Background

This study aimed to examine: (a) characteristics associated with long-term opioid use and (b) characteristics associated with problematic opioid use, here defined as prescription opioid use disorder (P-OUD), in patients referred to specialised pain care.

Methods

This cross-sectional study utilised baseline data from a clinical chronic pain cohort. Eligible participants included adults > 18 years old, not undergoing cancer treatment, had pain > 3 months, and had been referred to a specialised pain care centre in Sweden. Bivariate logistic regression and multivariable logistic regression with forward selection were used to examine the associations between biopsychosocial variables and either long-term opioid use or P-OUD.

Results

Of the 339 patients included, 194 (57%) were using opioids, 159 (47%) had long-term opioid use (> 90 days), and 34 (21% of those with long-term opioid use) had P-OUD. Longer pain duration, unemployment, more pain catastrophising, lower health-related quality of life, and worse balance increased the likelihood of long-term opioid use. Long-term use of high doses was associated with a greater prevalence of psychiatric and cognitive-behavioural problems compared to long-term use at low to moderate doses. Long-term opioid use, younger age, trauma exposure, more pain catastrophising, and fear of movement increased the likelihood of P-OUD.

Conclusions

Our results demonstrate the importance of identifying and treating salient factors that may sustain both the pain condition and long-term opioid use. Many of the biopsychosocial variables associated with long-term opioid use and P-OUD can be addressed within interdisciplinary pain management and rehabilitation programmes.

Significance

This study is part of the U-PAIN cohort study on a clinical sample from a highly specialised pain centre in Sweden. It is based on a deep and thorough characterisation of patients referred to the clinic to evaluate risks and benefits of opioid therapy in chronic pain. It adds valuable information on the complexity of opioid therapy in chronic pain; the results highlight the need for interdisciplinary multimodal evaluation and treatment.

Background: This study aimed to examine: (a) characteristics associated with long-term opioid use and (b) characteristics associated with problematic opioid use, here defined as prescription opioid use disorder (P-OUD), in patients referred to specialised pain care.

Methods: This cross-sectional study utilised baseline data from a clinical chronic pain cohort. Eligible participants included adults > 18 years old, not undergoing cancer treatment, had pain > 3 months, and had been referred to a specialised pain care centre in Sweden. Bivariate logistic regression and multivariable logistic regression with forward selection were used to examine the associations between biopsychosocial variables and either long-term opioid use or P-OUD.

Results: Of the 339 patients included, 194 (57%) were using opioids, 159 (47%) had long-term opioid use (> 90 days), and 34 (21% of those with long-term opioid use) had P-OUD. Longer pain duration, unemployment, more pain catastrophising, lower health-related quality of life, and worse balance increased the likelihood of long-term opioid use. Long-term use of high doses was associated with a greater prevalence of psychiatric and cognitive-behavioural problems compared to long-term use at low to moderate doses. Long-term opioid use, younger age, trauma exposure, more pain catastrophising, and fear of movement increased the likelihood of P-OUD.

Conclusions: Our results demonstrate the importance of identifying and treating salient factors that may sustain both the pain condition and long-term opioid use. Many of the biopsychosocial variables associated with long-term opioid use and P-OUD can be addressed within interdisciplinary pain management and rehabilitation programmes.

Objectives This study aimed to examine the psychometric properties of a Swedish version of the Medical Outcomes Study Social Support Survey (MOS-SSS).

Methods Standard forward-backward translation was used. A cross-sectional survey was conducted among treatment seeking individuals with chronic pain included in a clinical cohort. Internal consistency was measured with Cronbach’s α, test-retest reliability was examined with intraclass correlation, confirmatory factor analyses was used for examining factor structure, and correlations between the MOS-SSS and selected health validity measures were used for testing concurrent validity hypotheses.

Results 182 participants were included in the study. Internal consistency measured with Cronbach’s alpha was acceptable for all subscales and for the total support index of the MOS-SSS. Test-retest reliability was moderate – good for the different subscales, and was good for the overall support index. The original four factor model of the MOS-SSS was confirmed, and the concurrent validity hypotheses were also confirmed; however, the associations were weaker than expected.

Conclusions The Swedish version of the MOS-SSS was found psychometrically sound and offers a systematic assessment of social support in specialized pain care.

Abstract

Objective: To explore prescribers’ understanding of what makes initial prescription of opioids become long-term-opioid therapy (opioids >90 days).

Design: Qualitative study, using phenomenography for data analysis.

Methods: Semi-structured interviews conducted by one researcher were used for data collection. Participants were recruited consecutively until categorical saturation was reached. The transcripts were analyzed and categorized by two researchers. A third researcher checked for consistency between the data and the categories. An outcome space was constructed representing the logical relationship between the categories.

Setting: Primary, secondary and tertiary care in Sweden.

Subjects: Fifteen attending physicians working within the fields of general practice, rehab medicine, orthopedic surgery, neurosurgery, or obstetrics and gynecology.

Results: The analysis identified six categories: The addictive opioid, The deserving patient, The ignorant prescriber, The lost patient, The compassionate prescriber, and The exposed prescriber. The differences in conceptions among the categories were clarified through three main contributors related to opioid therapy: prescriber’s characteristics, patient’s characteristics, and the healthcare organization.

Conclusion: Opioids were understood as being addictive with long-term use promoting a downward spiral of tolerance and withdrawal driving the pain, leading to continued prescription. Long-term opioid therapy could be justified for patients who improved in function, and who were perceived as trustworthy. Inadequate follow-up of patients, poor training in pain management and addiction medicine, personal attitudes and beliefs about opioids, a perceived professional obligation to treat patients with pain, and lack of collegial support, were factors understood to promote clinically unindicated long-term opioid therapy.

Objectives: To examine acceptability of study participation and feasibility of (1) recruitment, (2) data collection and (3) outcome measures for the prospective U-PAIN cohort.

Design: Internal feasibility study of a prospective cohort.

Participants and setting: 64 patients, >18 years, with chronic pain at a multidisciplinary pain centre at a university hospital in Sweden.

Outcome measures: Acceptability of study participation was measured with a study-specific 10-item Likert scale. A score <3 was considered feasible, for the two items that assessed respondent burden a higher score indicated lesser participant burden and a score >3 was feasible. Recruitment was assessed by participation rates at baseline and retention at the 1-year follow-up, with threshold values for feasibility at 75% and 80%, respectively. Data collection and outcome measures were examined by completions rates of study procedures (90% was considered feasible), sample scores, internal consistency (alpha>0.70 was considered feasible), and agreement between self-reported data and data retrieved from medical records on opioid use (ICC or kappa>0.60 was considered feasible).

Results: Acceptability for study procedures was feasible, but participation rates were low: 25%. The retention rate at 1-year follow-up was 81% for those included in the feasibility study, that is, filling out computerised patient-reported outcome measures, and 65% for those using paper and pencil format. The completion rates for the different data collection methods ranged from 83% to 95%. Agreement between self-reported opioid use and prescribed dose and between opioid use disorder according to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), and clinical International Classification of Diseases-10 (ICD-10) diagnoses for opioid dependence were almost perfect (kappa=0.91and kappa=0.90, respectively).

Conclusions: This feasibility study has helped to explore and improve methods for recruitment, data collection and use of outcome measures for the U-PAIN cohort. Low participation rate and high refusal rate at baseline is a challenge that needs to be further addressed.

Objectives

The use of the Injustice Experience Questionnaire (IEQ) in psychological assessment of individuals with chronic pain is supported by research. The psychometric properties of the Swedish version, the IEQ-S, has not yet been evaluated. Hence, the aim was to investigate structural validity, and concurrent criterion validity of the IEQ-S against the Work Ability Index (WAI), the Pain Catastrophizing Scale (PCS-SW), the Patient Health Questionnaire 9-item depression module (PHQ-9), and the Generalized anxiety disorder 7-item scale (GAD-7). Internal consistency and test-retest reliability were also studied.

Methods

Sixty-five participants, referred to a University hospital, with a pain duration over three months were consecutively sampled. They completed the IEQ-S at admission and again within six weeks. A confirmatory factor analysis was performed for the study of structural validity. Concurrent criterion validity was evaluated using Spearman’s correlation coefficient. Internal consistency reliability for the full IEQ-S was calculated using the Cronbach’s alpha. Test-retest reliability was calculated using an Intraclass Correlation Coefficient (ICC).

Results

The median total score (0–48, where high scores indicate high levels of injustice) at admission (test 1) was 27.0 (n=64), 25th percentile=15.3, 75th percentile=37.8, range=3–48 points. A one-factor model was supported with item-loadings between 0.67–0.92. Spearman’s correlation coefficient between the IEQ-S and the WAI (n=56) was r _S =−0.46; the PCS-SW (n=63) was r _S =0.68, the PHQ-9 (n=64) was r _S =0.50 and the GAD-7 (n=64) was r _S =0.57, p<0.01. Cronbach’s alpha was 0.94 (n=64). The ICC was 0.80 (n=55), with a 95% confidence interval, ranging between 0.69–0.88.

Conclusions

Our study supported structural validity and concurrent criterion validity of the IEQ-S against other measures of psychological constructs and work ability. It also supported the internal consistency reliability of the IEQ-S and the test-retest reliability with a retest interval up to six weeks, was good. These findings support the use of the IEQ-S as an adjunct tool to assess appraisals of injustice in patients with chronic pain who are referred to tertiary care in Sweden. The added value might be identification of those who are at risk for slow or no improvement in their pain condition over time, and sick-leave, but this has to be confirmed in future studies.

The overarching aim of this thesis was to improve the understandings of opioid therapy for chronic non-cancer pain (CNCP) by examining the feasibility of different assessment methods of substance use, and opioid use disorder (OUD), and exploring the sense-making of opioid therapy in CNCP.  

Methods: In study I, the reliability of the Addiction Severity Index Self-Report form (ASI-SR) was assessed by the agreement (intraclass correlation (ICC)) between the composite scores (CS) of the ASI interview and the ASI-SR, internal consistency of the CS subscales measured with Cronbach’s α, and sensitivity and specificity of the alcohol and drug CS’s, using Receiver Operating Characteristics analyses. Study II was a feasibility study of the U-PAIN cohort. Cohen’s к, PABAK, and ICC were used to assess the agreement between self-reported data on opioid use and data from medical records. In study III, interpretative phenomenological analysis was used to explore the lived experience of managing CNCP with opioids. In Study IV, phenomenography was used to explore physicians’ understandings of prolonged opioid prescribing practices.

Results: In study I, 6/7 domains the ICC for the ASI interview and ASI-SR were good to excellent. Internal consistency was acceptable for 5/7 of the domains. Alcohol- and drug CS’s predicted clinical substance dependence diagnoses. In study II, the agreement between self-reported opioid use and prescribed dose, and the agreement between OUD according to DSM-5 and clinical ICD-10 opioid dependence diagnoses, were almost perfect. In study III, opioids were used to regain control over the pain, but opioid use could also be experienced as a downward spiral of pain, dependence, and stigmatization. In study IV, specifics of a patient could justify opioid therapy. Insufficient follow-up, ignorance about pain management and opioids, an obligation to treat patients’ pain, and lack of alternative treatments, were understood to drive continued opioid prescribing practices. 

Conclusion: The studies suggest that the examined assessment methods of self-reported opioid use were feasible for assessing patterns of opioid use. To manage CNCP pain with opioids was experienced and conceptualized as a balancing act between pain control and quality of life, and aversive effects of opioids, e.g., OUD and stigmatization. 

Background: The use of opioids to relieve chronic pain has increased during the last decades, but experiences of chronic opioid therapy (COT) (> 90 days) point at risks and loss of beneficial effects. Still, some patients report benefits from opioid medication, such as being able to stay at work. Guidelines for opioid use in chronic pain do not consider the individual experience of COT, including benefits and risks, making the first person perspective an important scientific component to explore. The aim of this study was to investigate the lived experience of managing chronic pain with opioids in a sample who have severe chronic pain but are able to manage their pain sufficiently to remain at work.

Methods: We used a qualitative research design: interpretative phenomenological analysis. Ten individuals with chronic pain and opioid therapy were purposively sampled in Swedish tertiary care.

Results: Three super-ordinate themes emerged from the analyses: Without opioids, the pain becomes the boss; Opioids as a salvation and a curse, and Acknowledgement of the pain and acceptance of opioid therapy enables transition to a novel self. The participants used opioids to regain control over their pain, thus reclaiming their wanted life and self, and sense of control over one's life-world. Using opioids to manage pain was not unproblematic and some of the participants had experienced a downward spiral of escalating pain and uncontrollable opioid use, and stigmatisation.

Conclusions: All participants emphasised the importance of control, regarding both pain and opioid use. To accomplish this, trust between participants and health care providers was essential for satisfactory treatment. Regardless of the potential sociocultural benefits of staying at work, participants had experiences of balancing positive and negative effects of opioid therapy, similar to what previous qualitative research has found. Measurable improvement of function and quality of life, may justify the long-term use of opioids in some cases. However, monitoring of adverse events should be mandatory. This requires close cooperation and a trusting relationship between the patients and their health care provider.

Objectives:

The Addiction Severity Index (ASI) is a standardized interview used to assess problems associated with substance use. Although widely used, the time required for the interview remains an obstacle to its acceptance in many clinical settings. We examined if a self-administered questionnaire based on the composite score (CS) items, the ASI Self-Report form (ASI-SR), offers a reliable alternative to the ASI in assessing current substance use and related problems.

Methods:

Participants were 59 treatment seeking individuals entering outpatient programs at the Addiction Psychiatric Clinic at Uppsala University Hospital who were assessed with Swedish versions of the ASI and ASI-SR. Agreement between the ASI interview's CS and ASI-SR's CS was evaluated on the individual basis by intraclass correlation analysis (ICC) and on group level with the Wilcoxon signed rank test. Reliability and internal consistency were evaluated using Cronbach's alpha.

Results:

For 6 out of 7 CS domains, the ICC for the ASI interview and ASI-SR were good to excellent. Internal consistency was acceptable for 6 out of 7 CS domains on the ASI interview and for 5 out of 7 CS domains on the ASI-SR.

Conclusions:

The present study suggests that the ASI-SR is a reliable alternative to the ASI interview for assessing current patient functioning and evaluation of problems related to alcohol and drug use.