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Risk of chronic opioid use in older persons with pre-existing anxiety

Anna K. Moffat, PhD, Nicole L. Pratt, PhD, Mhairi Kerr, MSc, Lisa M. Kalisch Ellett, PhD, Elizabeth E. Roughead, PhD


Objective: Work that has shown a relationship between anxiety and chronic opioid use has not focused on older people specifically, despite the additional risks in older populations. This study aimed to understand whether anxiety prior to opioid initiation increased the likelihood of chronic opioid use over time in persons aged 60 years or older.

Design: Administrative claims data were used to calculate time between initiation of opioids and a first chronic episode of opioid use. Patients were classified as having a history of anxiety if they were dispensed medicines in the anxiolytics class or had a hospitalization event for anxiety prior to treatment with an opioid. Proportional hazards models were used to compare the likelihood of experiencing a chronic episode of opioid use between those with and without a history of anxiety.

Results: The cohort was 15,000 persons, of which, 5,076 (34 percent) had history of anxiety. Those with anxiety prior to their first opioid dispensing were 30 percent more likely to have an episode of chronic use after adjustment for age, gender, number of comorbidities, and prior surgery (HR = 1.30, 95% CI = 1.16-1.47). The risk of a chronic episode in patients who had surgery prior to initiation of an opioid was 60 percent greater in those with anxiety compared to no anxiety (HR = 1.60, 95% CI = 1.21-2.11) and 24 percent greater in those with anxiety but no prior surgery (HR = 1.24, 95% CI = 1.08-1.42).

Conclusions: A significant proportion of older people will have a chronic episode of opioid use. This risk is increased where a history of anxiety is present.


chronic opioid use, anxiety, risk, older

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Edlund MJ, Steffick D, Hudson T, et al.: Risk factors for clinically recognized opioid abuse and dependence among veterans using opioids for chronic non-cancer pain. Pain. 2007; 129(3): 355-362.

Karanges EA, Blanch B, Buckley NA, et al.: Twenty-five years of prescription opioid use in Australia: A whole-of-population analysis using pharmaceutical claims. Br J Clin Pharmacol. 2016; 82(1): 255-267.

Degenhardt L, Black E, Breen C, et al.: Trends in morphine prescriptions, illicit morphine use and associated harms among regular injecting drug users in Australia. Drug Alcohol Rev. 2006; 25(5): 403-412.

Cicero TJ, Wong G, Tian Y, et al.: Co-morbidity and utilization of medical services by pain patients receiving opioid medications: Data from an insurance claims database. Pain. 2009; 144(1-2): 20-27.

Braden JB, Russo J, Fan MY, et al.: Emergency department visits among recipients of chronic opioid therapy. Arch Intern Med. 2010; 170(16): 1425-1432.

Birnbaum H, White AG, Reynolds JL, et al.: Estimated costs of prescription opioid analgesic abuse in the United States in 2001: A societal perspective. Clin J Pain. 2006; 22(8): 667-676.

Ballantyne JC, Mao J: Opioid therapy for chronic pain. N Engl J Med. 2003; 349(20): 1943-1953.

Daniell HW: Hypogonadism in men consuming sustained-action oral opioids. J Pain. 2002; 3(5): 377-384.

Roberts GW, Bekker TB, Carlsen HH, et al.: Postoperative nausea and vomiting are strongly influenced by postoperative opioid use in a dose-related manner. Anesth Analg. 2005; 101(5): 1343-1348.

Porreca F, Ossipov MH: Nausea and vomiting side effects with opioid analgesics during treatment of chronic pain: Mechanisms, implications, and management options. Pain Med. 2009; 10(4): 654-662.

Mitra S: Opioid-induced hyperalgesia: Pathophysiology and clinical implications. J Opioid Manag. 2008; 4(3): 123-130.

Hallinan R, Byrne A, Agho K, et al.: Erectile dysfunction in men receiving methadone and buprenorphine maintenance treatment. J Sex Med. 2008; 5(3): 684-692.

Center for Disease Control and Prevention: Vital signs: Overdoses of prescription opioid pain relieversùUnited States, 1999û2008. MMWR Morb Mortal Wkly Rep. 2011; 60(43): 1487.

Chu LF, Clark DJ, Angst MS: Opioid tolerance and hyperalgesia in chronic pain patients after one month of oral morphine therapy: A preliminary prospective study. J Pain. 2006; 7(1): 43-48.

Lanier RK, Lofwall MR, Mintzer MZ, et al.: Physical dependence potential of daily tramadol dosing in humans. Psychopharmacology. 2010; 211(4): 457-466.

Passik SD, Lowery A: Psychological variables potentially implicated in opioid-related mortality as observed in clinical practice. Pain Med. 2011; 12: S36-S42.

Pratt NL, Roughead EE: Can we reduce the prevalence of persistent opioid use after surgery by predicting the future? Anaesth Intensive Care. 2017; 45(6): 658-659.

Volkow ND, McLellan AT: Opioid abuse in chronic pain–Misconceptions and mitigation strategies. N Engl J Med. 2016; 374(13): 1253-1263.

Von Korff M: Long-term use of opioids for complex chronic pain. Best Pract Res Clin Rheumatol. 2013; 27(5): 663-672.

Miller M, Stⁿrmer T, Azrael D, et al.: Opioid analgesics and the risk of fractures in older adults with arthritis. J Am Geriatr Soc. 2011; 59(3): 430-438.

Saunders KW, Dunn KM, Merrill JO, et al.: Relationship of opioid use and dosage levels to fractures in older chronic pain patients. J Gen Intern Med. 2010; 25(4): 310-315.

Buckeridge D, Huang A, Hanley J, et al.: Risk of injury associated with opioid use in older adults. J Am Geriatr Soc. 2010; 58(9): 1664-1670.

Ensrud KE, Blackwell TL, Mangione CM, et al.: Central nervous system-active medications and risk for falls in older women. J Am Geriatr Soc. 2002; 50(10): 1629-1637.

Kalisch Ellett LM, Pratt NL, Ramsay EN, et al.: Central nervous system-acting medicines and risk of hospital admission for confusion, delirium, or dementia. J Am Med Dir Assoc. 2016; 17(6): 530-534.

Solomon DH, Rassen JA, Glynn RJ, et al.: The comparative safety of analgesics in older adults with arthritis. Arch Intern Med. 2010; 170(22): 1968-1978.

Barber JB, Gibson SJ: Treatment of chronic non-malignant pain in the elderly: Safety considerations. Drug Saf. 2009; 32(6): 457-474.

Holliday S, Hayes S, Dunlop A: Opioid use in chronic noncancer pain: Part 2: Prescribing issues and alternatives. Aust Fam Physician. 2013; 42(3): 104-111.

Sun EC, Darnall BD, Baker LC, et al.: Incidence of and risk factors for chronic opioid use among opioid-naive patients in the postoperative period. JAMA Intern Med. 2016; 176(9): 1286-1293.

Seal KH, Shi Y, Cohen G, et al.: Association of mental health disorders with prescription opioids and high-risk opioid use in us veterans of Iraq and Afghanistan. JAMA. 2012; 307(9): 940-947.

Edlund MJ, Martin BC, Devries A, et al.: Trends in use of opioids for chronic noncancer pain among individuals with mental health and substance use disorders: The TROUP study. Clin J Pain. 2010; 26(1): 1-8.

Edlund MJ, Forman-Hoffman VL, Winder CR, et al.: Opioid abuse and depression in adolescents: Results from the National Survey on Drug Use and Health. Drug Alcohol Depend. 2015; 152: 131-138.

Becker WC, Sullivan LE, Tetrault JM, et al.: Non-medical use, abuse and dependence on prescription opioids among U.S. adults: Psychiatric, medical and substance use correlates. Drug Alcohol Depend. 2008; 94(1-3): 38-47.

Colasanti A, Rabiner EA, Lingford-Hughes A, et al.: Opioids and anxiety. J Psychopharmacol. 2011; 25(11): 1415-1433.

Martins SS, Fenton MC, Keyes KM, et al.: Mood and anxiety disorders and their association with non-medical prescription opioid use and prescription opioid-use disorder: Longitudinal evidence from the National Epidemiologic Study on Alcohol and Related Conditions. Psychol Med. 2012; 42(6): 1261-1272.

Rhudy JL, Dubbert PM, Parker JD, et al.: Affective modulation of pain in substance-dependent veterans. Pain Med. 2006; 7(6): 483-500.

Wasan AD, Davar G, Jamison R: The association between negative affect and opioid analgesia in patients with discogenic low back pain. Pain. 2005; 117(3): 450-461.

Auret K, Schug SA: Underutilisation of opioids in elderly patients with chronic pain. Drugs Aging. 2005; 22(8): 641-654.

Spitz A, Moore AA, Papaleontiou M, et al.: Primary care providers’ perspective on prescribing opioids to older adults with chronic non-cancer pain: A qualitative study. BMC Geriatr. 2011; 11(1): 35.

Helmerhorst GT, Vranceanu AM, Vrahas M, et al.: Risk factors for continued opioid use one to two months after surgery for musculoskeletal trauma. J Bone Joint Surg Am. 2014; 96(6): 495-499.

De Cosmo G, Congedo E, Lai C, et al.: Preoperative psychologic and demographic predictors of pain perception and tramadol consumption using intravenous patient-controlled analgesia. Clin J Pain. 2008; 24(5): 399-405.

Özalp G, Sarioglu R, Tuncel G, et al.: Preoperative emotional states in patients with breast cancer and postoperative pain. Acta Anaesthesiol Scand. 2003; 47(1): 26-29.

Quinn PD, Hur K, Chang Z, et al.: Incident and long-term opioid therapy among patients with psychiatric conditions and medications: A national study of commercial healthcare claims. Pain. 2017; 158(1): 140-148.

Clarke H, Soneji N, Ko DT, et al.: Rates and risk factors for prolonged opioid use after major surgery: Population based cohort study. BMJ. 2014; 348: g1251.

Anatomical Therapeutic Chemical Classification Index with Defined Daily Doses. Oslo, Norway: World Health Organization Collaborating Centre for Drug Statistics Methodology, 2016. Available at Accessed June 20, 2016.

Australian Government Department of Health and Ageing: Pharmaceutical benefits scheme. 2016. Available at Accessed June 20, 2016.

International Statistical Classification of Diseases and Related Health Problems, 10th Revision. Geneva: World Health Organization, 2016. Available at Accessed June 20, 2016.

Hoffman EM, Watson JC, St Sauver J, et al.: Association of long-term opioid therapy with functional status, adverse outcomes, and mortality among patients with polyneuropathy. JAMA Neurol. 2017; 74(7): 773-779.

Martin BC, Fan MY, Edlund MJ, et al.: Long-term chronic opioid therapy discontinuation rates from the TROUP study. J Gen Intern Med. 2011; 26(12): 1450-1457.

Clark DO, Von Korff M, Saunders K, et al.: A chronic disease score with empirically derived weights. Med Care. 1995; 33(8): 783-795.

Von Korff M, Wagner EH, Saunders K: A chronic disease score from automated pharmacy data. J Clin Epidemiol. 1992; 45(2): 197-203.

Zacny J, Bigelow G, Compton P, et al.: College on problems of drug dependence taskforce on prescription opioid non-medical use and abuse: Position statement. Drug Alcohol Depend. 2003; 69(3): 215-232.

Kerridge BT, Saha TD, Chou SP, et al.: Gender and nonmedical prescription opioid use and DSM-5 nonmedical prescription opioid use disorder: Results from the National Epidemiologic Survey on Alcohol and Related Conditions – III. Drug Alcohol Depend. 2015; 156: 47-56.

Tetrault JM, Desai RA, Becker WC, et al.: Gender and nonmedical use of prescription opioids: Results from a national US survey. Addiction. 2008; 103(2): 258-268.

Campbell CI, Weisner C, Leresche L, et al.: Age and gender trends in long-term opioid analgesic use for noncancer pain. Am J Public Health. 2010; 100(12): 2541-2547.

Martins SS, Keyes KM, Storr CL, et al.: Pathways between nonmedical opioid use/dependence and psychiatric disorders: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. Drug Alcohol Depend. 2009; 103(1): 16-24.

Ballantyne JC: Opioids for the treatment of chronic pain: Mistakes made, lessons learned, and future directions. Anesth Analg. 2017; 125(5): 1769-1778.

Saunders KW, Von Korff M, Campbell CI, et al.: Concurrent use of alcohol and sedatives among persons prescribed chronic opioid therapy: Prevalence and risk factors. J Pain. 2012; 13(3): 266-275.

Martins SS, Storr CL, Zhu H, et al.: Correlates of extramedical use of OxyContin® versus other analgesic opioids among the US general population. Drug Alcohol Depend. 2009; 99(1-3): 58-67.

Jones CM, McAninch JK: Emergency department visits and overdose deaths from combined use of opioids and benzodiazepines. Am J Prev Med. 2015; 49(4): 493-501.



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