Friday, May 7, 2010

Do Men & Women Differ in Opioid-Abuse Risks?

Briefly NotedA study recently published in the Journal of Pain found important differences between men and women that determine risks for abuse of opioid analgesics prescribed for chronic noncancer pain. However, the indiscriminate application of such stereotypes may hinder effective pain management.

Researchers affiliated with Harvard Medical School enrolled 275 male and 335 female patients who had been prescribed opioid analgesics for chronic noncancer pain in a longitudinal predictive study. Participants were asked to complete a series of baseline questionnaires, including the revised Screener and Opioid Assessment for Pain Patients (SOAPP-R). After 5 months, subjects were administered the Prescription Drug Use Questionnaire (PDUQ) and submitted a urine sample for toxicology assessment. Their treating physicians also completed a substance misuse behavior checklist (Prescription Opioid Therapy Questionnaire; POTQ).

The results of the study showed that men and women have similar frequencies of aberrant drug-use behavior, but gender differences were found in risk factors for misuse of opioid medications. At the 5-month followup, women showed significantly higher scores on the PDUQ (p<.05), whereas men had a higher incidence of physician-rated aberrant drug behavior on the POTQ (p<.05). An item analysis of the SOAPP-R, PDUQ, and POTQ showed that women scored higher on items relating to psychological factors, whereas male patients reported having more legal and behavioral problems.

In a news release (via NewsWise), lead author Robert Jamison noted, “Our analysis showed that drug misuse by women is motivated more by emotional issues and psychological distress while in men this behavior usually stems from problematic social and behavioral problems that lead to substance abuse. Further, women who misuse pain drugs are more likely to admit to being sexually or physically abused or have a history of psychiatric or psychological problems.” The researchers recommend that for women being treated with opioids for chronic noncancer pain with evidence of significant affective stress, clinicians should treat the mood disorder and counsel on the dangers of relying on opioids to reduce stress and improve sleep. For men, closer monitoring of known or suspected behavioral problems, frequent urine screens, pill counts, and compliance monitoring are recommended to help reduce risks for drug misuse.

COMMENTARY: It should be noted that two of the study authors are affiliated with a commercial enterprise that develops and promotes opioid-abuse assessment questionnaires, so there could be inherent biases. While some of the available opioid misuse questionnaires have demonstrated strong internal validity (reliability, sensitivity, specificity) in clinical trials, their external validity and applicability in everyday pain management practice has been questioned. It should come as no surprise that men and women may differ in their motivations and personal factors influencing opioid misuse. This research seems to suggest that emotional factors are more important in women (“troubled girls”) and behavioral issues are prime factors in men (“bad boys”); however, relying on assessment questionnaires and/or arbitrarily applying stereotypes in practice, without careful consideration of each patient’s situation and needs, could foster mistreatment.

REFERENCE: Jamison RN, Butler SF, Budman SH, et al. Gender Differences in Risk Factors for Aberrant Prescription Opioid Use. J Pain. 2010;11(4):312-320 [abstract here].