logistic regression (χ2 = 25.98, df = 10, p = 0.004), people who had taken above the recommended maximum daily dose were less likely to have low income (AOR = 0.52, 95% CI = 0.27–0.99), more likely to use paracetamol/opioid combination analgesics (AOR = 2.01, 95% CI = 1.02–3.98) and more likely to take a higher opioid dose (AOR = 1.00, 95% CI = 1.00–1.01). Conclusion The majority of people with chronic non‐cancer pain prescribed opioids report using paracetamol appropriately. High income, use of paracetamol/opioid combination analgesics and higher opioid dose were independently associated with paracetamol use above the recommended maximum daily dose

Benzodiazepine use among chronic pain patients prescribed opioids: associations with pain, physical and mental health, and health service utilization

ObjectiveBenzodiazepines (BZDs) are commonly used by chronic pain patients, despite limited evidence of any long-term benefits and concerns regarding adverse events and drug interactions, particularly in older patients. This article aims to: describe patterns of BZDs use; the demographic, physical, and mental health correlates of BZD use; and examine if negative health outcomes are associated with BZD use after controlling for confounders

Cohort protocol paper:The Pain and Opioids In Treatment (POINT) study

Background: Internationally, there is concern about the increased prescribing of pharmaceutical opioids for chronic non-cancer pain (CNCP). In part, this is related to limited knowledge about the long-term benefits and outcomes of opioid use for CNCP. There has also been increased injection of some pharmaceutical opioids by people who inject drugs, and for some patients, the development of problematic and/or dependent use. To date, much of the research on the use of pharmaceutical opioids among people with CNCP, have been clinical trials that have excluded patients with complex needs, and have been of limited duration (i.e. fewer than 12 weeks). The Pain and Opioids In Treatment (POINT) study is unique study that aims to: 1) examine patterns of opioid use in a cohort of patients prescribed opioids for CNCP; 2) examine demographic and clinical predictors of adverse events, including opioid abuse or dependence, medication diversion, other drug use, and overdose; and 3) identify factors predicting poor pain relief and other outcomes

Benzodiazepine use amongst chronic pain patients prescribed opioids: associations with pain, physical and mental health and health service utilization

Objective: Benzodiazepines are commonly used by chronic pain patients, despite limited evidence of any long term benefits and concerns regarding adverse events and drug interactions, particularly in older patients. This paper aims to: describe patterns of benzodiazepines use; the demographic, physical and mental health correlates of benzodiazepine use; and examine if negative health outcomes are associated with benzodiazepine use after controlling for confounders.Subjects: A national sample of 1220 chronic non cancer pain (CNCP) patients prescribed long-term opioids.Methods: We report on baseline data from a prospective cohort study comparing four groups based on their current benzodiazepine use patterns. General demographics, pain, mental and physical co-morbidity, and health service utilisation were examined. Results: One-third (n = 398, 33%) of participants reported BZD use in the past month, and 17% (n = 212) reported daily BZD use. BZD use was associated with: 1) greater pain severity, pain interference with life and lower feelings of self-efficacy with respect to their pain; 2) being prescribed âhigher-riskâ (> 200mg oral morphine equivalent) doses of opioids; 3) using antidepressant and/or antipsychotic medications; 4) substance use (including more illicit and injection drug use, alcohol use disorder and daily nicotine use) and 5) greater mental health co-morbidity. After controlling for differences in demographic characteristics, physical and mental health, substance use and opioid dose, BZD use was independently associated with greater past-month use of emergency health care such as ambulance or accident and emergency services. Conclusions: CNCP patients using BZDs daily represent a high-risk group with multiple comorbid mental health conditions, and higher rates of emergency health care use. The high prevalence of BZD use is inconsistent with guidelines for the management of CNCP or chronic mental health conditions