Depression treatment helps non-cancer pain patients to stop taking opioids

Opioid cessation in non-cancer pain may be more successful when depression is treated to remission, a Saint Louis University study shows.

The study, "Impact of adherence to antidepressants and on long-term prescription opioid use" was published in the February issue of the British Journal of Psychiatry.

Jeffrey Scherrer, Ph.D., professor of family and community medicine at Saint Louis University and his co-authors have found depression is a consequence of chronic opioid use. In the current study, they find that patients with chronic prescription opioid use and depression who adhered to anti-depressant medications were more likely to stop opioids.

Exploratory analysis found that patients who adhered to anti-depression medications and stopped taking opioids experienced a rapid and greater decline in depression symptoms compared with patients who did not stop taking opioids.

"We can't be sure that a decrease in depression led to patients' choosing to stop opioid use and we know prospective studies are needed," Scherrer said. "Depression can worsen pain and is common in patients who remain long-term prescription opioid users. Our study should encourage clinicians to determine if their non-cancer pain patients are suffering from depression and aggressively treat patients' depression to reduce opioid use."

Long-term prescription opioid analgesic use (OAU) for chronic non-cancer pain is defined as daily or near-daily use for 90 days. Between 1.4 and 10 percent of patients with a new opioid prescription develop chronic OAU and a majority (65-80 percent) of patients who have persistent opioid analgesic use for 90 days are still taking opioids three to five years later.

These long-term patients are more likely than those that use opioids for a short term to develop opioid disorder and overdose. Chronic analgesic use is also associated with new depressive episodes and treatment-resistant depression.

"Effective depression treatment may break the mutually reinforcing opioid-depression relationship and increase the likelihood of successful opioid cessation," Scherrer said.

The study authors used a retrospective cohort design to compare adherence to anti-depressants versus non-adherence in patients with chronic non-cancer pain who were 90 day-plus prescription opioid users. Previous studies have shown the odds of depression improvement are markedly greater in patients who adhere to anti-depressants.

Scherrer and his co-authors used medical record data from 2000-2012 from the Veterans Health Administration (VHA).

A random sample of 500,000 patients was taken from a cohort of 2,910,335 identified with at least one out-patient visit in both fiscal years 1999 and 2000. The patients were ages 18 to 80 and excluded patients with an HIV or cancer diagnosis. Patients must have had at least one yearly visit in 2000-2001 during which they must have been free of a medical record depression diagnosis. All patients developed depression following more than 90 days of continuous prescription opioid use.

The odds of opioid cessation were compared between patients with anti-depressant adherence versus non-adherence.

The anti-depression medications included monoamine oxidase inhibitors (MAOIs), selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), tricyclics (TCAs) and non-classified ADMs.

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