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In a study that underscores the need to rethink pain treatment in the US, researchers have found that more than 6 out of 10 individuals who died of an opioid-related cause had received a diagnosis for a chronic noncancer pain condition within the preceding year. The same group was also more likely to have been diagnosed with psychiatric disorders and prescribed psychotropic medications--including benzodiazepines, which can increase the risk of death when combined with opioids.

The study, published in the American Journal of Psychiatry (abstract only available for free), focused on 13,089 opioid-related deaths among Medicaid patients under 65 years old. Researchers divided the decedents into 2 groups—those who had received a chronic noncancer pain diagnosis in the year preceding death, and those who didn't—and looked at other clinical diagnoses, filled medical prescriptions, and nonfatal poisonings during the 12 months preceding death as well as 30 days before death.

Among the findings:

  • Out of the 13,089 decedents included in the study, 61.5% were diagnosed with a chronic pain condition in the year preceding death. Within the chronic pain group, 59.3% were diagnosed with back pain, 24.5% with headaches, and 6.9% with neuropathies. Authors write that "virtually all the decedents in the chronic pain group were also diagnosed with other bodily pain conditions." Decedents in the chronic pain group were more likely to be female and white
  • Overall, 66.1% of decedents filled opioid prescriptions during the last 12 months, and 61.6% filled prescriptions for benzodiazepines—the class of drugs typically used to treat anxiety. During the last 30 days of life, decedents diagnosed with chronic pain were more likely to fill 1 or more prescriptions for opioids (49%) and benzodiazepines (52.1%) than the nonpain group (17.2% and 26.6%, respectively).
  • Decedents with a pain diagnosis were about twice as likely as those without a diagnosis to have experienced a nonfatal overdose during the 12 months prior to death.
  • In the chronic pain group, 45.6% of the fatal opioid poisonings were from natural and semisynthetic opioids, and 16.7% from other synthetic opioids. Among nonpain decedents the rates were 39% and 12.2%, respectively.
  • Within the last 12 months of life, the chronic pain group was more likely than the nonpain group to receive a mental health diagnosis, including drug use disorder (40.8% compared with 22.1%), depression disorder (29.6% compared with 13%), and anxiety disorder (25.8% compared with 8.4%). Authors note that although a diagnosis of substance use disorder was relatively common among both groups, a specific diagnosis of opioid use disorder was not—only 14.7% in the pain group, and 11.8% in the nonpain group.

Authors highlighted the prevalence of opioid prescriptions within the last 30 days of life as a particular concern, pointing out that the 36.8% average far exceeds the 8.8% average among all Americans for filling a prescription for an analgesic over a 30-day period. "This pattern raises the possibility that health care professionals may frequently be proximal sources of opioids in fatal overdoses," they write.

The researchers also asserted that given the high rate of mental health diagnoses, particularly among the pain group, health providers need to be particularly wary of prescribing benzodiazepines with opioids. They write that physicians should limit opioid and benzodiazepine coprescribing "to patients for whom alternative strategies have proven inadequate, carefully monitoring for sedation and respiratory depression, and limiting such coprescription to the minimum clinically required dosage and duration."

The study lends support to the idea that reliance on opioids for noncancer pain treatment is helping to fuel the opioid crisis in the US—a crisis that APTA is helping to address through its #ChoosePT opioid awareness campaign. The campaign is aimed at informing consumers that physical therapy is an effective alternative to drugs for the treatment of pain. Housed at, #ChoosePT includes a video public service announcement, as well as other targeted advertising and media outreach. Members can also learn more about the PT's role in pain management through offerings on PTNow, including a webpage with resources for pain management and an opioid awareness checklist.

Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. 

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