Opioid Use Disorder: A Qualitative Exploratory Analysis of Potential Misunderstandings in Patients with Chronic Non-Cancer Pain

Abstract

Purpose

Substance use disorders (SUD) are a challenging comorbidity in patients with chronic non-cancer pain (CNCP) as they complicate diagnosis and therapy, especially when opioids are part of the therapeutic regimen. A definite diagnosis of opioid use disorder (OUD) in patients with CNCP on long-term opioid therapy (LTOT) is a prerequisite for effective and targeted therapy but may be complicated as some criteria of OUD might be attributed to the desire of the patient to relieve the pain. For instance, the desire to increase the dose can be based on both a SUD as well as inadequate pain therapy. Many scientific studies use standardized questions. Therefore, potential misunderstandings due to possible diagnostic overlaps often cannot be clarified.

Methods

14 qualitative guided interviews were conducted and analyzed (Kuckartz content analysis), with the intention to verify if patient’s initial response to simple questions based on the wording of the DSM-5, as commonly used in research and practice, were consistent with the results of a more in-depth inquiry.

Results

The results suggest that without in-depth investigation, there is a particular risk of false-positive assessment of the DSM-5 criteria for OUD when opioids are prescribed, especially when the questions are considered independently of chronic pain. The risk of a false-negative assessment has also been shown in isolated cases.

Conclusion

Only after asking for and describing specific situations it was possible to determine whether the patient’s positive or negative answers were based on a misunderstanding of the question. To avoid misdiagnosis, staff conducting DSM-5 interviews should be trained in pain-specific follow-up questions that may help to uncover diagnostic confounding.

Keywords:

• chronic pain
• substance use disorder
• diagnoses
• DSM 5

Abbreviations

SUD, Substance use disorders; CNCP, chronic non-cancer pain; OUD, opioid use disorder; LTOT, long-term opioid therapy; DSM-5, Statistical Manual for Mental Disorders Version 5; CIDI, Composite International Diagnostic Interview; GP, treating physicians; HCP, health care providers; CPOD, complex persistent opioid dependence.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

W. Häuser and F. Petzke collaborated on the German S3 guidelines on long-term opioid therapy for chronic non-cancer pain. W. Häuser has received a lecture fee from Janssen-Cilag and the Falk Foundation. N. Scherbaum has received honoraria for several activities (eg, advisory board membership, lecture, manuscripts) from AbbVie, Camurus, Hexal, Janssen-Cilag, MSD, Medice, Mundipharma, Reckitt-Benckiser/Indivior, and Sanofi-Aventis. During the last three years he has participated in clinical trials financed by the pharmaceutical industry. The other authors declare no conflicts with regard to the manuscript.