Published online Dec 26, 2019. doi: 10.12998/wjcc.v7.i24.4254
Peer-review started: April 15, 2019
First decision: September 9, 2019
Revised: October 17, 2019
Accepted: November 26, 2019
Article in press: November 26, 2019
Published online: December 26, 2019
The prescription of opioid drugs as a treatment strategy for patients with chronic pain unrelated to cancer has increased considerably. However, the effectiveness of this drug treatment has not been fully demonstrated and opioid misuse is common in these patients. In addition, substance abuse has been shown to be common in people with mental health problems. These include post-traumatic stress disorder. Additionally, it has been detected that patients with posttraumatic stress have higher rates of opioid prescriptions. Since this disorder has a high co-morbidity with chronic pain, chronic non-cancer pain (CNCP) patients with posttraumatic stress disorder (PTSD) can be at risk due to the wrong use of opioid.
The identification of individuals in danger of developing opioid use disorder (OUD) is certainly relevant in the field of medical intervention for patients with CNCP. Despite this, there are no published systematic reviews on the association between posttraumatic stress, chronic pain of benign origin, and opioid intake (i.e., prescription, misuse, and abuse).
A systematic review was accomplished in order to offer a comprehensive overview on currently available data regarding opioid intake in CNCP patients with comorbid PTSD.
We organized a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2009 Checklist. The Patients, Intervention, Comparator, and Outcomes(PICOS) criteria were formulated a priori in the protocol of the systematic review. A search was conducted of the PROSPERO database. PubMed, MEDLINE, PsycINFO, Web of Science, and PILOTS was extensively investigated in March 2019 for any papers reporting the following terms: chronic pain, post-traumatic stress AND opioid. The search was limited to English and Spanish languages, peer-reviews, and human studies. No time limits were applied. Duplicate articles were removed. Remainder were screened out reading titles and abstracts. Manuscripts were assessed in full text if the study was quantitative, only included adults (> 18 years) and participants with both CNCP and posttraumatic stress receiving opioids for pain treatment. Selected studies were also assessed for methodological quality using the Scottish Intercollegiate Guidelines Network checklist for cohort studies. Given the nature of the studies, we decided not to meta-analyze data. To the best of our knowledge, this is the first systematic review on the topic.
In the preliminary search, 151 articles were identified. After duplicate were removed (n = 45), a pool of 106 manuscripts were remained for further evaluation. Reviewing articles by title and abstract, 86 were rejected because they did not meet the selection criteria and 10 were retained for analysis. The 10 eligible studies included 1622785 unique participants. In total, 196516 participants had comorbid CNCP and a PTSD, and were consuming opiates. The cross-study mean age was 35.2 years. The majority of participants were men of Caucasian origin, recruited from the veterans' health care system. Musculoskeletal pain was the most common chronic pain condition in the participants. In total, 42.4% of the participants across studies had a diagnosis of PTSD. All the studies reported evidence of a greater prevalence of this disorder in those patients who had been prescribed opioids. Regarding to opioid intake, 2 different outcome variables were identified across studies: opioid prescriptions and OUD. Opioid prescriptions were generally assessed according to the medical prescription-dispensing pattern, although this pattern was defined in different ways, such as total number of prescription days and pharmacy records of opioid prescriptions. The studies that investigated OUD shown that this disorder was associated with a diagnosis of posttraumatic stress in CNCP patients.
Our systematic review shows that participants with comorbid posttraumatic stress and CNCP obtain higher doses of opioids, receive more than 1 type of opioid concurrently, and are more likely to be receiving opioids chronically. Furthermore, the findings suggest that PTSD is associated with OUD in CNCP patients. In addition, the results of this review show that there is high co-occurrence between CNCP, PTSD, and other psychological disorders such as depression, anxiety, and substance abuse. The choice of opioid treatment for CNCP patients should include screening for baseline PTSD, particularly when combined with benzodiazepines.
Overall results of this systematic review are encouraging, but there is a lack of civilian population studies and also with female participants. Likewise, there are differences between the studies included in this review relating to the nature, the size of the samples and the criteria employed for assessing PTSD. More research is therefore needed in this area.