Sickle cell disease patients who have relatively low pain levels use opioids more when they are sad, anxious, or experience other negative emotions, a study indicates.
The Johns Hopkins University research was based on entries in 45 patients’ electronic diaries. It suggested that patients misused opioids when they increased their intake to deal with emotions. Doctors should keep a close watch on this kind of misuse, the team suggested.
They published their findings in the online version of The Journal of Pain. The title was “Daily Opioid Use Fluctuates as a Function of Pain, Catastrophizing, and Effect in Patients with Sickle Cell Disease: an Electronic Daily Diary Analysis.”
Because the study would be based on a few dozen diary excerpts, researchers purposely limited its scope to a possible connection between negative emotions and increased opioid use. They did not try to demonstrate that negative emotions or negative thinking can lead to increased opioid use.
“We showed that the way we think about pain is associated with opioid use even if our pain levels are low,” Dr. Patrick Finan, an assistant professor at Johns Hopkins who was the lead author of the study, said in a press release. “These data argue that physicians need better communication with patients on how to take their medications from day to day to minimize fluctuations based on mood or way of thinking.”
Many sickle cell disease patients suffer from chronic pain or severe pain episodes. So doctors often recommend that they take daily painkillers — either short-acting or long-acting, depending on their needs. Either type can lead to opioid overuse.
Long-acting opioids include morphine, oxycodone, methadone and fentanyl. Short-acting, or rescue painkillers, include oxycodone, hydromorphone, meperidine, tramadol and hydrocodone.
A secondary goal of the study was to come up with a better way of identifying patients at risk of opioid overuse. The idea was to help them control their pain while decreasing their dependency on opioids over the long term.
“When someone is prescribed a daily, long-acting opioid, it is typically supposed to be at a fixed dose, and their pain level or emotions shouldn’t dictate whether they take more of this prescription or not,” Finan said. “Although we can’t prove misuse of the medication in our study, these data suggest that physicians and patients should clearly communicate about how patients should be taking their daily, long-acting opioids in order to minimize the potential for misuse.”
To determine risk factors associated with opioid overuse, the researchers asked 85 adults with sickle cell disease to make electronic diary entries every evening for three months.
The team used entries from 45 patients in their study. They chose patients who had made entries more than 25 percent of the time and had taken at least one opioid pill during the study.
Researchers asked the patients to list the doses and type of opioid pill they took for long-acting and short-acting effects. The team also asked them to rank their pain level on a scale from 1 to 10, with 10 being the worst.
Patients were also asked to rank their emotional state from 1 to 10. Positive emotions included happiness, calmness and cheerfulness. Negative ones included loneliness, sadness and anxiety.
Researchers also analyzed patients’ negative thinking. They used the Pain Catastrophizing Scale to rate patients’ focus on pain, helplessness and other negative feelings.
The team discovered a connection between negative emotions and 31 patients’ increased use of long-acting opioids. They found no link between increases in patients’ long-acting opioid use and their daily pain level, positive emotions or negative thinking.
Researchers did find connections between increased use of short-acting opioids and patients’ pain levels and negative thinking. Neither positive nor negative emotions affected patients’ use of short-acting opioids, the team added.
“When pain was reported as low, sickle cell disease patients reported higher opioid use if they catastrophized, or focused their thinking on their pain, than if they didn’t,” Finan said. “When pain levels were higher, negative thinking played less of a role in influencing opioid use.”
Not only was this a small study, but Finan cautioned that patient self-reports are always subjective. Another limitation was that the study looked at only one time point per day — evening — although a person’s mood can change during the day.
Finan said the team will continue this line of research using smartphone technology to assess patients’ moods throughout the day.