Prescription painkiller misuse and addiction are widespread in chronic pain patients

A new scientific review of 148 studies enrolling over 4.3 million adult chronic pain patients treated with prescription opioid painkillers has found that nearly one in ten patients experiences opioid dependence or opioid use disorder and nearly one in three shows symptoms of dependence and opioid use disorder.  This review provides a more accurate -- and more concerning -- rate of opioid misuse than has previously been calculated.  It was conducted by researchers at the University of Bristol, funded by the National Institute for Health and Care Research (NIHR), and appears in the scientific journal Addiction.

Companies like Oxycontin manufacturer Purdue Pharma have claimed that fewer than 1% of opioid prescriptions result in problems for patients.  This new review makes clear that such claims greatly understate the risk of opioid misuse and addiction. 

The researchers divided the 148 studies into four general categories, depending on how the studies defined problematic opioid use:

1. dependence and opioid use disorder: 43 studies that identified problematic opioid use through diagnostic codes (formal diagnoses using precise definitions);
2. signs and symptoms of dependence and opioid use disorder:  44 studies that looked for behaviours indicating dependence and opioid use disorder, such as craving, tolerance, or withdrawal, without use of specific diagnostic codes; 
3. aberrant behaviour: 76 studies that looked for inappropriate or concerning behaviour, such as seeking early refills, repeated dose escalations, or frequently lost prescriptions; and
4. at risk of dependence and opioid use disorder: 8 studies that looked for characteristics that might increase the risk of developing opioid dependence or opioid use disorder in the future; however, the characteristics do not fall within previous categories of aberrant behaviour or dependence and opioid use disorder.

Some studies reported multiple results within the same participants using different measurement criteria, so the sum of the number of studies in each category equals more than 148.  The prevalence (frequency) of problematic opioid use for each category was:

1. Dependence and opioid use disorder:  9.3%, or nearly 1 in 10 patients.
2. Signs and symptoms of dependence and opioid use disorder: 29.6%, nearly 1 in 3 patients.
3. Aberrant behaviour:  22%, more than 1 in 5 patients.
4. At risk of dependence and opioid use disorder: 12.4%, nearly 1 in 8 patients.

Lead author Kyla Thomas, Professor of Public Health Medicine at the University of Bristol, explains, “Clinicians and policy makers need a more accurate estimate of the prevalence of problematic opioid use in pain patients so that they can gauge the true extent of the problem, change prescribing guidance if necessary, and develop and implement effective interventions to manage the problem.  Knowing the size of the problem is a necessary step to managing it.”

The studies in this review were predominantly from North American research and high-income countries. One hundred and six of the 148 studies were conducted between 2010 and 2021; the oldest study was from 1985.  Study size ranged from 15 to 2,304,181 patients. Due to the high heterogeneity of the studies, these findings should be interpreted with caution. 

-- Ends –

For editors:

This Open Access paper is available on the Wiley Online Library (https://onlinelibrary.wiley.com/doi/10.1111/add.16616) or you may request a copy from Jean O’Reilly, Editorial Manager, Addiction, jean@addictionjournal.org.

To speak with lead author Professor Kyla Thomas (Professor of Public Health Medicine), please contact her at the University of Bristol (UK) by e-mail (Kyla.Thomas@bristol.ac.uk). 

For further information or to arrange an interview with Professor Kyla Thomas please contact Joanne Fryer [Mon to Wed], email joanne.fryer@bristol.ac.uk, mobile: +44 (0)7747 768805 or Caroline Clancy [Wed to Fri], email caroline.clancy@bristol.ac.uk, mobile: +44 (0)7776 170238 in the University of Bristol Press Office.

Full citation for article: Thomas KH, Dalili MN, Cheng H-Y, Dawson S, Donnelly N, Higgins JPT, and Hickman M.  Prevalence of problematic pharmaceutical opioid use in patients with chronic non cancer pain: a systematic review and meta-analysis. Addiction. 2024. DOI: 10.1111/add.16616

Primary funding: National Institute for Health and Care Research:  PDF-2017-10-068

Declaration of interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: KT reports financial support from the National Institute for Health and Care Research (NIHR) for this study.

Addiction (www.addictionjournal.org) is a monthly international scientific journal publishing peer-reviewed research reports on alcohol, substances, tobacco, gambling, editorials, and other debate pieces. Owned by the Society for the Study of Addiction, it has been in continuous publication since 1884.

The mission of the National Institute for Health and Care Research (NIHR) (https://www.nihr.ac.uk/) is to improve the health and wealth of the nation through research. We do this by:

• Funding high quality, timely research that benefits the NHS, public health and social care;
• Investing in world-class expertise, facilities and a skilled delivery workforce to translate discoveries into improved treatments and services;
• Partnering with patients, service users, carers and communities, improving the relevance, quality and impact of our research;
• Attracting, training and supporting the best researchers to tackle complex health and social care challenges;
• Collaborating with other public funders, charities and industry to help shape a cohesive and globally competitive research system;
• Funding applied global health research and training to meet the needs of the poorest people in low and middle income countries.

NIHR is funded by the Department of Health and Social Care. Its work in low and middle income countries is principally funded through UK international development funding from the UK government.

Please note the following resources for chronic pain and opioids:

• NICE guidance on chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain: https://www.nice.org.uk/guidance/ng193/chapter/Recommendations#managing-chronic-primary-pain
• Opioids Aware: a resource for patients and healthcare professionals to support prescribing of opioid medicines for pain:  https://www.fpm.ac.uk/opioids-aware
• How to get NHS help for your pain:  https://www.nhs.uk/live-well/pain/how-to-get-nhs-help-for-your-pain/
• National Institute on Drug Abuse information on opioids: https://nida.nih.gov/research-topics/opioids
• CDC Clinical Practice Guideline for Prescribing Opioids for Pain (2022): https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm