Aberrant Opioid-related Behavior Research Articles

A Tale of Two “P”s: Palliative Care and Pain Management Approaches to Aberrant Drug and Opioid-Related Behavior in Patients with Life-Limiting Illness (S540)

A Tale of Two “P”s: Palliative Care and Pain Management Approaches to Aberrant Drug and Opioid-Related Behavior in Patients with Life-Limiting Illness (S540)

Lack of Premeditation Predicts Aberrant Behaviors Related to Prescription Opioids in Patients with Chronic Pain: A Cross-Sectional Study

Objective In light of the opioid epidemic, there is a need to identify factors that predict aberrant opioid behaviors including misuse and abuse. Impulsivity has been extensively studied in addiction literature, but not in the context of opioid misuse. Hence, this study aimed to identify which of the impulsivity facets (negative urgency, positive urgency, sensation seeking, lack of perseverance, and lack of premeditation) would predict current aberrant opioid-related behaviors in patients with chronic pain. Methods Data were collected through an online survey from patients with chronic pain who visited a tertiary pain clinic. Patients were predominately female (74%), middle aged (M = 55 years), and White/Caucasian (84%). Upon consent, they completed a series of surveys including UPPS-P Impulsive Behavior Scale, the Current Opioid misuse Measure, Pain Catastrophizing Scale, PROMIS-anxiety, depression, and physical function, and a 0-10 numerical pain rating scale. Ordinal regression analyses were conducted to test study hypotheses. Results Contrary to expectations, only lack of premeditation predicted higher odds of aberrant opioid-related behaviors in the past 30 days, after controlling for known covariates, and explained 26% of variance. Interestingly, lack of premeditation together with pain catastrophizing as a covariate explained 56% of the variance in aberrant opioid-related behaviors. Discussion The current study is the first to identify a potential role of lack of premeditation as an impulsivity facet predicting aberrant opioid-related behaviors among patients with chronic pain.

Translation, Cultural Adaptation and Validation of the Current Opioid Misuse Measure for European Portuguese.

Current practice guidelines recommend using Current Opioid Misuse Measure to screen aberrant opioid-related behaviorsin chronic pain patients. Our aims were to translate, adapt and validate it to be used in Portuguese chronic pain patients. Translation and cultural adaptation process followed guidelines and a model of principles for good practice.Adult chronic pain patients on opioid therapy, from one major hospital in Portugal, were invited to complete the translated version.Descriptive statistics, Cronbach's alpha, inter-item, item-total and intra-class correlation coefficients and principal components analysiswere applied. Translation process was performed as planned and the validation sample was composed by 98 patients (median age = 62.5years). Regarding internal consistency, a global Cronbach's alpha of 0.778 was obtained and item-total correlations of all items wereabove 0.20 with four exceptions. An intra-class correlation coefficient of 0.90 was found between test and retest. Regarding validity, all17 items presented a content validity index above 0.80. Six principal components were extracted and explained 66.3% of the variance. The Portuguese version of Current Opioid Misuse Measure was properly translated, adapted and validated; showing goodquality in terms of reliability and validity. This is the first instrument to screen aberrant opioid-related behaviors in Portuguese chronicpain patients. Consequently, it will aid and promote the identification of opioid misuse in these patients. The implementation of this questionnaire may reduce the incidence and morbimortality of opioid misuse among chronicpain patients and should improve chronic pain treatment in Portugal.

Validity of the screener and opioid assessment for patients with pain-revised (SOAPP-R) in patients with cancer

Objective: To determine the utility of the screener and opioid assessment for patients with pain-revised (SOAPP-R) for patients with cancer-related pain. Design: The authors performed a retrospective analysis of cancer patients screened with the SOAPP-R. Opiate abuse was determined using a combination of urine drug screens and analysis of patients’ electronic medical records.Setting/Patients: Patients who were seen at a palliative care clinic presenting with pain or needing an opioid prescription at an academic medical center with any type of cancer were screened using the SOAPP-R (N = 69).Outcome measures: Aberrant opioid-related behavior was determined using a combination of provider notes and urine drug screens.Results: A positive SOAPP-R score (≥18) was observed in 27 participants (39.1 percent). The sensitivity and specificity of the SOAPP-R in the study population was 0.75 and 0.80, respectively.Conclusions: The SOAPP-R, in its current form, may have value in screening patients with cancer for substance abuse. Incorporation of the screening tool in palliative and oncology settings may help reduce opioid abuse in cancer patients.

Validity of the screener and opioid assessment for patients with pain-revised (SOAPP-R) in patients with cancer.

To determine the utility of the screener and opioid assessment for patients with pain-revised (SOAPP-R) for patients with cancer-related pain. The authors performed a retrospective analysis of cancer patients screened with the SOAPP-R. Opiate abuse was determined using a combination of urine drug screens and analysis of patients' electronic medical records. Patients who were seen at a palliative care clinic presenting with pain or needing an opioid prescription at an academic medical center with any type of cancer were screened using the SOAPP-R (N = 69). Aberrant opioid-related behavior was determined using a combination of provider notes and urine drug screens. A positive SOAPP-R score (⩾18) was observed in 27 participants (39.1 percent). The sensitivity and specificity of the SOAPP-R in the study population was 0.75 and 0.80, respectively. The SOAPP-R, in its current form, may have value in screening patients with cancer for substance abuse. Incorporation of the screening tool in palliative and oncology settings may help reduce opioid abuse in cancer patients.

Setting Expectations, Following Orders, Safety, and Standardization: Clinicians’ Strategies to Guide Difficult Conversations About Opioid Prescribing

Evidence has continued to accumulate regarding the potential risks of treating chronic pain with long-term opioid therapy (LTOT). Clinical practice guidelines now encourage clinicians to implement practices designed to reduce opioid-related risks. Yet how clinicians implement these guidelines within the context of the patient encounter has received little attention. This secondary analysis aimed to identify and describe clinicians' strategies for managing prescription opioid misuse and aberrant behaviors among patients prescribed LTOT for chronic pain. Individual interviews guided by a semi-structured interview protocol probed: (1) methods clinicians utilize to reduce prescription opioid misuse and address aberrant opioid-related behaviors; (2) how clinicians respond to misuse; and (3) resources and constraints faced in managing and treating misuse among their patients. Interviews were conducted with 24 physicians and nurse practitioners, representing 22 Veterans Health Administration (VA) facilities across the USA, who had one or more patients in their clinical panels who were prescribed LTOT for the treatment of chronic non-cancer pain. Qualitative content analysis was the analytic approach utilized. A codebook was developed iteratively following group coding and discussion. All transcripts were coded with the finalized codebook. Quotes pertaining to key themes were retrieved and, following careful review, sorted into themes, which were then further categorized into sub-themes. Quotes that exemplified key sub-themes were selected for inclusion. We detail the challenges clinicians describe in navigating conversations with patients around prescription opioid misuse, which include patient objection as well as clinician ambivalence. We identify verbal heuristics as one strategy clinicians utilize to structure these difficult conversations, and describe four heuristics: setting expectations, following orders, safety, and standardization. Clinicians frequently use verbal heuristics to routinize and increase the efficiency of care management discussions related to opioid prescribing, redirect responsibility, and defuse the potential emotional charge of the encounter.

Outcomes of a Specialized Interdisciplinary Approach for Cancer Patients with Aberrant Opioid-Related Behavior: A Preliminary Report (S702)

Outcomes of a Specialized Interdisciplinary Approach for Cancer Patients with Aberrant Opioid-Related Behavior: A Preliminary Report (S702)

Development of a Brief Version of the Current Opioid Misuse Measure (COMM): The COMM-9.

The Current Opioid Misuse Measure (COMM) is a commonly used self-report instrument to identify and monitor aberrant opioid-related behavior in chronic pain patients on opioid therapy. However, the length of the COMM may limit its clinical utility. Additionally, this paper-and-pencil screener requires hand scoring, which increases paperwork and staff burden. Therefore, the current study presents development of the "COMM-9," a brief electronically administered form of the COMM. Patients (N = 517) with chronic noncancer pain on opioid therapy completed the COMM. Patients were classified as either being positive or negative for aberrant drug-related behavior based on self-report data from a structured interview, physician-report data, and urine toxicology screen (the Aberrant Drug Behavior Index [ADBI]). COMM items with the strongest classification accuracy were identified using the LASSO method as the selection criterion in conjunction with the leave-one-out cross-validation method as the stop criterion. A sub-set of patients (n=55) completed a second administration of the COMM one week later to evaluate test-retest reliability. Nine items were identified before the selection criterion stopped, and logistic regression was utilized to predict probabilities of positive ADBI from the 9 COMM items using all data and the cross-validation procedure. Receiver operating characteristic curves revealed high levels of classification accuracy that were essentially equivalent to the full COMM. Cut-points were identified to classify patients as having no/low risk, moderate risk, and high risk for aberrant opioid-related behavior. Test-retest reliability of the COMM-9 was comparable to the full 17-item COMM. This study presents the successful development of a brief electronic screener to identify current aberrant opioid-related behavior in chronic pain patients on long-term opioid therapy.

Outcomes of a specialized interdisciplinary approach for cancer patients with aberrant opioid-related behavior: A preliminary report.

212 Background: Data on the development and outcomes of effective interventions to address aberrant opioid-related behavior (AB) in cancer patients is lacking. Our outpatient supportive care clinic developed and implemented a specialized interdisciplinary team approach to manage patients with AB. The purpose of this study was to report clinical outcomes of this novel intervention. Methods: The medical records of 30 consecutive patients with evidence of AB who received the intervention and a random control group of 70 patients without evidence of AB between January 1, 2015 and August 31, 2016 were reviewed. Results: At baseline, pain intensity (p=0.002) and opioid dose (p=0.001) were significantly higher among patients with AB. During the course of the study, the median number of ABs per month significantly decreased from 3 pre-intervention to 0.4 post-intervention (p<0.0001). The median morphine equivalent daily dose decreased from 165mg/day at the first intervention visit to 112mg/day at the last follow up (p=0.018) although pain intensity did not significantly change (p= 0.984). ‘Request for opioid medication refills in the clinic earlier than the expected time’ was the AB with the highest frequency prior to the intervention and the greatest improvement during the study period. Younger age (p<0.0001) and higher ESAS anxiety score (p=0.005) were independent predictors of the presence of AB. Conclusions: The intervention was associated with a reduction in the frequency of AB and opioid utilization among cancer patients receiving chronic opioid therapy. More research is needed to further characterize the clinical effectiveness of this intervention. [Table: see text]

Outcomes of a Specialized Interdisciplinary Approach for Patients with Cancer with Aberrant Opioid-Related Behavior.

Data on the development and outcomes of effective interventions to address aberrant opioid-related behavior (AB) in patients with cancer are lacking. Our outpatient supportive care clinic developed and implemented a specialized interdisciplinary team approach to manage patients with AB. The purpose of this study was to report clinical outcomes of this novel intervention. The medical records of 30 consecutive patients with evidence of AB who received the intervention and a random control group of 70 patients without evidence of AB between January 1, 2015, and August 31, 2016, were reviewed. At baseline, pain intensity (p = .002) and opioid dose (p = .001) were significantly higher among patients with AB. During the course of the study, the median number of ABs per month significantly decreased from three preintervention to 0.4 postintervention (p < .0001). The median morphine equivalent daily dose decreased from 165 mg/day at the first intervention visit to 112 mg/day at the last follow-up (p = .018), although pain intensity did not significantly change (p = .984). "Request for opioid medication refills in the clinic earlier than the expected time" was the AB with the highest frequency prior to the intervention and the greatest improvement during the study period. Younger age (p < .0001) and higher Edmonton Symptom Assessment System anxiety score (p = .005) were independent predictors of the presence of AB. The intervention was associated with a reduction in the frequency of AB and opioid utilization among patients with cancer receiving chronic opioid therapy. More research is needed to further characterize the clinical effectiveness of this intervention. There are currently no well-defined and evidence-based strategies to manage cancer patients on chronic opioid therapy who demonstrate aberrant opioid-related behavior. The findings of this study offer a promising starting point for the creation of a standardized strategy for clinicians and provides valuable information to guide their practice regarding these patients. The study results will also help clinicians to better understand the types and frequencies of the most common aberrant behaviors observed among patients with cancer who are receiving chronic opioid therapy. This will enhance the process of timely patient identification, management, or referral to the appropriate specialist teams.

Development and Validation of an Eight-Item Brief Form of the SOAPP-R (SOAPP-8).

Although the Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R) has become a widely used screener for aberrant opioid-related behavior in adults, the length of the instrument may limit its utility. The purpose of the current study was to develop a short form of the SOAPP-R by retaining as few items as possible while maximizing predictive accuracy. Participants (N = 555), recruited from pain clinics, completed the 24-item SOAPP-R and participated in a five-month follow-up visit to evaluate aberrant drug-related behaviors. Opioid aberrant-related behavior was determined through self-report, physician report, and urine toxicology screen. The optimal subset of SOAPP-R items to predict aberrant opioid-related behavior was identified empirically by employing the LASSO selection method and the leave-one-out cross-validation (LOOCV) method offered in the GLMSELECT procedure in SAS 9.4 in conjunction with content expertise. Eight items were identified before the selection method stopped. The receiver operating characteristic curve generated from the predicted probabilities from the model produced an area under the curve (AUC) value greater than the AUC value produced by the 24-item SOAPP-R total score and yielded a sensitivity of 0.74 and a specificity of 0.66. These results provide strong preliminary support for the SOAPP-8 as a brief screening tool of aberrant opioid-related behavior in chronic pain patients.

Aberrant Opioid Use and Urine Drug Testing in Outpatient Palliative Care.

Aberrant opioid use is a public health issue, which has not been adequately described in the palliative care literature. With the increasing integration of palliative care into oncologic care, palliative care clinicians are seeing patients earlier in the disease trajectory, and therefore, more outpatients with chronic pain requiring chronic opioid therapy. This may have resulted in a concomitant rise in the number of patients with aberrant opioid use. In this article, we report on two patients with aberrant opioid-related behavior seen at our palliative care clinic. A high suspicion of opioid abuse, misuse, or diversion based on certain behavioral cues necessitated the ordering of a urine drug test (UDT). The tests helped the medical team to confirm an already existing pattern of maladaptive opioid use. In both cases, we provided ample opioid education and implemented effective strategies to address their aberrant opioid use. These cases suggest the need for palliative care clinicians to develop strategies to effectively address this issue in our field of medicine. It also highlights the usefulness of UDT in the outpatient palliative care setting.

Impact of an Electronic Pain and Opioid Risk Assessment Program: Are There Improvements in Patient Encounters and Clinic Notes?

A comprehensive electronic self-report assessment, called PainCAS® (Clinical Assessment System), was developed and implemented in three clinics. PainCAS captures demographic information, pain assessment, quality-of-life variables, and contains validated, electronic versions of screeners for risk of aberrant opioid-related behaviors (the SOAPP and COMM). This investigation sought to determine the impact of PainCAS on documentation of pain and opioid risk evaluations. Exploratory hypotheses examined changes in the content of the patient-provider interaction and any impact on outcome. In study 1, chart reviews were conducted between pain patients who completed the electronic program (N = 89) and controls who represented standard of care (N = 120). In study 2, two groups of chronic pain patients (treatment-as-usual Control condition = 75, PainCAS Experimental condition = 72) were interviewed after completing their index clinic visit and completed mailed questionnaires 3 months later. Results revealed significantly more key, pain-relevant chart elements documented in charts of patients who completed the PainCAS than those using a traditional paper questionnaire (Study 1; <0.001). In Study 2, the Experimental group reported more discussion about legal issues, substance use history, and medication safety compared with the Control group (p < 0.05). Satisfaction questionnaire responses supported provider and patient perceived benefit from using PainCAS. However, as expected, no differences were found between conditions on outcome measures of pain, mood, and function. Results indicate that use of the PainCAS electronic pain assessment improves documentation of chart elements in clinic notes and is associated with increased discussion of key, pain-relevant topics during the clinical visit.

Is pain associated with illicit opioid use or aberrant opioid-related behaviors in opioid substitution treatment patients

Aims: The limited literature on pain in opioid treatment samples indicates that current pain is highly prevalent. Understanding the clinical implications of current pain on treatment outcomes is important, particularly in light of ageing opioid treatment cohorts. This study aims to explore correlates of pain, including aberrant behaviors related to prescribed opioid use. Methods: Data on pain, physical health and previous tried pain treatments were collected in methadone or buprenorphine patients (n=141) fromthree treatment services.Measures included basic demographics, the Brief Pain Inventory, measures of general mental and physical health and quality of life questions, pain history and previous treatments tried for pain. Univariate andmultivariate analysis were used to examine correlates of pain. Results: Forty percent of the sample reported current pain. Of those with current pain, 68% reported trying some form of treatment other thanprescribed opioids. Correlates of current painwere depression, anxiety and poorer ratings of health. Current pain was not associated with greater use of illicit opioids (prescribed opioids or heroin) norwith any aberrant opioid related behaviors. Pain levels were comparable amongst methadone and buprenorphine treatment participants. Conclusions: The high prevalence of severe mental health comorbidity amongst opioid dependent people with current pain suggests screening for pain and tailoring of treatment where pain exists is warranted. The lack of association with pain and aberrant behaviors suggests it should not be assumed that those in opioid treatment misuse medications in response to pain. Financial support: Funding for the parent study was provided by Reckitt Benkiser in the form of an united educational grant; the funders had no role in study design; in the collection, analysis and interpretation of data; or in the decision to submit the paper for presentation at CPDD.

Different sensitivity for oxycodone-induced conditioned place preference and sensitization of locomotor activity in adolescent and adult mice

L’infiltrat lymphocytaire bénin, ou maladie de Jessner et Kanof (MJK), est une affection rare et bénigne, de traitement difficile.Cinq patients présentaient une MJK clinique. Dans tous les cas, la biopsie cutanée montrait un infiltrat lymphocytaire dense de toute la hauteur du derme, à disposition périvasculaire et périannexielle ; les examens complémentaires écartaient les diagnostics différentiels possibles. Les patients étaient traités par laser à colorant pulsé 595 nm avec une fluence de 5,5 à 8 J/cm2 et une durée de tir de 0,5 msec, avec une régression en une séance dans trois cas et deux à trois séances dans deux cas.À notre connaissance, un seul cas de traitement de la MJK par laser à colorant pulsé a été publié jusqu’ici. Le laser à colorant pulsé est utilisé dans certaines formes de lupus cutané et de granulome annulaire. La photothermolyse sélective permet l’ablation des capillaires dilatés impliqués dans l’érythème et l’inflammation.Le laser à colorant pulsé 595 nm pourrait être une alternative intéressante, y compris en première intention, pour cette maladie affichante mais sans conséquence générale.Jessner's lymphocytic infiltration of the skin (LIS) is a chronic, benign T-cell infiltrative disorder, usually manifesting as erythematous papules or plaques on the face, neck and back.Five patients presented LIS with numerous skin lesions on the face and back characteristic of this disease. Histological examination showed a lymphocytic infiltrate in the dermis without any modification of the epidermis. Direct immunofluorescent study was negative in all cases. Response to dermocorticoids proved inconsistent or negative in all patients. An excellent outcome was achieved in all five patients with pulsed dye laser. In one case, further skin lesions appeared at 1 year and responded to the same treatment. Following a single treatment session with 6–8 J/cm2, three of five patients showed normal skin. Regression occurred in the other two cases after two to three sessions. Pulsed dye laser appeared to be the best treatment for Jessner-Kanof disease for three patients at 4–8 years of follow-up.Only one case of Jessner-Kanof disease treated by pulsed dye laser has been reported. Pulsed dye laser has been used in cutaneous lupus and annular granuloma. Selective photothermolysis allows photocoagulation of dilated vessels.Pulsed dye laser at 595 nm could offer a valuable therapeutic alternative, and even a first-line treatment with no side effects.

Incorporación de los «cuidados paliativos precoces» en la actividad de una consulta externa de cuidados paliativos en un centro oncológico terciario

ObjectiveTo audit the quality of care delivered in our Outpatient Clinic (OC) after its inception following an early palliative care (EPC) model, and to compare our experience with the relevant literature. Material and methodsA descriptive observational retrospective study was conducted on 100 consecutive advanced cancer patients who attended our OC in 2013. The cases are analyzed using 20 variables selected by consensus, and grouped into 6 categories (demographics [2], primary tumor [1], access to OC [1], OC clinical diagnoses [6], OC activity [7], impact [3]) ResultsThe mean age of the patients was 75 years, and 38% suffered from lung cancer. EPC criteria were completely fulfilled by 17%, and a further 26% partially fulfilled them. Only 33% of the patients would be considered traditional terminal cancer patients. Emerging clinical diagnoses were found in the sample: vitamin D deficiency 35%, adrenal insufficiency 18%, hypogonadism 5%, chemotherapy and radiotherapy induced encephalopathy 4%, aberrant opioid related behaviors 2%. The average number of visits to the OC was 3.5, plus an average of 1.14 telephone consultations, and the median follow-up among patients who died was 3.7 months. Patients on chemotherapy (CTP) who completely fulfilled EPC criteria had a higher average number of visits (6.12), and survived longer until death (7.7) months. Complex hospital diagnostic and therapeutic procedures were required in 82% of the patients, and 31% received palliative radiotherapy. Two thirds of the patients were admitted to the inpatient acute Palliative Care Unit at any given point during follow-up, and the majority died in the Unit beds (44 patients out of 56 deaths). The number of visits to the emergency department within 30 days of death was low (39 visits for 56 patients), and CTP within 30 days of death was also low (5.3%). DiscussionThe non-statistical analysis suggests that the OC attends a population with a varied survival and origin, but with the common characteristics of complex palliative care needs. Our preliminary data do not contradict current hypothesis suggesting that EPC might be cost saving. ConclusionOur initial experience with an OC suggests that an EPC model is feasible in our own environment. On the other hand, our preliminary data does not fail to support the potential benefits associated with the implementation of EPC.

Preventing and managing aberrant drug-related behavior in primary care: Systematic review of outcomes evidence

Several strategies for preventing, identifying, and responding to aberrant opioid-related behaviors are recommended in pain management guidelines. This systematic review evaluated data supporting basic strategies for addressing aberrant opioid-related behaviors. Risk reduction strategies were identified via a review of available guidelines. Systematic literature searches of PubMed (May 1, 2007-January 18, 2013) identified articles with evidence relevant to nine basic strategies. Reference lists from relevant articles were reviewed for additional references of interest. Levels of evidence for articles identified were graded on a four-point scale (strongest evidence = level 1; weakest evidence = level 4) using Oxford Centre for Evidence-Based Medicine Levels of Evidence criteria. Weak to moderate evidence supports the value of thorough patient assessment, risk-screening tools, controlled-substance agreements, careful dose titration, opioid dose ceilings, compliance monitoring, and adherence to practice guidelines. Moderate to strong evidence suggests that prescribing tamper-resistant opioids may help prevent misuse but may also have the unintended consequence of prompting a migration of users to other marketed opioids, heroin, or other substances. Similarly, preliminary evidence suggests that although recent regulatory and legal efforts may reduce misuse, they also impose barriers to the legitimate treatment of pain. Despite an absence of consistent, strong supporting evidence, clinicians are advised to use each of the available risk-mitigation strategies in combination in an attempt to minimize the risk of abuse in opioid treatment patients. Physicians must critically evaluate their opioid prescribing and not only increase their efforts to prevent substance abuse but also not compromise pain management in patients who benefit from it.

Systematic review: managing aberrant drug behavior in primary care

Several strategies for preventing, identifying, and responding to aberrant opioid-related behaviors are recommended in pain management guidelines. This systematic review evaluated data in support of these strategies. Risk-reduction strategies were identified via a review of available guidelines. Systematic literature searches of PubMed were conducted (May 1, 2007 to May 21, 2012) to identify articles with evidence relevant to 9 basic strategies. Reference lists from relevant articles were reviewed for additional references of interest. Levels of evidence for articles identified were graded on a 4-point scale (strongest evidence=level 1; weakest evidence=level 4) using Oxford Centre for Evidence-based Medicine Levels of Evidence criteria. Weak to moderate evidence supported the value of thorough patient assessment, risk-screening tools, controlled-substance agreements, careful dose titration, opioid dose ceilings, compliance monitoring, and adherence to practice guidelines. Moderate to strong evidence suggests that tamper-resistant opioids may help prevent misuse but also that prescribing these formulations may have the unintended consequence of prompting a migration of users to other marketed opioids, heroin, or other substances. Similarly, there is preliminary evidence that recent regulatory and legal efforts may help reduce misuse but also impose barriers to the legitimate treatment of pain. Despite an absence of consistent, strong supporting evidence, clinicians are advised to use each of the available risk-mitigation strategies in combination as an attempt to minimize the risk of abuse in opioid treatment patients. Efforts to prevent abuse should not compromise pain management or promote other forms of substance abuse. Supported by Endo Pharmaceuticals Inc. (Chadds Ford, PA), who also funded editorial support provided by Complete Healthcare Communications, Inc. (Chadds Ford, PA).

The Prevalence and Significance of Cannabis Use in Patients Prescribed Chronic Opioid Therapy: A Review of the Extant Literature

Cannabis is the most widely consumed illicit drug in the United States. Its use, particularly in early initiates, is associated with subsequent development of other drug and alcohol use disorders. The authors examined the prevalence of cannabis use and the association between cannabis use and aberrant opioid-related behaviors in patients prescribed chronic opioid therapy for persistent pain. PubMed was queried for studies of chronic opioid therapy in which aberrant opioid-related behaviors were quantitatively examined and in which cannabis use data (as determined by cannabinoid-positive urine drug tests) were extricable from that of other substances of abuse. The prevalence of cannabis use among patients prescribed chronic opioid therapy in these studies ranged from 6.2% to 39%, compared with 5.8% in the general United States population. Furthermore, cannabis use in chronic opioid patients shows statistically significant associations with present and future aberrant opioid-related behaviors. Cannabis use is prevalent in patients prescribed chronic opioid therapy and is associated with opioid misuse. Further research is necessary to clarify the strength and the nature of the association between cannabis use and opioid misuse, and to address additional questions about the consequences of cannabis use in the context of chronic opioid therapy.