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Study: Americans With Mental Health Disorders Prescribed Opioids at High Rate



Valley News Staff Writer
Monday, June 26, 2017

Lebanon — A research team including a Dartmouth-Hitchcock anesthesiologist has found that doctors are much more likely to prescribe opioids for patients with depression and anxiety than those who do not have a mental illness.

The findings, which appear in the July issue of the Journal of the American Board of Family Medicine, show that nearly 19 percent of the 38.6 million American adults with mental health disorders use prescription opioids, which are designed to relieve acute pain, compared with only 5 percent of those without a disorder.

Adults with depression and anxiety receive 51 percent of the 115 million opioid prescriptions distributed each year in the U.S., the study found.

The higher rate of use of opioids among those with the two most common types of mental illness in the country holds true across all levels of pain and across different types of pain, including that stemming from cancer and arthritis, the study found.

“Independent of pain and independent of medical conditions, having a mental health disorder is strongly associated with getting an opioid prescription, which is really, really concerning,” Dr. Brian Sites, the anesthesiologist, said in an interview in his office at Dartmouth-Hitchcock Medical Center last week.

The finding “suggests that there may be additional patient- and provider-related factors specific to those with mental illness that increase the likelihood of receiving prescription opioids,” the study authors wrote.

Being able to identify a subset of the population that might be more likely to use opioids regardless of their pain levels could help providers and policy makers address opioid use, the authors wrote.

Sites, who called the results “absolutely breathtaking,” said managing pain for patients he sees before, during and after surgery can be complicated when those patients have mental health disorders.

“I realize how complicated it is to deal with some of these issues from a pain standpoint for an operation,” said Sites, who had recently been in an operating room and was wearing scrubs during the interview. “I figure maybe there are issues kind of on a larger scale as well.”

He noted that the study is coming out in the midst of an opioid epidemic, which claimed the lives of 112 Vermonters and about 420 Granite Staters in 2016. Though only some of those overdoses were from prescription medications, previous studies have shown that some people begin using opioids through a prescription and then move on to illegal drugs, said Sites, who is also the associate dean of continuing medical education at Geisel School of Medicine.

Dr. Marc Larochelle, an internist at Boston Medical Center who sees a lot of patients with pain and addiction issues, said he did not find the results of the study to be shocking because the relationship between mental health issues and pain — which opioids are designed to treat — is well documented.

But, Larochelle, who was not involved in the study, said he did find it striking to see that this segment of the population is receiving more than half of the opioids providers prescribe. It’s a statistic he hadn’t seen before, he said.

The study “highlights a population that is worth looking at,” Larochelle said.

This is especially true because the country’s use of prescription opioids is concentrated among this population and because those with mental illness are known to have a higher risk of opioid-related harm, he said.

The research team, which was led by Matthew Davis, a University of Michigan researcher who earned his doctorate at Dartmouth College and a master’s in public health from Geisel School of Medicine, used the 2011 and 2013 data from the national Medical Expenditure Panel Survey, MEPS, to find the relationship between opioid use and the two most common mental health conditions affecting American adults — depression and anxiety.

The MEPS is a set of surveys of U.S. families and individuals, their medical providers and employers on the health services that patients use, how often they use them, the costs they incur and how they pay.

Researchers excluded those who were institutionalized during the study period, and were left with a sample of 51,891 adults. They identified those with mental health conditions based on self reports and clinical diagnoses. Similarly, opioid use was tracked through self reports and pharmacy data.

The new study’s authors acknowledge several limitations to their work. It does not describe the relationship between mental health disorders and opioid use. The study did not direcly address whether having a mental health condition means someone is more likely to use opioids or whether using opioids might make people more likely to develop a mental health disorder.

This is a relationship that Larochelle described as being akin to the chicken and the egg. But, the authors note that other recent studies have found evidence that people with mental health disorders who have never taken opioids are more likely to start and transition to longer-term use than those without a disorder.

In addition, the study focused solely on prescription opioid use and did not examine illicit drug use.

It also solely focused on American adults in the general population, not children or people living in institutions, so the findings may not hold across those populations. Members of the military were also not part of the study.

Lastly, the survey used by the authors for the study relies on self-reported information and could have inaccuracies. However, the authors note that the self-reported information is verified through health care and insurance providers.

The study did not determine what might be causing the increased rate of opioid prescriptions for those with mental health disorders, but it may indicate a problem in providers’ prescription practices, Sites said.

“We know that the relationship between mental health issues and pain is very complicated because pain is a subjective phenomena, (for which) there’s no biological measure,” he said. “There’s some conceivable interaction there that could drive prescribers.”

There are several factors which go into providers’ decision of whether or not to prescribe an opioid, including the patient’s subjective description of their pain, the provider’s background and experience, the specific health system in which a provider practices and the U.S. health system as a whole, Sites said.

A person with anxiety or depression might be more likely to have a condition known as “pain catastrophizing,” in which people dwell on or feel hopeless about their pain, Sites said.

If patients have anxiety or depression, it’s also possible that their condition might make physicians more likely to prescribe opioids out of empathy, Sites said.

Physicians may also be motivated by a payment structure that is tied to patient satisfaction scores, he said.

“Patients are often happier when they get things,” Sites said.

Lastly, Sites said there may be a short-term antidepressant effect of opioid use that makes those with depression want to continue to use opioids once they start.

To address the overprescription problem, Sites suggests that physicians need more ready access to alternatives to opioids such as cognitive behavioral therapy, acupuncture, acupressure, massage therapy, physical therapy and nonopioid pharmaceuticals that are effective.

“You need infrastructure and funding to make those things available,” he said.

The goals of opioid therapy also need to be more clearly defined, Sites said.

Identifying those who are more likely to be affected by the opioid epidemic should make it easier for future researchers to find solutions to the problem, Sites said.

“It may be that really what we need to do is treat mental illness better,” he said.

Lawmakers took note of Sites’ study on Monday. In separate statements, U.S. Rep. Annie Kuster, D-N.H., and Sen. Maggie Hassan, D-N.H., both highlighted its findings.

Kuster described the value of maintaining access to mental health care in a press conference held at Dartmouth-Hitchcock in Nashua on Monday, with Sites in attendence.

Both Kuster and Hassan voiced concerns about Republican efforts to replace the Affordable Care Act, which they fear would reduce insurance coverage for mental health services.

“Sadly, the Republican healthcare bills would strip the requirement that these services be included in coverage,” Kuster said in a release. “We know there are improvements that can be made to our current system, but we can’t do this at the expense of those who need this care the most.”

Hassan said she opposes proposed cuts to Medicaid that would affect coverage of mental health and substance abuse services.

“As we work to combat the horrific substance misuse crisis that is devastating our communities and taking a major toll on our economy in New Hampshire, this study highlights how dangerous Trumpcare, which includes massive cuts to Medicaid, would be for our state,” Hassan said in a release.

“We need a comprehensive, holistic approach to combating this epidemic that addresses the underlying causes of addiction, including mental health issues.”

Staff Writer Nora Doyle-Burr can be reached at ndoyleburr@vnews.com or 603-727-3213.