Diagnosing Prescription Opioid Use Disorder in Patients Using Prescribed Opioids for Chronic Pain
Publication: American Journal of Psychiatry
Abstract
Objective:
The diagnostic criteria for opioid use disorder, originally developed for heroin, did not anticipate the surge in prescription opioid use and the resulting complexities in diagnosing prescription opioid use disorder (POUD), including differentiation of pain relief (therapeutic intent) from more common drug use motives, such as to get high or to cope with negative affect. The authors examined the validity of the Psychiatric Research Interview for Substance and Mental Disorders, DSM-5 opioid version, an instrument designed to make this differentiation.
Methods:
Patients (N=606) from pain clinics and inpatient substance treatment who ever received a ≥30-day opioid prescription for chronic pain were evaluated for DSM-5 POUD (i.e., withdrawal and tolerance were not considered positive if patients used opioids only as prescribed, per DSM-5 guidelines) and pain-adjusted POUD (behavioral/subjective criteria were not considered positive if pain relief [therapeutic intent] was the sole motive). Bivariate correlated-outcome regression models indicated associations of 10 validators with DSM-5 and pain-adjusted POUD measures, using mean ratios for dimensional measures and odds ratios for binary measures.
Results:
The prevalences of DSM-5 and pain-adjusted POUD, respectively, were 44.4% and 30.4% at the ≥2-criteria threshold and 29.5% and 25.3% at the ≥4-criteria threshold. Pain adjustment had little effect on prevalence among substance treatment patients but resulted in substantially lower prevalence among pain treatment patients. All validators had significantly stronger associations with pain-adjusted than with DSM-5 dimensional POUD measures (ratios of mean ratios, 1.22–2.31). For most validators, pain-adjusted binary POUD had larger odds ratios than DSM-5 measures.
Conclusions:
Adapting POUD measures for pain relief (therapeutic intent) improved validity. Studies should investigate the clinical utility of differentiating between therapeutic and nontherapeutic intent in evaluating POUD diagnostic criteria.
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Information & Authors
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History
Received: 16 July 2021
Revision received: 21 January 2022
Accepted: 7 February 2022
Published online: 15 June 2022
Published in print: October 2022
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Funding Information
This study was funded by the Opioid Postmarketing Consortium (OPC) as part of a U.S. Food and Drug Administration (FDA) postmarketing requirement for opioid analgesics. The OPC member companies included the following: Allergan, Assertio Therapeutics, BioDelivery Sciences, Collegium Pharmaceutical, Daiichi Sankyo, Egalet Corporation, Endo Pharmaceuticals, Hikma Pharmaceuticals USA, Janssen Pharmaceuticals, Mallinckrodt, Pernix Therapeutics Holdings, Pfizer, and Purdue Pharma. The role of the OPC in the study was to provide input regarding the study design and review of the final study report to the FDA and review of the manuscript. The OPC had no role in the conduct of the study, in the collection, management, analysis, or interpretation of the data, in preparation or approval of the final manuscript, or in the decision to submit the manuscript for publication.Dr. Hasin has a contract with the Opioid Postmarketing Consortium to contribute supportive services to U.S. Food and Drug Administration postmarketing requirement study 3033-1 on the prevalence and incidence of misuse of, abuse of, and addiction to prescription opioid analgesics. Dr. Aharonovich has a contract with Alkermes for a study of self-reported cognitive and other functioning in subjects on buprenorphine or extended-release naltrexone treatment for opioid use disorder. Dr. Petronis was an employee of Pfizer at the time of this work and has stocks/stock options in Pfizer. Dr. Ross has received research funding from Reset Pharmaceuticals. Dr. Inturrisi has a licensing agreement with and receives consulting fees from Relmada Therapeutics for the development of d-methadone for the treatment of psychiatric symptoms, for the treatment or prevention of disorders of the nervous system and symptoms and manifestations thereof, and for cytoprotection against diseases and aging of cells. The other authors report no financial relationships with commercial interests.
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