To understand the factors related to mortality among persons under age 65, the authors reviewed and analyzed 13,089 opioid-related deaths delineated by the presence or absence of diagnosis of chronic non-cancer pain in the last year of life. The analysis also looked at nonfatal opioid related incidences at both 12 months and 30 days before death.
The data on chronic pain is shocking. Over 100 million Americans currently suffer from chronic pain. Other than those receiving palliative care, the use of opioid medication is controversial, yet few treatment options are available to clinicians, and numerous obstacles, new regulations only compound and confound the problem for both patients and clinicians.
In this analysis, the authors found that 61.5% of decedents had received a medical diagnoses of chronic non-cancer pain in the last year of their life. These patients were significantly more likely to have prescriptions for opioids and benzodiazepines during the last 30 days of life when compared to persons without a diagnosis of chronic non-cancer pain. Yet a diagnoses of opioid use disorder during this period was rarely seen in either group (4.2% versus 4.3%). The chronic pain group was also significantly more likely than the non-chronic pain group to receive clinical diagnoses of a drug use issue, (40.8% versus 22.1%), depression (29.6% versus 13.0%) or anxiety (25.8% during the last year of life).
It is not surprising that patients with chronic pain would receive a diagnosis for depression of a drug use concern, but only 4% were diagnosed with a substance use disorder, and thus, most certainly did not receive any treatment for that disease.
Why Does This Matter?
The concern is twofold. First, chronic non-cancer pain is epidemic in the U.S. and becomes more prevalent as we age. This is a public health crisis with very limited resources available to address it medically. Second, the epidemic of ignorance regarding chronic pain, aging, depression and opioid use exists. Current data suggest that approximately 12 percent of patients treated for chronic non-cancer pain will misuse or abuse their medication. This number is consistent with the prevalence rate of persons with SUDs in the U.S.
Chronic pain and depression are bi directionally related. Solving the nation’s opioid overdose problem is more closely related to identifying and treating depression than we ever realized. Continuing care for patients with pain syndromes must include a re-evaluation progress, assessing tolerance and harmful effects—all necessary when managing any chronic disease. A Narcan policy to prevent death from overdose is helpful for some persons, but is far from a solution.
For those with genuine chronic pain, opioids can dramatically improve the quality of their life, despite their inherent risks. But far too many clinicians are inadequately trained to manage these patients. At present, doctors certified in pain management and addiction medicine are having the best outcomes. My former fellow and colleague, William Jacobs, MD, at the Medical College of Georgia, is triple boarded in anesthesiology, pain management and addiction medicine—maybe the only one in the U.S. with these credentials. He is arguably the reigning expert in treating patients with chronic pain and addictive disease. His expertise and compassion for these patients is a model for how to do best manage these suffering souls. Certainly more research and non opioid, therapeutic options for treating pain are needed. That requires an investment in research of these dreadful diseases.
Olfson M, Wall M, Wang S, Crystal S, Blanco C. Service Use Preceding Opioid-Related Fatality. Am J Psychiatry. 2017 Nov 28:appiajp201717070808. doi: 10.1176/appi.ajp.2017.17070808. [Epub ahead of print]