Depression, Chronic Pain and Taming the Opioid Epidemic
Large national surveys come up with amazing findings, but it is often difficult to decide what they mean and how they should influence policy.
A paper recently published in the Journal of the American Board of Family Medicine analyzed data on patterns of national opioid prescription in 51,000 patients during the period 2011-2013.
The startling and alarming finding is that people with symptoms of anxiety and depression seem to be receiving a very disproportionate number of prescriptions – more than half, despite the fact that they may constitute less than 10% of the population. This suggests that they are especially vulnerable to becoming dependent on prescription opioids and should only receive them as a last resort.
I agree with this conclusion, but must admit that the survey opens as many questions as it answers. Let’s first discuss why surveys are in general so hard to interpret and then why I think this particular one provides a very clear and urgent call to action.
It is so enormously expensive to gather data on large numbers of patients that lots of shortcuts are always required.
The data must be already available or easily obtainable – the more patients you include in the study, the less likely you are to know about each patient and the less accurate the information.
The data you collect are likely to be superficial. In this study, determinations of the presence of depression and anxiety were obtained by self-report, not by much more accurate clinical interview. Many, or perhaps most, of the people reporting depression or anxiety would not meet the DSM-5 severity and duration criteria for a specific psychiatric disorder, were their symptoms evaluated rigorously via systematic clinical interview.
And correlation does not tell you very much about causality. Several different scenarios are probable contributors to the findings:
- People with pain are more likely to have depression and anxiety secondary to the pain, not causative of the prescription.
- People with depression and anxiety may have pain as part of their psychiatric presentation or may react more strongly to pain caused by independent physical or medical problems.
- People who take opioids may be more likely to self-report pain, depression, and anxiety – either because of underlying personality features, or because of conscious drug seeking, or both.
- Doctors may be more likely to feel that opioids are necessary when their pain patients present with co-occurring depression or anxiety.
- Depressed and anxious patients may be more insistent in their demands for relief and press for opioid prescriptions.
- Opioids reduce sadness and anxiety in the short term and may be overused among depressed/anxious patients for this reason.
Though extensive, the survey data are too superficial to determine how much the presence of psychiatric symptoms is more a driver of opioid use or more a secondary phenomenon.
The elephant in the room is our unprecedented epidemic of opioid overuse, addiction, overdose, and deaths.
Opioid prescriptions have quadrupled in fewer than twenty years and more than 200,000 people have already died of overdoses. The primary prescription opioid epidemic has also spawned an almost equally deadly secondary epidemic of heroin, fentanyl, and carfentanil addiction.
There is no one cause for this epidemic and there will be no one solution. Previous Pro Talk installments have proposed a number of urgent responses needed to tame the epidemic and save patients from the hazards of addiction and death.
Patients with pain who have co-occurring depression or anxiety are the most likely to want opioid pill pain relief, and to appear to need it, but they are also most likely to be harmed by it. This is true whether the depression or anxiety is secondary to the pain, primary, or independently coexisting.-Allen Frances
However imperfect this survey, and however difficult to interpret its results, a clear counter-intuitive clinical pearl stands out. Patients with pain who have co-occurring depression or anxiety are the most likely to want opioid pill pain relief, and to appear to need it, but they are also most likely to be harmed by it. This is true whether the depression or anxiety is secondary to the pain, primary, or independently coexisting.
A compelling conclusion applies across scenarios – opioids should be used especially cautiously in all depressed and anxious patients. Prescription opioids should be started only under two very restrictive conditions. They are completely appropriate as an essential component of palliative care for those with terminal illnesses. They are helpful, but somewhat risky, very short term for acute and surgical pain. They are especially dangerous when chronic pain coexists with depression and anxiety.
In previous articles, we have discussed the complexity of helping those who are already dependent on opioids.
Pain management for chronic pain, especially when accompanied by depression or anxiety, must focus on the alternative techniques we used before Pharma seduced us into the opioid epidemic – CBT, physical therapy, exercise, massage, acupuncture, non-addicting meds, acceptance.
Zero pain is an unrealistic goal. Prescription opioids have among the worst risk/benefit ratios of any medicines known to man.
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