Opioid use disorder seems to be driven by physical or psychological pain as often as it is driven by a vulnerability to recreational opioid use. Those who began using primarily for the treatment of pain, however, view themselves as fundamentally different from recreational users which creates important barriers to care.
Given the growing prevalence of opioid use disorders over the past decade, and their continued rise despite efforts to prevent prescription misuse, it is important to accurately understand which pathways different individuals take that can result in problematic opioid use. There are scant prospective data documenting how individuals develop opioid use disorders, so we are limited to retrospective analyses. Understanding the pathways taken to opioid use disorders may shed light on possible routes rarely considered, so that efforts to prevent harmful opioid use might be enhanced and treatments might be tailored to greater effect.
Five pathways to opioid use disorder emerged from spontaneous open-ended interviews:
The different pain pathways, taken together, account for as large a percentage (50%) of new opioid use disorder as recreational use and prior substance use vulnerabilities combined.
Opioids used as antidepressants?Relief of emotional distress by opioids is anecdotally perceived by some to have an antidepressant or energizing effect (different from the dissociated high typically associated with opioid misuse) that also reinforces use and requires escalating doses to maintain this effect.
Fear of uncontrolled pain inhibits efforts to seek addiction treatment or reduce opioid use
Identifying as a pain patient may interfere with identifying as having a substance use disorder: The participants who were first treated for pain and then developed an opioid use disorder view themselves anecdotally in a different category as others with a similar opioid use disorder, acting as a further barrier to participating in substance use disorder treatment. When participating in treatment, they often focus on the differences between themselves and the others in treatment, thus potentially decreasing the effectiveness of treatment.
WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?
Pain, both physical and psychological, is a driver of opioid misuse and is simultaneously a barrier to treatment given concerns that the pain will not be adequately addressed once the opioids are stopped.
Pain patients do not identify with broader opioid use disorder patients and may benefit from specialized substance use treatment focused on those primarily using opioids for pain.
Furthermore, relief of emotional distress may reinforce misuse (there is increasing research on the antidepressant effect of some of the opiate receptor pathways) and may explain in part the increased risk of opioid misuse among those with mental health diagnoses. Thus screening for prior substance use vulnerabilities and prior mental health struggles is strongly recommended prior to the initiation of opioid prescriptions.