Re: Does Prescription Opioid Misuse Affect the Level of Health Care Satisfaction Endorsed by Patients on Opioid Therapy?

To the Editor: I commend Dr. Jerant and colleagues¹ on their article entitled “Satisfaction with Health Care among Prescription Opioid Recipients.” In the said article, the authors rightfully noted that 2 potential explanations for the findings could be the long duration of opioid use with ≥ 6 opioid prescriptions and the pharmacological euphoric effects of opioids. Moreover, insofar as trust indicates patients' satisfaction,^2,3 the authors' findings seem to be supported by Sherman and colleagues,⁴ who also noted that patients on chronic opioid therapy trust their health care providers, whereas patients who were worried that their prescription opioids would be reduced in an opioid reduction initiative were less likely to trust their health care providers. However, there is an issue regarding confounders that I would like to be clarified.

The authors noted that the full regression model controlled for physical and mental health status, using the 12-item Short-Form Health Survey (SF-12) as a proxy. However, the SF-12 does not account for opioid misuse and substance use. Substance use and a high daily dose of prescription opioids are predictors of opioid misuse.⁵ Because opioid misuse (not conforming to the prescribed pattern of opioid use, irrespective of one's adverse effects status⁶) is highly prevalent among patients with legitimate opioid prescriptions (occurring in 21% to 29% of these patients⁶), and illicit drug use coupled with alcohol abuse has been identified to predict opioid misuse among chronic pain patients,⁷ it might be educative to include substance use as a covariate in the regression model. This is because doing so might help in answering such relevant questions as, are prescription opioid misusers more or less likely to endorse high or low patient satisfaction in health care? In addition, physicians' prescription serve as a major source of diversion⁸ and misuse,⁹ is it possible that patients who would like to divert (share/sell prescription opioids to others¹⁰) their prescription opioids may endorse higher satisfaction, with an increased number of prescriptions by their health care providers? In this regard, it may be interesting and educative to observe the effect of both opioid misuse and substance use adjusted for in the full regression model. However, it is entirely possible that these variables were not available in the dataset used for the analysis.