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By Rahul Gupta, MD, MPH, FACP
Clinical Assistant Professor, West Virginia University School of Medicine, Charleston, WV
Dr. Gupta reports no financial relationships relevant to this field of study.
Synopsis: In a study of veterans with no recent history of depression or opioid use, the risk of developing depression increased as the duration of opioid analgesic exposure increased.
Source: Scherrer JF, et al. Prescription opioid analgesics increase the risk of depression. J Gen Intern Med 2014;29: 491-499.
In a clinical setting, patient visits for complaint of pain are exceedingly common. According to a report from the Institute of Medicine, chronic pain affects about 100 million American adults, more than those affected by heart disease, cancer, and diabetes combined.1 Interestingly, however, this number does not include patients with acute pain or children with pain. Pain also costs our nation up to $635 billion each year in medical treatment and lost productivity. Thus, chronic pain is not only a severe and frequent health care problem in terms of patient suffering and disability, but also has significant economic implications for society. More than half of chronic pain is related to musculoskeletal etiology. Prescriptions for opioid analgesics to manage moderate-to-severe chronic non-cancer pain have increased markedly over the last decade. An unintentional consequence of rising prescription opioid utilization has been the parallel increase in misuse, abuse, and overdose, which are serious risks associated with all opioid analgesics. Better opioid prescribing practices depend on fully understanding the risks and benefits of treatment. Evidence suggests that not only is persistent pain a commonly reported health complaint among primary care patients but it is consistently associated with psychological illnesses such as anxiety and depression.2 Whether such psychological symptoms are a cause or a consequence of opioid use is less clear. Previous research has suggested that patients with depression at baseline are more likely than non-depressed patients to initiate and continue opioid use.3 However, whether depression can develop as a consequence of routine opioid analgesic exposure has not yet been clearly studied.
In their research, Scherrer et al conducted a retrospective cohort study analyzing the medical record data of 49,770 veterans who had no history of opioid use or depression within the past 24 months, and were subsequently prescribed opioids. At baseline, the mean age of patients was 54.6 years and most were males. Of the 49,770 patients who were prescribed an opioid analgesic, 91% had a prescription for < 90 days, 4% for 90-180 days, and 5% for > 180 days. Hydrocodone accounted for 41.2% of incident prescriptions followed by codeine (33%), oxycodone (23.6%), morphine (0.9%), fentanyl (0.6%), meperidine (0.4%), hydromorphone (0.2%), and pentazocine (0.04%).
The researchers found that patients who started and remained on opioids for ≥ 180 days were at a 53% increased risk (hazard ratio [HR] = 1.53; 95% confidence interval [CI], 1.33-1.76 for > 180 days) of developing a new episode of depression, and those using opioids for 90-180 days were at a 25% increased risk (HR = 1.25; 95% CI, 1.06-1.47 for 90-180 days) compared to patients who never took opioids for longer than 1-89 days.
As a complex and multidimensional public health problem, it is vital to better understand the full scope of the issue of pain and its management. On one hand, there have been significant increases in opioid prescription use, which correlates with abuse and misuse, resulting in drug overdose becoming a leading cause of accidental death in the United States. On the other hand, is the issue of potential under-treatment of pain. The American Academy of Pain Medicine estimates that more than 4 of 10 patients with moderate-to-severe pain do not get adequate relief from their analgesics, while nearly 1 of 4 patients change health care professionals ≥ 3 times because of perceptions of suboptimal pain care.4 The current study finds that opioid use for more than 90 days significantly increases the risk of developing depression. Often felt elation is typically a transient effect of opioids that may occur even in the face of ongoing depression. Since this study demonstrates that the longer one is exposed to opioids the greater their risk is of developing depression, primary care providers should increasingly aim at tailoring pain care to each person’s experience, and self-management of pain should be promoted. The best strategy may be to first try to completely avoid opioid therapy, and if unavoidable, limit such therapy to 90 days or less. Finally, if there is no alternative to including long-term prescription opioids as part of a comprehensive pain management program, it may be worthwhile to screen the patient at baseline and then periodically for depressive disorder as well as keep the daily dose of opioids as low as possible.