Research ArticleOriginal Research

Factors Associated with Pain Treatment Satisfaction Among Patients with Chronic Non-Cancer Pain and Substance Use

Leslie W. Suen, Vanessa M. McMahan, Christopher Rowe, Sumeet Bhardwaj, Kelly Knight, Margot B. Kushel, Glenn-Milo Santos and Phillip Coffin
The Journal of the American Board of Family Medicine November 2021, 34 (6) 1082-1095; DOI: https://doi.org/10.3122/jabfm.2021.06.210214

Article Figures & Data

Tables

  • Table 1.

    Demographic and Substance Use Characteristics of Safety-Net Patients on or Recently on Long-Term Opioid Therapy for Chronic Noncancer Pain, by Level of Satisfaction with Pain Treatment*

    Characteristic, Median (IQR) or N (%)All Participants (n = 300)Low Satisfaction (n = 116)Moderate Satisfaction (n = 85)High Satisfaction (n = 98)P Value
    Age57.5 (±8.1)56.9 (9.1)57.6 (7.9)58.1 (7.2)0.57
    Gender
        Cisgender female101 (34%)52 (51%)25 (25%)24 (24%)0.002
        Cisgender male182 (60%)63 (35%)54 (30%)64 (35%)
        Gender minority person17 (6%)1 (6%)6 (35%)10 (59%)
    Race/ethnicity†
        Non-Hispanic White95 (32%)34 (36%)28 (30%)32 (34%)0.26
        Non-Hispanic Black131 (44%)55 (42.0%)36 (28%)40 (31%)
        Hispanic/Latinx33 (11%)17 (52%)5 (15%)11 (33%)
        Mixed or other40 (13%)10 (24%)15 (38%)15 (37%)
    Education
        Some high school or less74 (25%)27 (37%)21 (29%)25 (34%)0.95
        GED/some college169 (56%)66 (39%)50 (30%)53 (31%)
        Vocational training/college or higher57 (19%)23 (40%)14 (25%)20 (35%)
    Income†
        < $999956 (19%)22 (39%)18 (32%)16 (29%)0.93
        $10,000-$19,999193 (65%)75 (39%)52 (27%)66 (34%)
        >$20,00049 (16%)18 (38%)14 (29%)16 (33%)
    Comorbidities
        Ever homeless230 (77%)93 (41%)69 (30%)67 (29%)0.06
        HIV positive105 (35%)32 (31%)30 (29%)43 (41%)0.05
        History of hepatitis C infection151 (50%)60 (40%)46 (31%)44 (29%)0.42
        Brief Symptom Inventory (BSI) score ≥63‡83 (28%)36 (43%)29 (35%)18 (22%)0.006
        Patient Health Questionnaire-8 (PHQ-8) Depression Scale ≥1083 (28%)38 (46%)28 (34%)17 (21%)0.02
        Post-traumatic stress disorder screen ≥399 (33%)45 (46%)31 (32%)22 (23%)0.03
        Mini-physical performance test (mPPT) ≤11§145 (52%)60 (41%)41 (28%)44 (30%)0.72
    Self-reported substance use in past year‖
        No drugs, alcohol, or tobacco66 (22%)21 (32%)16 (24%)29 (44%)0.09
        Alcohol154 (51%)61 (40%)48 (31%)44 (29%)0.27
        Tobacco169 (56%)74 (44%)50 (30%)44 (26%)0.02
        Any illicit substances121 (40%)52 (43%)34 (28%)35 (29%)0.40
        - Heroin51 (17%)25 (49%)12 (24%)14 (28%)0.26
        - Methamphetamine or speed66 (22%)28 (42%)21 (32%)17 (26%)0.39
        - Cocaine or crack cocaine72 (24%)34 (47%)21 (29%)17 (24%)0.12
        - Other18 (6%)7 (39%)5 (28%)6 (33%)0.99
    History of substance use treatment203 (68%)79 (39%)58 (29%)65 (32%)0.95
    History of prior overdose56 (19%)27 (48%)13 (23%)16 (29%)0.27

    • IQR, interquartile range.

    • ↵* One participant did not respond to the pain treatment satisfaction question.

    • ↵† One participant declined to state their race, and two participants declined to state their income.

    • ↵‡ BSI scores only interpretable for 282 cisgender participants and considered positive if either global score or two subscale scores were ≥63.

    • ↵§ mPPT scores were conducted in 277 participants at baseline. We used a cut-off score of 11 or lower as evidence of functional impairment.

    • ↵‖ Measure does not include cannabis use.

    • ↵ Other substances including inhalants or hallucinogens.

  • Table 2.

    Characteristics of Pain Treatment for Safety-Net Patients on or Recently on Long-Term Opioid Therapy for Chronic Noncancer Pain, by Level of Satisfaction with Pain Treatment*

    Characteristic, Median (IQR) or n (%)All Participants (n = 300)Low Satisfaction (n = 116)Moderate Satisfaction (n = 85)High Satisfaction (n = 98)P Value
    Pain characteristics
        Pain on average in the past 3 months7 (6 to 9)8 (7 to 9)7 (6 to 8)7 (6 to 9)0.015
        Pain Catastrophizing Scale ≥ 3096 (32%)45 (47%)27 (28%)23 (24%)0.06
        Cold pressor threshold score7.5 (5.1 to 11.5)7.7 (5.2 to 11.6)7.6 (5.3 to 11.7)7.0 (4.3 to 11.0)0.61
        Cold pressor tolerance score10.9 (7.0 to 17.7)11.1 (6.9 to 17.7)11.5 (7.5 to 17.7)10.5 (6.6 to 18.6)0.74
        Douleur Neuropathique 4 (Neuropathic Pain Assessment) ≥4†161 (56%)66 (41%)48 (30%)46 (29%)0.23
    Prescribed opioid MME at baseline60 (17.5 to 180)43 (6 to 171)60 (23 to 150)60 (20 to 222)0.22
        0 MME50 (17%)27 (54%)11 (22%)12 (24%)0.25
        1 to 19 MME25 (8%)8 (32%)6 (24%)11 (44%)
        20 to 89 MME102 (34%)38 (37%)33 (32%)31 (31%)
        90 to 199 MME57 (19%)19 (33%)20 (35%)18 (32%)
        ≥200 MME66 (22%)24 (37%)15 (23%)26 (40%)
        Max MME in past year112.5 (36.0 to 246.3)105 (40 to 270)90 (36 to 216)120 (30 to 270)0.77
        MME decreased >30% and not stopped in past year53 (18%)24 (45%)11 (21%)18 (34%)0.36
        MME increased >30% in past year42 (14%)13 (31%)14 (33%)15 (36%)0.52
        Opioid(s) discontinued in past year43 (14%)26 (61%)9 (21%)8 (19%)0.006
    Self-reported prescribed opioids
        Oxycodone, hydrocodone167 (56%)60 (36%)46 (28%)60 (36%)0.36
        Hydromorphone6 (2%)1 (16%)0 (0%)5 (83%)0.03
        Morphine81 (27%)25 (31%)28 (35%)27 (34%)0.19
        Methadone54 (18%)26 (48%)16 (30%)12 (22%)0.15
        Fentanyl12 (4%)3 (25%)5 (42%)4 (33%)0.53
        Codeine21 (7%)6 (29%)7 (33%)8 (38%)0.61
        Other opioid6 (2%)1 (17%)4 (68%)1 (17%)0.11
        No opioids38 (13%)22 (58%)6 (16%)10 (26%)0.03
    Self-reported nonopioid medications
        Acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs)94 (31%)36 (39%)29 (31%)28 (30%)0.72
        Gabapentinoids (gabapentin, pregabalin)105 (35%)38 (37%)36 (35%)30 (29%)0.21
        Cannabis (prescribed)93 (31%)25 (27%)30 (33%)37 (40%)0.02
        Muscle relaxants43 (14%)10 (24%)17 (41%)15 (36%)0.07
        Other neuropathic medications‡29 (10%)10 (36%)7 (25%)11 (39%)0.74
        Topical medications (lidocaine, capsaicin)28 (9%)14 (50%)4 (14%)10 (36%)0.20
        Other medications or do not remember12 (4%)4 (33%)4 (33%)4 (33%)0.93
        No nonopioid medications80 (27%)36 (45%)17 (21%)27 (34%)0.21
    Nonmedication treatments
        No medications10 (3%)8 (80%)1 (10%)1 (10%)0.04
        Local injections55 (18%)26 (47%)15 (27%)14 (26%)0.30
        Chiropractic care24 (8%)12 (52%)4 (17%)7 (30%)0.34
        Physical or occupational therapy86 (29%)35 (41%)29 (34%)22 (26%)0.20
        Acupuncture49 (16%)17 (35%)12 (25%)19 (40%)0.55
        Massage therapy59 (20%)20 (35%)15 (26%)23 (40%)0.46
        Group or individual behavioral counseling53 (18%)20 (38%)18 (34%)15 (28%)0.58
    Opioid stewardship interventions
        Pain agreement documented in chart208 (69%)80 (39%)62 (30%)66 (32%)0.70
        Naloxone prescribed in chart182 (61%)75 (41%)52 (29%)55 (30%)0.44
        Urine drug screen done in the past year247 (82%)100 (40%)68 (28%)79 (32%)0.42

    • IQR, interquartile range; MME, Morphine milligram equivalents.

    • ↵* One participant did not respond to the pain treatment satisfaction question.

    • ↵† There were 14 participants who did not complete neuropathic pain assessment.

    • ↵‡ Other neuropathic medications including tricyclic antidepressants (amitriptyline, desipramine), serotonin-norepinephrine reuptake inhibitors (duloxetine, venlafaxine), migraine medications (sumatriptan, fioricet, midrin, ergotamine, topiramate), and antiseizure medications (valproic acid).

  • Table 3.

    Results of Urine Drug Screen (UDS) at Study Enrollment for Safety-Net Patients on or Recently on Long-Term Opioid Therapy for Chronic Noncancer Pain (n = 276)*

    Characteristic, Median (IQR) or n (%)All Participants (n = 300)Low Satisfaction (n = 116)Moderate Satisfaction (n = 85)High Satisfaction (n = 98)P Value
    Drugs detected on baseline UDS
        No drugs detected41 (15%)15 (37%)12 (29%)14 (34%)0.93
        Opioids (including methadone and buprenorphine)178 (65%)71 (40%)50 (28%)56 (32%)0.79
        Methadone72 (26%)33 (46%)19 (26%)20 (28%)0.38
        Buprenorphine7 (3%)0 (0%)5 (71%)2 (29%)0.01
        Benzodiazepines17 (6%)6 (35%)4 (24%)7 (41%)0.76
        Cocaine58 (21%)28 (48%)18 (31%)12 (21%)0.07
        Amphetamines/methamphetamine37 (13%)37 (35%)30 (28%)40 (37%)0.37
        Tetrahydrocannabinol (THC)107 (39%)18 (49%)12 (32%)7 (19%)0.14
        Other drugs†3 (1%)0 (0%)2 (67%)1 (3%)0.19
    Opioids in combination with other drugs
        No opioids98 (36%)37 (38%)26 (27%)35 (36%)0.13
        Opioids only (including methadone and buprenorphine)117 (42%)42 (36%)32 (28%)42 (36%)
        Opioids and stimulants only (ie, cocaine or amphetamines)49 (18%)26 (53%)15 (31%)8 (16%)
        Opioids and other combination of drugs‡12 (4%)3 (25%)3 (25%)6 (50%)
    If UDS consistent with prescribing§
        UDS consistent with prescribing201 (74%)82 (41%)54 (27%)65 (32%)0.58
        UDS positive for opioids and not prescribed detectable opioid therapy25 (9%)12 (48%)6 (24%)7 (28%)
        UDS negative for opioids and prescribed detectable opioid therapy47 (17%)14 (30%)14 (30%)19 (40%)
        20 to 89 MME at baseline30 (11)11 (37%)8 (27%)11 (37%)
        90 to 199 MME at baseline11 (4%)1 (9%)4 (36%)6 (55%)
        ≥200 MME at baseline6 (2%)2 (33%)2 (33%)2 (33%)

    • IQR, interquartile range.

    • ↵* Twenty-four participants did not complete a UDS at baseline.

    • ↵† Other drugs detected include phencyclidine (PCP) or barbiturates.

    • ↵‡ Including opioids combined with benzodiazepines, PCP, barbiturates, with or without stimulants such as cocaine or methamphetamine.

    • ↵§ Detectable opioid therapy defined as milligram morphine equivalent (MME) of at least 20 and taking a full agonist or partial opioid excluding fentanyl, which would not return positive on UDS. Two participants were prescribed only fentanyl as their opioid therapy so were excluded from this measure.

  • Table 4.

    Multivariable Analysis of Greater Pain Satisfaction among Safety-Net Patients on or Recently on Long-Term Opioid Therapy for Chronic Noncancer Pain (n = 299)*

    CharacteristicAdjusted Odds Ratio (95% CI)P Value
    Age (per 10 years)1.1 (0.8-1.5)0.49
    Gender
        Cisgender femaleRef
        Cisgender male1.5 (0.9-2.4)0.12
        Gender minority person30.8 (1.9 to 14.8)0.20
    HIV-positive1.6 (1.0 to 2.7)0.04
    Depression0.9 (0.5-1.7)0.87
    Brief Symptom Inventory (BSI) score ≥ 630.8 (0.5-1.5)0.51
    Post-traumatic stress disorder0.6 (0.3-0.9)0.02
    Tobacco use0.6 (0.4-0.9)0.02
    Average pain in past 3 months0.9 (0.8-1.0)0.007
    Opioids discontinued0.4 (0.2-0.9)0.02
    Medical cannabis use1.7 (1.0 to 2.7)0.03

    • CI, confidence interval.

    • ↵* One participant did not respond answer the pain treatment satisfaction question.

  • Appendix 1.

    List of Detectable Substances on Urine Drug Screen

    Amphetamines
    Barbiturates
    Benzodiazepines
    Buprenorphine
    Cocaine (detected as benzoylecgonine)
    Methadone (detected as methadone and 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine [EDDP])
    Methamphetamine
    Opioids
    Oxycodone
    Phencyclidine (PCP)
    Tetrahydrocannabinol (THC)
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