Findings from a longitudinal study of more than 600 patients with chronic noncancer pain reveal risk factors for opioid misuse are not the same in women as they are in men. The research, published in The Journal of Pain, correlated responses from several validated questionnaires to actual opioid misuse and found women with emotional and affective distress were more likely to misuse both prescribed and nonprescribed drugs, whereas behavioral issues predisposed men to drug misuse (J Pain 2010;11:312-320).

Lead investigator Robert Jamison, PhD, associate professor, Departments of Psychiatry, Anesthesiology, and Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, said insights like these might transform the way clinicians approach the management of patients at risk for opioid misuse.

“Given the prominence of sex differences in a variety of pain-related processes, we may eventually arrive at a method for tailoring risk assessment and risk-reducing interventions in part as a function of gender,” he said.

Prior studies have yielded conflicting results regarding gender-specific differences in the quality and incidence of pain, as well as the risk factors that predict medication misuse. To further elucidate the relationship between sex and opioid misuse, Dr. Jamison and several colleagues recruited 276 male and 335 female patients with chronic noncancer pain who were treated at pain management centers in five states. Nearly 67% of patients (average age, 50 years), had chronic low back pain. Forty-six percent were married, 80% were white and 72.5% had a high school education. The patients had been prescribed a variety of opioids, with 27% taking both long- and short-acting medications. To identify factors predictive of opioid misuse, at baseline and five months subsequent, the researchers administered the Screener and Opioid Assessment for Pain Patients (SOAPP-R), the Brief Pain Inventory (BPI) and the Prescription Drug Use Questionnaire (PDUQ). Clinicians completed the Prescription Opioid Therapy Questionnaire (POTQ) and the Aberrant Drug Behavior Index (ADBI). At study outset and completion, urine samples from 356 of the patients were tested for both prescribed and nonprescribed substances. Multiple regression analyses identified significant correlations between specific questionnaire responses and actual opioid misuse, and controlled for possible intervening variables.

Dr. Jamison and his team found women who misused opioids had significantly higher ratings on five particular SOAPP-R items, indicating they felt overwhelmed, had been engaging in arguments or experiencing hurt, were impatient with their physician, had been sexually abused, and were concerned about how they were judged by others. In contrast, men who misused opioids had significantly higher scores on SOAPP-R items indicating a history of arrest, a bad temper, and having friends with alcohol or drug use problems. Significantly more women than men admitted opioid misuse on the PDUQ, whereas men who misused opioids had significantly higher physician-rated ADBI scores than women (P<0.05 for both). On the PDUQ and POTQ, women were more likely than men to report a history of physical and sexual abuse, a history of psychiatric diagnoses and family concerns, whereas men were more concerned with addiction and unexpected positive urine results (P<0.05).

Although the findings indicate important gender-specific risk factors for opioid misuse, Dr. Jamison cautioned that because the study population was older, mostly disabled and had a long duration of pain, these results should not be extrapolated to younger, better-functioning patients with recent-onset pain. Nevertheless, he said, the results should help clinicians discern those patients at highest risk for opioid misuse.

According to Joseph Shurman, MD, chairman of pain management at Scripps Memorial Hospital, La Jolla, Calif., and chair of Casa Palmera, a private treatment center in del Mar, Calif., the findings confirm that, among other risk factors, women who have been sexually abused are more likely to misuse opiates.

“One very brief and sensitive clinical tool for detecting sexual abuse, which the investigators failed to include and which clinicians would do well to use, is the opioid risk tool,” Dr. Shurman told Pain Medicine News. “It measures a broad range of established risk factors, most significantly checking for a history of sexual abuse.”