Transcript Journal Club Alcohol, Other Drugs, and Health: Current Evidence November-December 2007 www.aodhealth.org Featured Article Risk factors for clinically recognized opioid abuse and dependence among veterans using.

Journal Club
Alcohol, Other Drugs, and Health: Current Evidence
November-December 2007
www.aodhealth.org
1
Featured Article
Risk factors for clinically recognized
opioid abuse and dependence
among veterans using opioids for
chronic non-cancer pain
Edlund MJ, et al. Pain. 2007;129(3):355–362.
www.aodhealth.org
2
Study Objective
To identify…
• risk factors for diagnosed opioid abuse
or dependence among chronic opioid
users
www.aodhealth.org
3
Study Design
• Researchers analyzed demographic and clinical data
from 15,160 veterans with…
– chronic opioid use (>90 day prescription) for noncancer
pain but
– no diagnosis of an opioid use disorder (opioid abuse or
dependence) in their medical records in 2000–2002.
• Researchers then compared veterans with a
subsequent diagnosis of an opioid use disorder in
2003–2005 with veterans without this diagnosis in
the same period.
www.aodhealth.org
4
Assessing Validity of an
Article About Harm
• Are the results valid?
• What are the results?
• How can I apply the results to
patient care?
www.aodhealth.org
5
Are the Results Valid?
• Did the investigators demonstrate similarity in all
known determinants of outcomes? Did they
adjust for differences in the analysis?
• Were exposed patients equally likely to be
identified in the two groups?
• Were the outcomes measured in the same way in
the groups being compared?
• Was follow-up sufficiently complete?
www.aodhealth.org
6
Did the investigators demonstrate similarity in
all known determinants of outcomes? Did they
adjust for differences in the analysis?
• All subjects were prescribed opioids.
• Factors known to be associated with developing
prescription drug dependence (substance use
disorders and psychiatric comorbidity) were controlled
for in the mulitvariable analyses.
• Multivariable analyses did not adjust for the type of
opioid (short vs. long-acting, weak vs. potent) that
was prescribed.
www.aodhealth.org
7
Were exposed patients equally likely
to be identified in the two groups?
 All patients were prescribed opioids.
www.aodhealth.org
8
Were the outcomes measured in the
same way in the groups being compared?

Passive surveillance was conducted for ICD-9
diagnoses of opioid abuse or dependence.

There was no attempt to systematically
assess patients for opioid abuse or
dependence.
www.aodhealth.org
9
Was follow-up sufficiently complete?
• Follow-up was obtained on all individuals in
the cohort at 1–3 years.
• This may not be sufficient time for a
diagnosis of opioid abuse or dependence to
be recognized.
www.aodhealth.org
10
What are the Results?
• How strong is the association between
exposure and outcomes?
• How precise is the estimate of the risk?
www.aodhealth.org
11
What are the Results?
• From 2000-2002 to 2003-2005, 2% were diagnosed
with opioid abuse or dependence.
• In adjusted analyses, veterans with the following in
2002 were more likely to have a subsequent opioid
abuse or dependence diagnosis:
– nonopioid substance use disorder (OR, 2.34)
– mental health disorder (OR, 1.46)
– greater number of outpatient healthcare visits (OR, 1.52
for 20+ visits versus 0–6 visits)
– greater number of days supplied with opioids (OR, 1.84
for 211+ days versus 91–150 days)
www.aodhealth.org
12
How strong is the association between
exposure and outcome?
Variable
Adjusted Odds Ratios and
95% Confidence Intervals
Nonopioid abuse or dependence
2.34 (1.75-3.14)
Mental health disorder
1.46 (1.12-1.91)
Greater # of outpatient visits
1.52 (1.03-2.25)
Greater # of days supplied with
opioids
1.84 (1.35-2.51)
www.aodhealth.org
13
How precise is the estimate of the risk?
• The sample size is large.
• The confidence intervals are reasonable.
www.aodhealth.org
14
How Can I Apply the Results to
Patient Care?
• Were the study patients similar to the patients in
my practice?
• Was the duration of follow-up adequate?
• What was the magnitude of the risk?
• Should I attempt to stop the exposure?
www.aodhealth.org
15
Were the study patients similar to the
patients in my practice?
•
•
•
•
•
•
•
95% were male.
80% were ≥50 years old.
All were veterans.
71% were white.
54% had back pain.
45% had a mental health diagnosis.
47% received >211 days of opioids in the first
treatment year.
www.aodhealth.org
16
Was the duration of follow-up adequate?
• No:
– 1–3 years is a short period of time for an
individual’s opioid abuse or dependence to
come to clinical recognition.
www.aodhealth.org
17
What was the magnitude of the risk?
• 2% (298 patients) of the sample had their
chronic substance use disorder clinically
recognized (diagnosis in medical record).
www.aodhealth.org
18
Should I attempt to stop the exposure?
• No information is presented on the benefit of the opioid
therapy that was prescribed.
• According to this study, clinicians should assess the benefit
of opioid therapy against the potential risk for opioid abuse
and dependence…
– especially in patients with prior diagnoses of substance
use disorders, mental health disorders, high volume of
clinic visits, and long-term opioid prescriptions.
www.aodhealth.org
19