Abstract
Background
One major concern of long-term opioid therapy (LTOT) for chronic noncancer pain (CNCP) is the risk of abuse of prescribed opioids.
Objective
To examine the prevalence and predictors of opioid use-related hospitalizations and potential abuse of prescribed opioids by persons with LTOT for CNCP in a sample representative of the German statutory health insurance companies.
Methods
Retrospective cross-sectional study in 2014. Anonymized German health claims database, including 4,028,618 insured individuals of 69 German statutory health insurances. Univariate logistic regression models to evaluate demographic and medical characteristics associated with hospital stays and a diagnosis of mental and behavioral disorders due to alcohol, opioids, tranquilizers, multiple substances and intoxications by narcotic agents in insured individuals with CNCP receiving LTOT.
Results
The prevalence of LTOT for CNCP was 0.8%; 9.9% of these insured individuals received high-dose LTOT (≥120 morphine equivalent mg/day). The 1‑year prevalence of hospital stays with a diagnosis of mental and behavioral disorders due to alcohol, opioids, tranquilizers, multiple substances and intoxications by narcotic agents was 1.75% of persons with LTOT. These diagnoses were strongly associated with prescriptions of tranquilizers (odds ratio [OR] 3.63; 95% confidence interval [CI] 3.03; 4.36) and moderately associated with diagnosis of depression (OR 2.52; 95% CI 2.12; 3.00) and slightly associated with diagnosis of somatoform pain disorder (OR 1.89; 95% CI 1.56; 2.28) and high-dose LTOT (OR 1.81; 95% CI 1.44; 2.27).
Discussion
The study is in line with the recommendations of the German national guidelines on long-term opioid therapy of chronic non-cancer pain (LONTS) to avoid concomitant prescription of tranquilizers for CNCP and to carefully select and monitor patients with depression and somatoform pain disorder.
Zusammenfassung
Hintergrund
Bedenken bezüglich einer Langzeitopioidtherapie (LTOT) bei chronischen nichttumorbedingten Schmerzen (CNCP) bestehen wegen des Risikos der missbräuchlichen Verwendung der verschriebenen Opioide.
Fragestellung
Feststellung der Prävalenz und Prädiktoren der Krankenhausaufenthalte von Personen mit einer Langzeitopioidtherapie wegen nichttumorbedingter Schmerzen und möglicher missbräuchlicher Verwendung von rezeptierten Opioiden in einer repräsentativen Stichprobe gesetzlich Krankenversicherter.
Methoden
Retrospektive Querschnittsstudie im Jahr 2014. Anonymisierte Routinedaten von 69 gesetzlichen Krankenversicherungen mit 4.028.618 Versicherten. Univariate logistische Regressionsanalysen, um demografische und medizinische Charakteristika zu identifizieren, die bei gesetzlich Krankenversicherten mit einer LTOT wegen CNCP mit einem Krankenhausaufenthalt und Diagnosen von psychischen und Verhaltensstörungen wegen Alkohol, Opioiden, Tranquilizern und multiplem Substanzgebrauch sowie Vergiftungen durch Betäubungsmittel assoziiert waren.
Ergebnisse
Die Prävalenz der LTOT wegen CNCP war 0,8 %. 9,9 % dieser Versicherten erhielten eine Hochdosis-LTOT (≥120 mg Morphinäquivalent/Tag). Die 1‑Jahres-Prävalenz von Krankenhausaufenthalten mit Diagnosen von psychischen und Verhaltensstörungen wegen Alkohol, Opioiden, Tranquilizern und multiplem Substanzgebrauch und Vergiftungen durch Betäubungsmittel lag bei 1,75 % der Versicherten mit LTOT. Diese Diagnosen waren stark mit der Verschreibung von Tranquilizern (Odds Ratio [OR] 3,63; 95 %-Konfidenzintervall [KI] 3,03; 4,36) und mäßig mit Diagnosen depressiver Störungen (OR 2,52; 95 %-KI 2,12; 3,00) und leicht mit Diagnosen von somatoformer Schmerzstörung (OR 1,89; 95 %-KI 1,56; 2,28) und Hochdosis-LTOT (OR 1,81; 95 %-KI 1,44; 2,27) assoziiert.
Diskussion
Die Studie unterstreicht Empfehlungen der Leitlinie LONTS, die gleichzeitige Verschreibung von Opioiden und Tranquilizern zu vermeiden und Patienten mit depressiver und somatoformer Schmerzstörung sorgfältig auszuwählen und zu überwachen.
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Change history
05 February 2021
An Erratum to this paper has been published: https://doi.org/10.1007/s00482-020-00518-1
Notes
Roughly 90% of the population in Germany are members of statutory health insurance and are entitled to receive benefits to improve, maintain and restore their health. Statutory health insurance is financed by statutory health insurance funds which, being public-law corporations, are financially and organisationally independent.
In Germany, a qualified narcotics prescription form is necessary for the prescription of opioid analgesics except for tramadol and tilidine in fixed combination with naloxone, which can be prescribed using an ordinary prescription form. There are no over the counter opioid analgesics in Germany. However, a physician can prescribe an opioid analgesic without naming the statutory health insurance on the prescription form (so called private prescription). In this case, the medication has to be paid by the patient, and is not paid by the statutory insurance, respectively. The extent of private prescription of opioid analgesics in Germany is not known.
Diazepam, chlordiazepoxide, medazepam, oxazepam, potassium clorazepate, lorazepam; adinazolam, bromazepam, clobazam, ketazolam, prazepam, alprazolam, halazepam, pinazepam, camazepam, nordazepam, fludiazepam, ethyl loflazepate, etizolam, clotiazepam, cloxazolam, tofisopam, bentazepam, lorazepam, combinations, flurazepam, nitrazepam, flunitrazepam, estazolam, triazolam lormetazepam, temazepam, midazolam, brotizolam, quazepam, loprazolam, doxefazepam, cinolazepam, climazolam.
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W. Häuser received fees for one lecture from Grünenthal in the past three years. N. Scherbaum received honoraria (advisory boards, lectures, manuscripts, educational material) from AbbVie, Janssen-Cilag, Lundbeck, Medice, Mundipharma, Reckitt-Benckiser / Indivior, and Sanofi-Aventis in the past three years. T. Tölle received fees for lectures and reimbursement of travel expenses from Pfizer, Lilly, Grünenthal, Mundipharma, Indivior, Janssen and Astellas in the past three years. T. Schubert received a fee for data analysis and lecture honoraria from Indivior in the past three years. N. Scherbaum received honoraria from AbbVie, Janssen-Cilag, Lundbeck, Medice, Mundipharma, Reckitt-Benckiser/Indivior, and Sanofi-Aventis in the past three years. T. Tölle received honoraria for lectures and reimbursement of travel expenses from Pfizer, Lilly, Grünenthal, Mundipharma, Indivior, Janssen and Astellas in the past three years.
This article does not contain any studies with human participants or animals performed by any of the authors.
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This study used anonymized existing health claim data, and therefore it was exempt from requiring ethical approval and patient informed consent.
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The original online version of this article was revised: Section “Are some opioids more frequently associated with abuse and addiction than others?”: The first sentence was corrected.
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Häuser, W., Schubert, T., Scherbaum, N. et al. Long-term opioid therapy of non-cancer pain. Schmerz 34 (Suppl 1), 8–15 (2020). https://doi.org/10.1007/s00482-018-0331-5
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DOI: https://doi.org/10.1007/s00482-018-0331-5
Keywords
- Chronic noncancer pain
- Long-term opioid therapy
- Substance abuse
- Substance dependence
- Health care services research