A qualitative study of chronic pain and opioid use: The impact of restrictive prescribing

Cara L. Sedney; Patricia Dekeseredy; Marissa Davis; Treah Haggerty

doi:10.5055/jom.2023.0803

Authors

Cara L. Sedney, MD, MA
Patricia Dekeseredy, MScN, RN https://orcid.org/0000-0001-6083-5358
Marissa Davis, BS
Treah Haggerty, MD, MS

DOI:

https://doi.org/10.5055/jom.2023.0803

Keywords:

chronic pain, opioid use disorder

Abstract

Objectives: To explore the continuum of pain and addiction for patients with chronic pain (CP) who used opioids during a time of restrictive opioid prescribing in West Virginia.

Design: This qualitative descriptive study used a content analysis of semi-structured interviews. Themes were identified through a reflective, iterative coding process. Consolidated criteria for reporting qualitative research guidelines were followed.

Setting: West Virginia.

Participants: Twenty people who used opioids to treat a CP condition, 10 pharmacists, 10 primary care providers, and 10 specialists.

Intervention: Semistructured interviews.

Main outcome measure: To better understand the impact of restrictive prescribing measures on people who used opioids for CP.

Results: Patients initiated opioids for acute, painful conditions and described how long-term use led to physical dependence and, for some, opioid use disorder. Restrictive opioid prescribing laws led to care interruptions and decreased access and availability of prescribed opioid pain medication, driving some patients to seek illicit drugs. Economic considerations influenced drug use as the price of purchasing prescription opioids on the street went up, making heroin a cheaper alternative. Patients who transitioned to buprenorphine/naloxone as a treatment for pain or opioid use disorder viewed it as a positive change and a “life saver.”

Conclusions: Opioid use for CP is complex and multifaceted. The continuum of pain and opioid use disorder can begin with a prescription for acute pain and continue for the treatment of CP. Patients described how continued opioid use was not to “get high” but for pain control to improve their quality of life, continue to work, and be productive. For those who experience physical dependence on opioids, access to treatment is vital to recovery and pain management.

Key message: Without individualized managed care, people confronted with a sudden interruption in prescription opioids may turn to illicit drugs to mitigate symptoms of opioid withdrawal and physical dependence.

Author Biographies

Cara L. Sedney, MD, MA

Department of Neurosurgery, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, West Virginia

Patricia Dekeseredy, MScN, RN

Department of Neurosurgery, Rockefeller Neuroscience Institute, WestVirginia University, Morgantown, West Virginia

Marissa Davis, BS

School of Medicine, West Virginia University, Morgantown, West Virginia

Treah Haggerty, MD, MS

Department of Family Medicine, West Virginia University, Morgantown, West Virginia

References

National Institutes of Health: NIH analysis shows Americans are in pain. News Releases. 2015. Available at https://www.nih.gov/news-events/news-releases/nih-analysis-shows-americans-are-pain#:~:text=Itfoundthatanestimated25.3millionadults,arealsolikelytohaveworsehealthstatus. Accessed October 13, 2022.

Yong RJ, Mullins PM, Bhattacharyya N: Prevalence of chronic pain among adults in the United States. Pain. 2022; 163(2): e328-e332. DOI: 10.1097/j.pain.0000000000002291.

National Center for Complementary and Integrative Health: Chronic pain: What you need to know. 2023. Available at https://www.nccih.nih.gov/health/chronic-pain-what-you-need-to-know. Accessed January 26, 2023.

Hadi MA, McHugh GA, Closs SJ: Impact of chronic pain on patients' quality of life: A comparative mixed-methods study. J Patient Exp. 2019; 6(2): 133-141. DOI: 10.1177/2374373518786013.

Mills S, Torrance N, Smith BH: Identification and management of chronic pain in primary care: A review. Curr Psychiatry Rep. 2016; 18(22). DOI: 10.1007/s11920-015-0659-9.

Dunn KM, Saunders KW, Rutter CM, et al.: Opioid prescriptions for chronic pain and overdose: A cohort study. Ann Intern Med. 2010; 152(2): 85-92. DOI: 10.7326/0003-4819-152-2-201001190-00006.

Centers for Disease Control and Prevention (CDC): Prescription opioids. 2017. Available at https://www.cdc.gov/opioids/basics/prescribed.html. Accessed January 26, 2023.

Ciccarone D: The triple wave epidemic: Supply and demand drivers of the US opioid overdose crisis. Int J Drug Policy. 2019; 71: 183-188. DOI: 10.1016/j.drugpo.2019.01.010.

Morone NE, Weiner DK: Pain as the fifth vital sign: Exposing the vital need for pain education. Clin Ther. 2013; 35(11): 1728-1732. DOI: 10.1016/j.clinthera.2013.10.001.

Mularski RA, White-Chu F, Overbay D, et al.: Measuring pain as the 5th vital sign does not improve quality of pain management. J Gen Intern Med. 2006; 21(6): 607-612. DOI: 10.1111/j.1525-1497.2006.00415.x.

West Virginia Legislature: Enrolled committee substitute for committee substitute for senate bill 273. 2018. Available at http://www.wvlegislature.gov/Bill_Text_HTML/2018_SESSIONS/RS/bills/SB273 SUB2 ENR.pdf. Accessed April 1, 2021.

Gourlay DL, Heit HA: Pain and addiction: Managing risk through comprehensive care. J Addict Dis. 2008; 27(3): 23-30. DOI: 10.1080/10550880802122570.

Han B, Compton WM, Blanco C, et al.: Prescription opioid use, misuse, and use disorders in US adults: 2015 National Survey on Drug Use and Health. Ann Intern Med. 2017; 167(5): 293-301. DOI: 10.7326/M17-0865.

National Institute on Drug Abuse: Prescription opioids DrugFacts. 2021. Available at https://nida.nih.gov/publications/drugfacts/prescription-opioids. Accessed January 26, 2023.

Volkow N, Benveniste H, McLellan AT: Use and misuse of opioids in chronic pain. Annu Rev Med. 2018; 69(69): 451-465. DOI: 10.1146/annurev-med-011817-044739.

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Virginia: American Psychiatric Association, 2013.

Miller NS, Dackis CA, Gold MS: The relationship of addiction, tolerance, and dependence to alcohol and drugs: A neurochemical approach. J Subst Abuse Treat. 1987; 4(3-4): 197-207. DOI: 10.1016/S0740-5472(87)80014-4.

Manhapre A, Becker WC: Pain and addiction. Med Clin North Am. 2018; 102(4): 745-763. DOI: 10.1016/j.mcna.2018.02.013.

Hsieh HF, Shannon SE: Three approaches to qualitative content analysis. Qual Health Res. 2005; 15(9): 1277-1288. DOI: 10.1177/1049732305276687.

Sandelowski M: Whatever happened to qualitative description? Res Nurs Health. 2000; 23(4): 334-340. DOI: 10.1002/1098-240X(200008)23:4<334::AID-NUR9>3.0.CO;2-G.

Sedney CL, Khodaverdi M, Pollini R, et al.: Assessing the impact of a restrictive opioid prescribing law in West Virginia. Subst Abuse Treat Prev Policy. 2021; 16(1). DOI: 10.1186/s13011-021-00349-y.

Sedney CL, Haggerty T, Dekeseredy P, et al.: The DEA “would come in and destroy you”: A qualitative study of fear and unintended consequences emerging from restrictive opioid prescribing policies in West Virginia. Subst Abus Treat Prev Policy. 2022; 17(1). DOI: 10.1186/s13011-022-00447-5.

QSR International Pty Ltd: NVivo Qualitative Data Analysis Software. Burlington, MA: QSR International Pty Ltd, 2018.

Kalso E, Allan L, Dellemijn PLI, et al.: Recommendations for using opioids in chronic non-cancer pain. Eur J Pain. 2003; 7(5): 381-386. DOI: 10.1016/S1090-3801(02)00143-X.

Allan L, Richarz U, Simpson K, et al.: Transdermal fentanyl versus sustained release oral morphine in strong-opioid naïve patients with chronic low back pain. Spine (Phila Pa 1976). 2005; 30(22): 2484-2490. DOI: 10.1097/01.brs.0000186860.23078.a8.

National Institute on Drug Abuse (NIDA): Prescription opioids and heroin research report—Heroin use is driven by its low cost and high availability. 2022. Available at https://nida.nih.gov/publications/research-reports/prescription-opioids-heroin/heroin-use-driven-by-its-low-cost-high-availability. Accessed January 27, 2023.

Mars SG, Bourgois P, Karandinos G, et al.: “Every ‘never’ I ever said came true”: Transitions from opioid pills to heroin injecting. Int J Drug Policy. 2014; 25(2): 257-266. DOI: 10.1016/j.drugpo.2013.10.004.

Dowell D, Haegerich TM, Chou R: CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA. 2016; 315(15): 1624-1645. DOI: 10.1001/jama.2016.1464.

Centers for Disease Control and Prevention (CDC): Transcript for telebriefing: Updated clinical practice guidelines for prescribing opioids for pain. Press Briefing Transcript. 2022. Available at https://www.cdc.gov/media/releases/2022/t1109-prescribing-opioids.html. Accessed January 27, 2023.

Dowell D, Ragan KR, Jones CM, et al.: CDC clinical practice guideline for prescribing opioids for pain—United States, 2022. MMWR Recomm Rep. 2022; 71(3): 1-95. DOI: 10.15585/mmwr.rr7103a1.