Further Evidence of Associations Between Higher Prescribed Opioid Dose and Poor Chronic Pain Outcomes

Higher opioid doses for chronic pain have been associated with multiple adverse outcomes compared with lower doses, including falls, fractures, and opioid overdose. Fewer data are available on patient-reported outcomes of chronic pain treatment. Researchers explored associations between long-term doses of prescribed opioids and patient-reported chronic pain outcomes. Data included electronic medical record (EMR) diagnoses and self-report measures obtained at the baseline in-person visit of a prospective study of predictors and outcomes of opioid dose escalation. To allow for study of possible future dose escalation, patients with baseline daily doses >120mg morphine equivalent dose (MED) were excluded.

  • 517 participants (including 186 veterans) with musculoskeletal pain diagnoses who were receiving stable doses of long-term opioid therapy were divided into 3 groups (low dose: 5–20 mg MED, 38.5% of patients; moderate dose: 20.1–50 mg MED, 36.8%; higher dose: 50.1–120 mg MED, 24.8%).
  • Patients receiving higher-doses reported greater pain intensity, worse functioning and quality of life, poorer self-efficacy for managing pain, greater fear avoidance, and more health care utilization, compared with those in the low and moderate dose groups.
  • Evidence for differences in mental health, depression, and alcohol and drug problems by opioid dose level was inconsistent across EMR and self-report measures.

Comments: This study supports prior studies showing the association of higher prescribed opioid doses with poor chronic pain outcomes and extends those findings to include additional potential predictors of poor outcomes, including self-efficacy and fear avoidance. An observational study cannot determine whether higher doses play a causative role in poor outcomes or whether more severe problems led to higher doses. Sample selection strategies that excluded patients receiving the highest doses may partially explain the inconsistent associations between dose and mental health and addiction problems found in prior studies.

Joseph Merrill, MD, MPH

Reference: Morasco BJ, Yarborough BJ, Smith NX, et al. Higher prescription opioid dose is associated with worse patient-reported pain outcomes and more health care utilization. J Pain. 2017;18(4):437-445.

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