Elsevier

Journal of Affective Disorders

Volume 218, 15 August 2017, Pages 1-7
Journal of Affective Disorders

Research paper
Depression and anxiety among chronic pain patients receiving prescription opioids and medical marijuana

https://doi.org/10.1016/j.jad.2017.04.026Get rights and content

Highlights

  • Levels of depression and anxiety among chronic pain patients we assessed.

  • We compared patients receiving prescription opioids and medical marihuana.

  • Prescription opioids use was associated with increased odds for depression.

  • Prescription opioids use was associated with increased odds for anxiety.

Abstract

Background

High rates of depression and anxiety have been consistently reported among patients suffering from chronic pain. Prescription opioids are one of the most common modalities for pharmacological treatment of pain, however in recent years medical marijuana(MM) has been increasingly used for pain control in the US and in several countries worldwide. The aim of this study was to compare levels of depression and anxiety among pain patients receiving prescription opioids and MM.

Methods

Participants were patients suffering from chronic pain treated with prescription opioids (OP,N=474), MM (N=329) or both (OPMM,N=77). Depression and anxiety were assessed using the depression module of the Patient Health Questionnaire (PHQ-9) and the Generalized Anxiety Disorder scale (GAD-7).

Results

Prevalence of depression among patients in the OP, MM and OPMM groups was 57.1%, 22.3% and 51.4%, respectively and rates of anxiety were 48.4%, 21.5% and 38.7%, respectively. After controlling for confounders, patients in the OP group were significantly more likely to screen positive for depression (Adjusted Odds Ratio(AOR)=6.18;95%CI=4.12–9.338) and anxiety(AOR=4.12;CI=3.84–5.71)) compared to those in the MM group. Individuals in the OPMM group were more prone for depression (AOR for depression=3.34;CI=1.52–7.34)) compared to those in the MM group.

Limitations

Cross-sectional study, restricting inference of causality.

Conclusions

Levels of depression and anxiety are higher among chronic pain patients receiving prescription opioids compared to those receiving MM. Findings should be taken into consideration when deciding on the most appropriate treatment modality for chronic pain, particularly among those at risk for depression and anxiety.

Introduction

Chronic pain has been reported to affect at least 8% of the population in developed countries annually (Andrew et al., 2014). The total healthcare cost associated with pain in the US has been estimated at $261 to $300 billion per year (Gaskin and Richard, 2012), with average annual costs of pain patients estimated to be three times higher than of individuals without chronic pain (Berger et al., 2004). Chronic pain has been associated with a significant decrease in daily activities, occupational productivity and quality of life (Breivik et al., 2006, Patel et al., 2012, Smith et al., 2007). In addition, individuals suffering from chronic pain have high rates of comorbid psychiatric disorders which may further reduce activity and quality of life, including drug and alcohol use disorders, mood and anxiety disorders (Demyttenaere et al., 2007, Feingold et al., 2016a, Gerrits et al., 2014, Gerrits et al., 2012).

The association between chronic pain, depression and anxiety has gained particular attention due to high rates of co-morbidity (Dersh et al., 2002). Up to 54% of pain patients have been reported to suffer from co-morbid depression, and up to 50% have been reported to suffer from anxiety, with particularly high rates of Generalized Anxiety Disorder (Gadermann et al., 2012), specific phobia and panic disorder (Banks and Kerns, 1996, Dersh et al., 2002, Knaster et al., 2012, McWilliams et al., 2003). The causal association between depression and anxiety and chronic pain is yet unclear, with findings supporting both an antecedent and consequent association (Magni et al., 1994, Polatin et al., 1993).

Prescription opioids are one of the most common modalities for the pharmacological treatment of pain, and have proven useful for the treatment of acute pain (Moore and McQuay, 1997, Shang and Gan, 2003) and pain related to cancer (Carr et al., 2004). In addition, these medications have been increasingly used for the treatment of chronic nonmalignant pain (Compton and Volkow, 2006). However, in the past two decades there is gradual awareness of public health risks associated with the increase in prescriptions to opioids (such as risks of diversion, overdose and addiction (Volkow and McLellan, 2016)) warranting the search for alternatives means for treatment of chronic pain. Medical marijuana (MM) has been used widely for pain control in the US and in several countries worldwide, becoming increasingly popular as a potential alternative to prescription opioids for the treatment of chronic pain (Hill, 2015, Jensen et al., 2015). However, due to great variability in the legal status of MM in different countries, data pertaining to the sociodemographic and clinical characteristics of chronic pain patients receiving MM compared to those receiving prescription opioids is scarce (Hall and Weier, 2015). Specifically, there is a lack of data regarding rates of co-occurring depression and anxiety among individuals receiving these two treatments. This may be important as the use of opioids and marijuana may in itself differentially affect levels of depression, anxiety and perceived pain.

The aim of the present study is to explore rates of depression and anxiety among individual receiving treatment for chronic pain, comparing individuals receiving prescription opioids and those receiving MM.

Section snippets

Sample

Subjects for this study were recruited during a 6-month period in two large pain centers in Israel. Patients treated for chronic pain (i.e. pain lasting for more than three months (Elliott et al., 1999)) were approached for recruitment for the study. The response rate was 57%, encompassing a total of 890 participants. Patients participating in the study were not reimbursed for their participation and all subjects were required to sign an informed consent form prior to participation, which was

Sociodemographic and clinical data

The following data was collected from each participant using self-administered questionnaires:

  • 1.

    Socio-demographic data, including sex, age country of birth, type of residence (urban/rural), years of education, employment status, eligibility for disability allowance, marital status and number of children.

  • 2.

    Medical history: participants were asked regarding lifetime diagnoses of common medical conditions including hypertension, liver disease, heart disease, ulcer or duodenum disease, migraine,

Results

Among participants, 474 (59%) were treated with prescription opioids exclusively, 329 (41%) were treated with MM exclusively and 77 (8.6%) received both. The remaining 10 subjects, receiving neither prescription opioids nor MM were excluded from analyses in this study. The proportion of women was significantly higher in the OP group compared to the MM group (p<0.01) group, as was the proportion of patients receiving a disability allowance (p<0.01) (Table 1). Patients in the OP group were more

Discussion

In this study we explored rates of depression and anxiety among patients receiving treatment for chronic pain, comparing patients receiving prescription opioids and those receiving MM. Though no differences were found in rates of common medical conditions associated with pain and in rates of co-occurring substance use, patients in the OP group had higher rates of depression and anxiety compared to those in the MM group. After controlling for potentially confounding factors, patients in the OP

Acknowledgements

None.

References (65)

  • M.M. Gerrits et al.

    Impact of pain on the course of depressive and anxiety disorders

    Pain

    (2012)
  • M.M. Gerrits et al.

    Pain and the onset of depressive and anxiety disorders

    Pain

    (2014)
  • P. Knaster et al.

    Psychiatric disorders as assessed with SCID in chronic pain patients: the anxiety disorders precede the onset of pain

    Gen. Hosp. Psychiatry

    (2012)
  • R.D. Kocalevent et al.

    Standardization of the depression screener patient health questionnaire (PHQ-9) in the general population

    Gen. Hosp. Psychiatry

    (2013)
  • G. Magni et al.

    Prospective study on the relationship between depressive symptoms and chronic musculoskeletal pain

    Pain

    (1994)
  • L.A. McWilliams et al.

    Mood and anxiety disorders associated with chronic pain: an examination in a nationally representative sample

    Pain

    (2003)
  • V. Micale et al.

    Endocannabinoid system and mood disorders: priming a target for new therapies

    Pharmacol. Ther.

    (2013)
  • R.A. Moore et al.

    Single-patient data meta-analysis of 3453 postoperative patients: oral tramadol versus placebo, codeine and combination analgesics

    Pain

    (1997)
  • M.J. Zvolensky et al.

    Lifetime associations between cannabis, use, abuse, and dependence and panic attacks in a representative sample

    J. Psychiatr. Res.

    (2006)
  • R. Andrew et al.

    The costs and consequences of adequately managed chronic non-cancer pain and chronic neuropathic pain

    Pain Pract.: Off. J. World Inst. Pain

    (2014)
  • M.J. Bair et al.

    Association of depression and anxiety alone and in combination with chronic musculoskeletal pain in primary care patients

    Psychosom. Med.

    (2008)
  • S.M. Banks et al.

    Explaining high rates of depression in chronic pain: A diathesis-stress framework

    Psychol. Bull.

    (1996)
  • A. Bowling

    Data Collection Methods in Quantitative Research: Questionnaire, Interviews and their Response Rates

    (1996)
  • G. Campbell et al.

    The pain and opioids in treatment study: characteristics of a cohort using opioids to manage chronic non-cancer pain

    Pain

    (2015)
  • D.B. Carr et al.

    Evidence report on the treatment of pain in cancer patients

    J. Natl. Cancer Inst. Monogr.

    (2004)
  • M.D. Cheatle et al.

    Chronic pain and comorbid mood and substance use disorders: a biopsychosocial treatment approach

    Curr. Psychiatry Rep.

    (2006)
  • A. Colasanti et al.

    Opioids and anxiety

    J. Psychopharmacol.

    (2011)
  • F.K. Del Boca et al.

    Truth or consequences: the validity of self-report data in health services research on addictions

    Addiction

    (2000)
  • J. Dersh et al.

    Chronic pain and psychopathology: research findings and theoretical considerations

    Psychosom. Med.

    (2002)
  • D.C. D'Souza et al.

    The psychotomimetic effects of intravenous delta-9-tetrahydrocannabinol in healthy individuals: implications for psychosis

    Neuropsychopharmacol.: Off. Publ. Am. Coll. Neuropsychopharmacol.

    (2004)
  • D. Feingold et al.

    ProblematIc use of prescription opioids and medicinal cannabis among patients suffering from chronic pain

    Pain medicine.

    (2016)
  • A.M. Gadermann et al.

    Comorbidity and disease burden in the national comorbidity survey replication (NCS-R)

    Depression Anxiety

    (2012)
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