• Users Online: 115
  • Print this page
  • Email this page

ORIGINAL ARTICLE Table of Contents  
Ahead of print publication
Prevalence of opioid misuse, abuse and dependence among chronic pain patients on opioids followed in chronic pain clinic in a tertiary care hospital Riyadh, Saudi Arabia


1 Department of Anesthesia; King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
2 Al Faisal Medical School, Riyadh, Saudi Arabia

Click here for correspondence address and email

 

  Abstract 


Background: Opioids have proven very useful for treatment of acute pain and cancer pain, and in the developed countries, opioids are increasingly used for the treatment of chronic non-malignant pain patients as well. Treatment of chronic pain patients with opioids may have several long-term consequences; especially, addiction that has been a feared complication. Objective: The objective of the study was to estimate the prevalence of opioid misuse, abuse and dependence amongst chronic pain patients on opioids followed in chronic pain clinic. Study Design and Settings: This is a cross-sectional study that carried out in chronic pain clinic in a tertiary care hospital Riyadh, Saudi Arabia (King Faisal Specialist Hospital and Research Centre [KFSH and RC]). All chronic pain patients on opioids, apart from acute pain patients and children, were eligible for the study. The Alcohol, Smoking and Substance Involvement Screening Test (Opioid ASSIST) screening questionnaire in Arabic was used as a screening tool for opioid misuse, abuse and dependence. Results: A total of 219 chronic pain patients participated in the study. There were 80 males (36.5%) and 139 females (63.5%). Prevalence of opioids misuse, abuse and dependence in chronic pain patients attending chronic pain clinic in KFSH and RC is 12.8%, 9.1% and 3.2%, respectively, based on opioids ASSIST questionnaire cut points. Conclusion: Opioid use disorders are common in pain clinics. They should be considered as serious complications of using opioids in managing chronic pain patients. Considering the high risk of opioid misuse, abuse and dependence amongst chronic pain patients, more screening and rehabilitation services are necessary.

Keywords: Abuse, alcohol, smoking and substance involvement screening test, chronic pain, dependace, King Faisal Specialist Hospital and Research Centre, opioids misuse


How to cite this URL:
Al Maharbi S, Abolkhair A, Al Ghamdi H, Haddara M, Valtysson B, Tolba Y, Alaujan R, Abu-Khait S. Prevalence of opioid misuse, abuse and dependence among chronic pain patients on opioids followed in chronic pain clinic in a tertiary care hospital Riyadh, Saudi Arabia. Hamdan Med J [Epub ahead of print] [cited 2019 Mar 20]. Available from: http://www.hamdanjournal.org/preprintarticle.asp?id=241085





  Introduction Top


Opioids are used frequently in the treatment of both acute and cancer pains and proven to be effective in that. In developed world, opioids are increasingly also used for the treatment of patients with chronic non-malignant pain[1] Using opioids for treatment of chronic pain carrys many risks and complications. Addiction is one important complication[2],[3] In the treatment of chronic pain patients, it is well known that using opioids may initially be a part of the solution, but by time and follow-up, it will turn to be substantial part of the problem.[4] Chronic pain patients with substance use disorders and/or mental health disorders are more prone for misuse of prescribed opioids.[5] Furthermore, the increasing use of opioid analgesics and the introduction of high-dose, extended-release oral tablet formulations of opioids, for treating chronic non-cancer pain, has increased risks for the inappropriate use of prescribed opioids.[6],[7],[8],[9] Addictive disease may complicate the management of pain and increase the difficulty in controlling pain syndromes.[10],[11]

By all of these means, it is obligatory and challenging to recognise and manage all kinds of opioid misuse during therapeutic long-term opioid therapy of chronic pain patients.[1]

In recent comprehensive review, Vowles et al. collected data of 38 researches in problematic opioids use. They found that the prevalence of opioids misuse averaged between 21% and 29% (range: 95% confidence interval [CI]: 13%–38%). Furthermore, some studies showed that rates of addiction averaged between 8% and 12% (range: 95% CI: 3%–17%). Abuse prevalence was reported in only one study with 0.08%–81%.[12]

In Centers for Disease Control guideline published in March 2016, ten uncontrolled studies with very serious limitations were reviewed. In primary care settings, prevalence of opioid abuse ranged from 0.6% to 8% and prevalence of dependence ranged from 3% to 26%. In pain clinic settings, prevalence of misuse ranged from 8% to 16% and addiction ranged from 2% to 14%. Prevalence of aberrant drug-related behaviours ranged from 6% to 37%.[13]

Misuse of prescribed medication is increased in Arabic countries. Evidence regarding opioid misuse in chronic pain patients in Arabic countries is lack. Researches in the abuse of medical agents are sparse and less comparing to smoking and tobacco materials in Arab world.[14],[15],[16],[17]


  Materials and Methods Top


This is a cross-sectional study that was done over a period of 3 months from June 2016 to August 2016. All chronic pain patients attending chronic pain clinic at King Faisal Specialist Hospital and Research Centre (KFSH and RC) were eligible for the study. Before commencement, ethical approval was obtained from the Research Centre in KFSH and RC on 30 May 2016 (Project # 2161 114). Verbal consent was taken before distributing the questionnaires to patients. Opioid Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) screening questionnaire in Arabic was used as a screening tool for opioid misuse, abuse and dependence. The questionnaires were distributed in the vital sign room, while the study participants were waiting to be seen for their regular clinic appointment at the pain clinic. Assistance in completing the questionnaire was provided to the illiterate subjects as well as those who needed help by the assigned investigators. The instructions were given clearly to ensure that study participants understood the contents of the questionnaires. Acute pain patients, patients not on opioids, uncompleted questionnaires, admitted patients and children were excluded from the study. All questionnaires were given a study number. All measures were taken to keep information confidential.

Alcohol, smoking and substance involvement screening test questionnaire

The ASSIST was developed for the World Health Organization (WHO) by an international group of substance abuse researchers to detect and manage substance use and related problems in primary and general medical care settings.

The ASSIST has undergone significant testing in three sequential phases (I, II and III) to ensure that it is feasible, reliable, valid, flexible, comprehensive and cross-culturally relevant and able to be linked to brief interventions. It is validated to many languages including Arabic.[18]

The ASSIST is an 8-item questionnaire designed to be administered by a health worker. Overall, the results show that the ASSIST can discriminate between low, moderate and high risk of substance use, but that the ASSIST better discriminates between abuse (moderate risk) and use (low risk) than between abuse (moderate risk) and dependence (high risk).[19]

Opioid alcohol, smoking and substance involvement screening test

The specific substance involvement score for each substance (sometimes termed the alcohol ASSIST score, the cannabis ASSIST score, etc.) is the score designed to be used for clinical purposes. Opioid ASSIST scores are derived from general ASSIST questionnaire [Figure 1]. Risk level of use according to ASSIST is classified as (0–3) for low risk (4–26) for moderate risk or abuse, and (more than 27 ) for high risk or dependence. Opioid misuse will include all three risk levels (low, moderate and high).
Figure 1: Opioid ASSIST questionnaire

Click here to view


Statistical methods

A convenient sample of 219 participants was determined for this study. All the statistical analyses of this cross-sectional study were done using the software package SAS version 9.4 (SAS Institute Inc., Cary, NC, USA). Descriptive statistics for the continuous variables were reported as a mean ± standard deviation and categorical variables were summarised as frequencies and percentages. All the categorical variables were compared by Chi-square test. Univariate and multivariate logistic regression analysis were used to define which demographic and clinical characteristics were most likely to be associated with depression. The level of statistical significance was set at P < 0.05.


  Results Top


A total of 219 chronic pain patients participated in the study. There were 80 males (36.5%) and 139 females (63.5%). Most of chronic pain patients participating in the study were middle aged (40–59) (45.2%) followed by elderly (≥60) (40.6%). The prevalence of opioid misuse in the total sample size was 12.8% (n = 28) comparing to 87.2% (n = 121) who were taking opioids with no risk of misuse [Table 1]. Based on opioids' ASSIST cut points, the study showed that 0.5% (n = 1) of chronic pain patients on opioids had low-risk level of misuse compared to 9.1% (n = 20) and 3.2% (n = 7) who were having moderate (abuse) and severe risk (dependence) level of misuse [Table 1].
Table 1: Prevalence of problematic opioids use

Click here to view



  Discussion Top


The results of this study showed that the prevalence of opioids misuse, abuse and dependence in chronic pain patients attending chronic pain clinic in KFSH and RC is 12.8%, 9.1% and 3.2%, respectively, based on opioids' ASSIST questionnaire cut points. The rate of prevalence of opioids' use disorders observed in our study is variable in comparing with other previous studies. The substantial variability in studies evaluating problematic opioid use remains obvious as there were many designs used, methods of identification used and study settings examined.[12] Other important cause of variability is the use of different assessment tools to screen for opioids' use disorders.[12] However, in the literature, the validity of the ASSIST was evaluated in the Phase II study which suggested that the ASSIST provides a valid measure of substance-related risk both for individual substances and total substance involvement. Scores on the ASSIST were significantly correlated with other screening tools for problematic substance use including the MINI-Plus (r = 0.76, P < 0.01) and the addiction severity index (r = 0.84, P < 0.01).[20] Furthermore, this variation in prevalence of these disorders has been explained to be due to cultural differences, differences in the healthcare system and differences in the population in addition to the tools used in the study.

Limitations

Most self-report instruments, like our questionnaire, are susceptible to deception by the patient. As a result, they may miss substance abusers who intentionally give false responses. Another limitation is that these questionnaires do not specifically explore aberrant behaviour during treatment.[9]

Although ASSIST questionnaire was proven as a reliable screening tool, WHO recommendation was used in primary care settings[18],[19],[20] and no previous studies used it in pain clinic or in derived form. Actually, we used this questionnaire as we could not find any validated screening tools for opioids' use disorders in Arabic version apart from this tool.

There is a need to have a multidisciplinary approach for detecting and managing opioid use disorders in chronic pain patients in hospitals. In addition, the results suggest the need for establishment of good screening tools and rehabilitations activities targeting chronic pain patients with problematic opioid use.

Our study did not explore the risk factors that may increase the prevalence of opioid use disorders. Furthermore, it did not ask about the type of opioids. Another limitation is low sample size. Future qualitative research is warranted for better understanding of the correlation between problematic opioids use and other risk factors.


  Conclusion Top


This study concludes that chronic pain patients on opioids attending the pain clinic at a tertiary care hospital have signs of problematic opioid use. This prevalence is variable to that reported in other studies. This emphasising the need and importance of screening all chronic pain patients on opioids for opioids' use disorders. The study findings highlight the need for valid screening tools and rehabilitation activities targeting chronic pain patients with problematic opioid use.

Acknowledgement

We are thankful to patients who participated in this study and to Mr Abdelmoneim Eldali, technical specialist in Biostatistics-Epidemiology and Scientific Computing Department-Riyadh, BESC, who helped us in data analysis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Højsted J, Sjøgren P. Addiction to opioids in chronic pain patients: A literature review. Eur J Pain 2007;11:490-518.  Back to cited text no. 1
    
2.
Højsted J, Sjøgren P. An update on the role of opioids in the management of chronic pain of nonmalignant origin. Curr Opin Anaesthesiol 2007;20:451-5.  Back to cited text no. 2
    
3.
Trescot AM, Helm S, Hansen H, Benyamin R, Glaser SE, Adlaka R, et al. Opioids in the management of chronic non-cancer pain: An update of American Society of the Interventional Pain Physicians' (ASIPP) guidelines. Pain Physician 2008;11:S5-62.  Back to cited text no. 3
    
4.
Eriksen J. Opioids in chronic non-malignant pain. Eur J Pain 2001;5:231-2.  Back to cited text no. 4
    
5.
Chou R, Fanciullo GJ, Fine PG, Adler JA, Ballantyne JC, Davies P, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain 2009;10:113-30.  Back to cited text no. 5
    
6.
Manchikanti L, Fellows B, Ailinani H, Pampati V. Therapeutic use, abuse, and nonmedical use of opioids: A ten-year perspective. Pain Physician 2010;13:401-35.  Back to cited text no. 6
    
7.
Christo PJ, Manchikanti L, Ruan X, Bottros M, Hansen H, Solanki DR, et al. Urine drug testing in chronic pain. Pain Physician 2011;14:123-43.  Back to cited text no. 7
    
8.
Ballantyne JC. Opioid analgesia: Perspectives on right use and utility. Pain Physician 2007;10:479-91.  Back to cited text no. 8
    
9.
Sehgal N, Manchikanti L, Smith HS. Prescription opioid abuse in chronic pain: A review of opioid abuse predictors and strategies to curb opioid abuse. Pain Physician 2012;15:ES67-92.  Back to cited text no. 9
    
10.
Compton MA. Cold-Pressor pain tolerance in opiate and cocaine abusers: Correlates of drug type and use status. J Pain Symptom Manage 1994;9:462-73.  Back to cited text no. 10
    
11.
Savage SR. Long-term opioid therapy: Assessment of consequences and risks. J Pain Symptom Manage 1996;11:274-86.  Back to cited text no. 11
    
12.
Vowles KE, McEntee ML, Julnes PS, Frohe T, Ney JP, van der Goes DN, et al. Rates of opioid misuse, abuse, and addiction in chronic pain: A systematic review and data synthesis. Pain 2015;156:569-76.  Back to cited text no. 12
    
13.
Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain – United States, 2016. JAMA 2016;315:1624-45.  Back to cited text no. 13
    
14.
AlMarri TS, Oei TP. Alcohol and substance use in the Arabian Gulf region: A review. Int J Psychol 2009;44:222-33.  Back to cited text no. 14
    
15.
Al Kandari FH, Yacoub K, Omu FE. Effect of drug addiction on the bio psychosocial aspects of persons with addiction in Kuwait: Nursing implication. J Addict Nurs 2007;18:31-40.  Back to cited text no. 15
    
16.
Effat S. Patterns of alcohol and illicit drug use in Kuwait: A preliminary study. New Egypt J Med 1994;11:130-5.  Back to cited text no. 16
    
17.
Sweileh WM, Zyoud SH, Al-Jabi SW, Sawalha AF. Substance use disorders in Arab countries: Research activity and bibliometric analysis. Subst Abuse Treat Prev Policy 2014;9:33.  Back to cited text no. 17
    
18.
Available from: http://www.who.int/substance_abuse/activities/assist_arabic.pdf?ua=1. [Last accessed on 2016 Aug 10].  Back to cited text no. 18
    
19.
Validation of the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) and pilot brief intervention [electronic resource]: A technical report of phase II findings of the WHO ASSIST Project/ prepared by Rachel Humeniuk & Robert Ali, on behalf of the WHO ASSIST Phase II Study Group, WHO 2006. p. 44,50.  Back to cited text no. 19
    
20.
Henry-Edwards S, Humeniuk R, Ali R, Poznyak V, Monteiro M. The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST): Guidelines for Use in Primary Care (Draft Version 1.1 for Field Testing). Geneva, World Health Organization, 2003.  Back to cited text no. 20
    

Top
Correspondence Address:
Sameeh Al Maharbi,
King Faisal Specialist Hospital and Research Centre, Riyadh
Saudi Arabia
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2227-2437.241085



    Figures

  [Figure 1]
 
 
    Tables

  [Table 1]



 

Top
 
  Search
 
   Ahead Of Print
  
 Article in PDF
     Search Pubmed for
 
    -  Al Maharbi S
    -  Abolkhair A
    -  Al Ghamdi H
    -  Haddara M
    -  Valtysson B
    -  Tolba Y
    -  Alaujan R
    -  Abu-Khait S


Abstract
Introduction
Materials and Me...
Results
Discussion
Conclusion
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed470    
    PDF Downloaded32    

Recommend this journal