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Exploratory study examining associations between prescription opioid dose and delay discounting in patients with chronic pain

Benjamin J. Morasco, PhD, Steven K. Dobscha, MD, Stephanie Hyde, MA, Suzanne H. Mitchell, PhD


Objective: Although some research has identified correlates of high-dose opioid prescriptions, relatively little is known about factors that lead to higher doses. Delay discounting (DD), defined as the subjective value of a reward declining as a function of the delay to that reward, is an objective measure of impulsivity. DD is commonly studied in the context of addictive behaviors, and findings consistently demonstrate greater DD among individuals with opioid use disorders. The authors conducted a preliminary investigation to examine the extent to which DD is associated with prescription opioid dose among patients with musculoskeletal pain.

Design: Cross-sectional study.

Setting: A single veterans affairs medical center located in the Pacific Northwest.

Subjects: Participants with chronic musculoskeletal pain. The authors identified patients prescribed with high doses of opioids (100 mg morphine equivalent per day [MED] or more; n = 17), traditional doses of opioids (5-99 mg MED; n = 34), and patients with pain who were not prescribed opioids (n = 24).

Methods: All participants completed a battery of self-report measures assessing demographic characteristics, pain-related variables, and psychiatric symptoms. Participants also completed a computerized DD task.

Results: DD was negatively correlated with average daily opioid dose (p = 0.003) and positively correlated with anxiety (p = 0.013). In a multivariable regression analysis, after controlling for the effects of demographic and clinical factors, DD was significantly associated with prescription opioid dose.

Conclusions: Contrary to study expectations, higher opioid dose was associated with less DD. These findings call for prospective research to further elucidate the relationships between DD and other measures of impulsivity and prescription opioid doses.


chronic pain, prescription opioids, delay discounting, opioid dose

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Boudreau D, Von Korff M, Rutter CM, et al.: Trends in long-term opioid therapy for chronic non-cancer pain. Pharmacoepidemiol Drug Saf. 2009; 18: 1166-1175.

Caudill-Slosberg MA, Schwartz LM, Woloshin S: Office visits and analgesic prescriptions for musculoskeletal pain in US: 1980 vs. 2000. Pain. 2004; 109: 514-519.

Becker WC, Gordon K, Edelman J, et al.: Trends in any and high-dose opioid analgesic receipt among aging patients with and without HIV. AIDS Behav. 2016; 20: 679-686.

Weisner CM, Campbell CI, Ray GT, et al.: Trends in prescribed opioid therapy for non-cancer pain for individuals with prior substance use disorders. Pain. 2009; 145: 287-293.

Chou R, Turner JA, Devine EB, et al.: The effectiveness and risks of long-term opioid therapy for chronic pain: A systematic review for a National Institutes of Health Pathways to Prevention Workshop. Ann Intern Med. 2015; 162: 276-286.

Kobus AM, Smith DH, Morasco BJ, et al.: Correlates of high-dose opioid medication use for low back pain in primary care. J Pain. 2012; 13: 1131-1138.

Merrill JO, Von Korff M, Banta-Green CJ, et al.: Prescribed opioid difficulties, depression and opioid dose among chronic opioid therapy patients. Gen Hosp Psychiatry. 2012; 34: 581-587.

Morasco BJ, Duckart JP, Carr TP, et al.: Clinical characteristics of veterans prescribed high doses of opioid medications for chronic non-cancer pain. Pain. 2010; 151: 625-632.

Morasco BJ, Yarborough BJ, Smith NX, et al.: Higher prescription opioid dose is associated with worse patient-reported pain outcomes and more health care utilization. J Pain. 2017; 18: 437-445.

Dasgupta N, Jonsson M, Proescholdbell S, et al.: Cohort study of the impact of high-dose opioid analgesics on overdose mortality. Pain Med. 2016; 17: 85-98.

Madden GJ, Johnson PS: A delay-discounting primer. In Madden GJ, Bickel WK (eds.): Impulsivity: The Behavioral and Neurological Science of Discounting. Washington, DC: American Psychological Association, 2010: 213-242.

Rachlin H: Diminishing marginal value as delay discounting. J Experimental Analysis Behav. 1992; 57: 407-415.

Robles E, Huang BE, Simpson PM, et al.: Delay discounting, impulsiveness, and addiction severity in opioid-dependent patients. J Sub Abuse Treat. 2011; 41: 354-362.

Dennhardt AA, Murphy JG: Associations between depression, distress tolerance, delay discounting, and alcohol-related problems in European American and African American college students. Psychol Addict Behav. 2011; 25: 595-604.

Joos L, Goudriaan AE, Schmaal L, et al.: The relationship between impulsivity and craving in alcohol dependent patients. Psychopharmacology. 2013; 226: 273-283.

Kirby KN, Petry NM: Heroin and cocaine abusers have higher discount rates for delayed rewards than alcoholics or non-drug-using controls. Addict. 2004; 99: 461-471.

Yi R, Mitchell SH, Bickell WK: Delay discounting and substance abuse. In Maden GJ, Bickel WK (eds.): Impulsivity: The Behavioral and Neurological Science of Discounting. Washington, DC: American Psychological Association, 2010: 191-211.

Madden GJ, Petry NM, Badger GJ, et al.: Impulsive and self-control choices in opioid-dependent patients and non-drug-using control patients: Drug and monetary rewards. Exp Clin Psychopharmacol. 1997; 5: 256-262.

Bickel WK, Koffarnus MN, Moody L, et al.: The behavioral and neuro-economic process of temporal discounting: A candidate behavioral marker of addiction. Neuropharmacology. 2014; 76(Pt B): 518-527.

Mackillop J, Amlung MT, Few LR, et al.: Delayed reward discounting and addictive behavior: A meta-analysis. Psychopharmacology. 2011; 216: 305-321.

Tomkins DA, Johnson PS, Smith MT, et al.: Temporal preference in individuals reporting chronic pain: Discounting of delayed pain-related and monetary outcomes. Pain. 2016; 157: 1724-1732.

Elman I, Borsook D: Common brain mechanisms of chronic pain and addiction. Neuron. 2016; 89: 11-36.

Kerns RD, Turk DC, Rudy TE: The West Haven-Yale Multidimensional Pain Inventory (WHYMPI). Pain. 1985; 23: 345-356.

Beck AT, Steer RA, Brown GK: The Beck Depression Inventory. 2nd ed. San Antonio, TX: The Psychological Corporation, 1996.

Spitzer RL, Kroenke K, Williams JBW, et al.: A brief measure for assessing generalized anxiety disorder: The GAD-7. Arch Int Med. 2006; 166: 1092-1097.

Kroenke K, Spitzer RL, Williams JB, et al.: Anxiety disorders in primary care: Prevalence, #impairment, |comorbidity, and detection. Ann Intern Med. 2007; 146: 317-327.

Adams LL, Gatchel RJ, Robinson RC, et al.: Development of a self-report screening instrument for assessing potential opioid medication misuse in chronic pain patients. J Pain Symptom Manage. 2004; 27: 440-459.

Sobell LC, Sobell MB: Timeline follow-back: A technique for assessing self-reported alcohol consumption. In Litton RZ, Allen JP (eds.): Measuring Alcohol Consumption: Psychosocial and Biochemical Methods. Clifton, NJ: Human Press, 1992: 41-72.

Mitchell SH: Measures of impulsivity in cigarette smokers and non-smokers. Psychopharmacology. 1999; 146: 455-464.

Mazur JE: An adjusting procedure for studying delayed reinforcement. In Commons ML, Mazur JE, Nevin JA, Rachlin H (eds.): The Effect of Delay and of Intervening Event on Reinforcement Value. Quantitative Analyses of Behavior. Vol. 5. Hillsdale, NJ: Lawrence Erlbaum Associates, Inc, 1987: 55-73.

Amlung M, Vedelago L, Acker J, et al.: Steep delay discounting and addictive behavior: A meta-analysis of continuous associations. Addict. 2017; 112: 51-62.

Ersche K, Roiser J, Clark L, et al.: Punishment induces risky decision-making in methadone-maintained opiate users but not in heroin users or healthy volunteers. Neuropsychopharmacology. 2005; 30: 2115-2124.

Giordano LA, Bickel WK, Loewenstein G, et al.: Mild opioid deprivation increases the degree that opioid-dependent outpatients discount delayed heroin and money. Psychopharmacology. 2002; 163: 174-182.

Dobscha SK, Corson K, Flores JA, et al.: Veterans Affairs primary care clinicians’ attitudes toward chronic pain and correlates of opioid prescribing rates. Pain Med. 2008; 9: 564-571.

Fredheim OMS, Borchgrevink PC, Mahic M, et al.: A pharmacoepidemiological cohort study of subjects starting strong opioids for nonmalignant pain: A study from the Norwegian Prescription Database. Pain. 2013; 154: 2487-2493.

Henry SG, Wilsey BL, Melnikow J, et al.: Dose escalation during the first year of long-term opioid therapy for chronic pain. Pain Med. 2015; 16: 733-744.

Hirsch A, Proescholdbell SK, Bronson W, et al.: Prescription histories and dose strengths associated with overdose deaths. Pain Med. 2014; 15: 1187-1195.

Siegler JE, Kable JW, Chatterjee A: Resident decision making: Opioids in the outpatient setting. J Grad Med Educ. 2016; 8: 138-141.

Le Merrer J, Becker JAJ, Befort K, et al.: Reward processing by the opioid system in the brain. Physiol Rev. 2009; 89: 1379-1412.

Dhingra L, Ahmed E, Shin J, et al.: Cognitive effects and sedation. Pain Med. 2015; 16(suppl 1): S37-S43.

Zlott DA, Byrne M: Mechanisms by which pharmacologic agents may contribute to fatigue. Phys Med Rehabil. 2010; 2: 451-455.

Paterson C, Ledgerwood K, Arnold C, et al.: Resisting prescribed opioids: A qualitative study of decision making in patients taking opioids for chronic noncancer pain. Pain Med. 2016; 17: 717-727.

Schumacher KL, West C, Dodd M, et al.: Pain management autobiographies and reluctance to use opioids for cancer pain management. Cancer Nurs. 2002; 25: 125-133.



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