Opioids Less Potent When Psychiatric Disorders Present with Chronic Pain

Opioids produce less pain relief and more side effects in chronic lower back pain patients with high levels of depression and anxiety.

For new research published in Anesthesiology, researchers prospectively studied 55 patients with chronic lower back pain plus low, moderate, or high levels of depression or anxiety symptoms.

The patients were given oral morphine, oxycodone, or placebo to take as needed over a 6-month period, throughout which they recorded their daily pain levels and drug doses in an electronic diary.

Those with low levels of depression or anxiety saw an average 39% improvement in pain, compared with only 21% among those with high levels of psychiatric comorbidity. High-level patients also had a significantly greater rate of opioid abuse and reported more and intense treatment-related side effects.

These findings were not surprising to Jeffrey Fudin, PharmD, DAAPM, FCCP, FASHP, founder and chairman of Professionals for Rational Opioid Monitoring & Pharmacotherapy, an advocacy group in favor of safe opioid prescribing.

“Pharmacists could and should play an important role in monitoring this risk because their hands and eyes are the last stop before dispensing these combinations,” Dr. Fudin told Pharmacy Times. “At the very least, pharmacists could advocate for in-home naloxone use and participate in training for the patients and their caregivers.”

Dr. Fudin added that pharmacists could also make an effort to identify the signs and symptoms of depression in a way that is comforting to the patient, yet informative about the risks.

He noted that patients with chronic lower back pain could experience depression or anxiety in response to lost time from work and the inability to do simple life activities.

“These things alone are problematic, but when coupled with anxiety, fear, opioids, benzodiazepines, and antidepressants, it is a clear recipe for disaster,” Dr. Fudin said.

The study results suggested that physicians should weigh the risks and benefits of opioid therapy in chronic lower back pain patients who exhibit high levels of depression and anxiety differently than they would for with low levels of these psychiatric comorbidities.

“Rather than refusing to prescribe opioids, we suggest that these conditions be treated early and preferably before lower back pain becomes chronic,” stated study author Ajay Wasan, MD, in a press release. “For those prescribed opioids, successful treatment of underlying psychiatric disorders may improve pain relief and reduce the chance of opioid abuse in these patients.”