NASS member Tom Mayer, MD, and colleagues studied 1,200 patients who successfully completed an intensive functional rehabilitation program. Although most were using substantial amounts of opioids when they entered the program, all patients had tapered off the drugs by graduation. One year later, however, 15% were opioid-dependent, and that nearly doubled the risk that a patient would be out of work, and doubled the likelihood that a patient had engaged in excessive healthcare-seeking behavior, apparently to find a physician willing to provide opioids.
There is considerable debate in the medical community about the role of opioids in the treatment of chronic, nonmalignant pain. The new report suggests that in certain individuals opioids may cause harm in unexpected ways.
"Giving prescription opioids to patients with chronic disabling back pain is fraught with risk," said Mayer, of the PRIDE Productive Rehabilitation Institute in Dallas, Texas.
The researchers used a structured clinicial interview based on formal DSM-IV criteria to evaluate patients for opioid dependence before enrollment in the rehabilitation program. (For details of the DSM-IV criteria, see below.) The patients retained severe functional limitations.
Those who became opioid dependent one year after completing the program were burdened by substantial psychosocial and medical problems. Typically they had been disabled a year longer than their nonopioid-dependent counterparts (29 vs. 17 months). They were also 2.5 times more likely to have had prior surgery, 2.6 times more likely to have an antisocial or borderline personality disorder, about twice as likely to have had a pre-injury substance use disorder, and 1.7 times more likely to have a major depressive or anxiety disorder.
Even after controlling for these factors, the researchers found that opioid dependence was an independent risk factor for poorer treatment outcomes. Physicians who treat patients with chronic disabling back pain "must be cautious in prescribing chronic opioid medication, and be alert to the de-motivating effect such medication can have," advise Mayer and colleagues.
Despite their disability and functional limitations, "Patients found doctors who were willing to give them the opioids and, more importantly, keep them on opioids," noted Mayer. "Prescription for benign conditions is probably excessive."