Pain, Opioids, and Psychiatrists

Everyone knows of the famous parable of a group of blind men being asked to describe an elephant based on each feeling a different part of the animal. The man who touches the tail speaks of something very different from those who place their hands on the trunk or a leg.

Over the past several months, I’ve been reminded of this story by the positions taken by some psychiatrists who have weighed in on the debate over balancing the proper clinical use of prescription opioid analgesics versus the misuse and abuse of these drugs. As with the blind men, most of these psychiatrists have viewed the issue based primarily or even solely on one part of it, the abuse one, while generally ignoring the equally important issue of ensuring that when these medications are prescribed, it will be done correctly and with the most benefit to the patients who are taking them.

Among the issues psychiatrists have taken a lead in recently are attempts to make naloxone more easily available to prevent deaths due to opioid overdoses; a change in Drug Enforcement Administration scheduling of hydrocodone combination products such as hydrocodone with acetaminophen (Vicodin, Lortab); tightening labeling of opioids to indicate more limited use; and the debate over the FDA approval of the first extended-release hydrocodone product (Zohydro ER).

I do not have any problems with these stands and generally support them, although I must admit that I feel any labeling change will have little if any effect. What I am bothered by is that many of the psychiatrists who have expressed their views seem to believe that by doing so, they have done their duty with regard to the topic and that the issue of patients receiving proper pain management is somebody else’s problem.

One example is the debate over Zohydro ER. Almost all the psychiatrists who have expressed an opinion about its approval have focused on its potency and the fact that the formulation is not one that deters its potential for abuse. What has generally been overlooked is that if Zohydro ER is used as it is supposed to be, it would probably be infrequently prescribed.

All immediate-release/short-acting (IR/SA) forms of hydrocodone are only available in this country in combination with other medications, making Zohydro ER the only single hydrocodone product. Since all extended-release/long-acting (ER/LA) opioids take several days to reach an optimal analgesic effect, it is generally recommended that patients are initially given an IR/SA form of the drug. (Oxycodone, oxymorphone, hydromorphone, and morphine are available as both IR/SA and ER/LA.) This also provides the prescriber with a guide to dosing before proceeding to the ER/LA form.

So what expanded roles should psychiatrists be playing in the provision of proper pain management without taking their eyes off the issue of prescription opioid misuse and abuse? The roles are many, but a couple of recent studies on patients undergoing spine surgery highlight at least one largely overlooked area. The studies examined the use of opioid analgesics in these patients. Baseline information was gathered before surgery and the patients were followed for up to a year postoperatively.

For the first study, patients were asked to provide self-reports of medication use; the Zung Depression Scale (ZDS) and the Modified Somatic Perception Questionnaire (MSPQ) were administered to evaluate their psychological states at the initial preoperative visits.¹ Three factors were found to independently correlate with the preoperative use of narcotics for pain: prior spine surgery, preoperative pain, and the score on the ZDS. Although it did not reach the level of significance, the score on MSPQ also was associated with the narcotic use. The researchers concluded that patients who were categorized as depressed or anxious on the basis of the ZDS and MSPQ scores were significantly more likely to be using narcotics preoperatively.

The importance of preoperative use of opioids is borne out by the results of the postoperative study on the same group of patients.² In this study, instruments to evaluate overall physical health, level of disability, and quality of life were administered at 3 and 12 months postoperatively. There was an inverse relationship between the levels of improvement in these areas and the amounts of opioids patients were taking before the surgery; the more opioids patients took, the lower the levels of improvement.

On the basis of the findings of these studies, the authors recommend a preoperative psychological evaluation. Also, caregivers should pay attention to the amount of opioids patients are taking preoperatively because this appears to be correlated with how beneficial the surgery will be. Although the authors felt that surgery was indicated in all the patients, had preoperative opioid use as well as the psychological state of the patient been addressed, perhaps fewer patients would have needed surgery.

The association between depression, anxiety, and chronic pain is well established. Although it can be difficult to determine which is causing which, we do know that when psychological problems and pain are both present, they can exacerbate each other. Long-term opioid use can result in hyperalgesia in which there is a lowering of the pain threshold; this, too, may have a role in the pain.

That spine surgery may be avoided without detrimental effect on a patient’s health is shown by another recent study.³ Findings confirm what earlier studies have shown-even patients who have true disc herniation, in itself a relatively rare cause of back pain, do not suffer any greater degradation of their physical status if they do not have spine surgery than if they do. Thus, patients will have greater benefits if we are able to reduce the pain and improve functionality without surgery.

I am very well aware that the abuse of prescription opioids is a significant public health issue. However, so is the mismanagement of pain. Psychiatrists should have just as much a role in pain management as they do in fighting drug abuse.

References:

1. Armaghani SJ, Lee DS, Bible JE, et al. Preoperative narcotic use and its relation to depression and anxiety in patients undergoing spine surgery. Spine (Phila Pa 1976). 2013;38:2196-2200.

2. Lee DS, Armaghani SJ, Bible JE. Preoperative Narcotic Use Predicts Worse Postoperative Self-Reported Outcomes in Patients Undergoing Spine Surgery. Present at the 28th Annual Meeting of the North American Spine Society; October 2013; New Orleans.

3. Lurie JD, Tosteson TD, Tosteson AN, et al. Surgical versus nonoperative treatment for lumbar disc herniation. Spine (Phila Pa 1976). 2014;39:3-16.