Could Higher Doses of Opioids be Detrimental to Patients?

Patients on higher doses of opioids tend to have worse pain, worse function, and higher healthcare utilization when compared with patients on lower doses of opioids, according to a study designed to examine the relationships between prescription opioid dose and self-reported pain intensity, function, quality of life, and mental health. Results from this study were recently published in the Journal of Pain.¹

In this cross-sectional study, Benjamin Morasco, PhD, and colleagues used administrative databases from Kaiser Permanente Northwest and the VA Portland Health Care System, Oregon, to identify patients with documentation of a stable dose of at least 90 consecutive days of opioid therapy and one or more musculoskeletal pain diagnoses. Patients with pain-related litigation or disability claims, were younger than 18 years of age, had cancer, had participated in opioid substitution programs, lacked telephone access, or had received opioids at 120 mg Morphine Equivalent Dose (MED) or more, were excluded from the study. Patients included in the study (n=517) provided demographic information and filled out various standardized self-reporting instruments.

Results showed that higher doses of opioids were associated with greater pain intensity and disability, poorer physical functioning, lower self-efficacy, and more fear-avoidance beliefs about physical activity, higher rates of past-year depressive disorder diagnoses, and more healthcare utilization.

In an interview with Clinical Pain Advisor, Joanna Starrels, MD, attending physician in the division of internal medicine at Montefiore Health System, New York, stated that the results of this research highlight the fact that pain management specialists need to be cautious about escalating opioid doses, and suggest that clinicians should not expect improvement in pain, function, or healthcare utilization as a result of higher doses. “However, and this is very important, this study compared individuals who were taking different doses at one point in time. It did not examine what happens when the opioid dose for an individual is increased. This will require a longitudinal study,” she added.

Summary and Clinical Applicability

“Pain specialists should be aware of these findings, but they are not sufficient to trigger a change in practice because of potential confounding in a cross-sectional study,” stated Dr Starrels. “That is, patients with the most severe pain, high functional limitations, poor self-efficacy, and high healthcare utilization are likely to be the ones who end up treated with higher doses of opioids, rather than, or in addition to, opioids causing these outcomes. The results should not be misinterpreted as suggesting that increasing the dose worsens pain or function, or increases healthcare utilization. There is too much potential for confounding in this cross-sectional study to reach that conclusion.”

Disclosures

Study co-investigators, Drs Yarborough, Perrin, and Green have received grant support from Purdue Pharma LP, and the Industry PMR Consortium. No other author reports having any potential conflict of interest with this study.

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Reference

1. Morasco BJ, Yarborough BJ, Smith NX, et al. Higher prescription opioid dose is associated with worse patient-reported pain outcomes and more health care utilization [published online December 18, 2017]. J Pain. doi:10.1016/j.jpain.2016.12.004.