Psychiatric Comorbidity and Co-Occurring Opioid Misuse: Depression Mediates the Relationship between Post-Traumatic Stress Disorder and Opioid Misuse in Community Pharmacy Settings
Restricted accessResearch articleFirst published online January, 2020
Psychiatric Comorbidity and Co-Occurring Opioid Misuse: Depression Mediates the Relationship between Post-Traumatic Stress Disorder and Opioid Misuse in Community Pharmacy Settings
Individuals who misuse opioids frequently have comorbid psychiatric issues, including post-traumatic stress disorder (PTSD) and depression. However, little is known about the mechanisms by which these disorders are associated with opioid misuse and specifically in community pharmacy settings. The current study examined whether depression mediated the relationship between PTSD and opioid misuse in patients filling opioid prescriptions.
Methods
We administered a health survey in four community pharmacies among patients filling opioid medications in southwestern Pennsylvania. Univariate statistics were used to assess relationships among demographic and clinical characteristics of PTSD, depression, and opioid misuse behaviors. We then examined whether depression mediated the relationship between PTSD and opioid misuse using ordinary least squares path analysis with bootstrapping.
Results
A total of 333 participants completed the health survey. Opioid misuse was reported among 15.9% of all participants, 33.3% among those with a positive PTSD screen, and 29.3% of those who screened positive for depression. Depression significantly mediated the relationship between PTSD and opioid misuse. Specifically, there was a statistically significant indirect effect (ab) of PTSD on opioid misuse through a pathway mediated by depression (ab = .06, SEab = .02, 95% CI = .02–.10). The direct effect (c’) of PTSD on opioid misuse was also significant (c’ = .12, SEc’ = .05, P = .01, 95% CI = .03–.22), suggesting partial mediation.
Conclusions
Results suggest an indirect pathway by which clinical intervention may help ameliorate outcomes in patients with PTSD. Further, there is an increased need for screening, assessment, and intervention protocols for this patient population in which community pharmacy is a novel setting to expand future efforts within the patient population.
ChenLH, HedegaardH, WarnerM. Drug-poisoning deaths involving opioid analgesics: United States, 1999–2011. NCHS data brief, no 166. Hyattsville, MD: National Center for Health Statistics; 2014. http://www.cdc.gov/nchs/data/databriefs/db166.pdf.
2.
RuddRA. Increases in drug and opioid-involved overdose deaths—United States, 2010–2015. MMWR Morb Mortal Wkly Rep.2016;65(50–51):1445–1452.
3.
FlorenceCS, ZhouC, LuoF, XuL. The economic burden of prescription opioid overdose, abuse, and dependence in the United States, 2013. Med Care.2016;54(10):901–906.
4.
MartelMO, DolmanAJ, EdwardsRR, JamisonRN, WasanAD. The association between negative affect and prescription opioid misuse in patients with chronic pain: the mediating role of opioid craving. J Pain.2014;15(1):90–100.
5.
BradyKT, McCauleyJL, BackSE. Prescription opioid misuse, abuse, and treatment in the United States: an update. AJP.2016;173(1):18–26.
6.
BeckerWC, SullivanLE, TetraultJM, DesaiRA, FiellinDA. Non-medical use, abuse and dependence on prescription opioids among U.S. adults: psychiatric, medical and substance use correlates. Drug Alcohol Depend.2008;94(1–3):38–47.
7.
WhiteAG, BirnbaumHG, SchillerM, TangJ, KatzNP. Analytic models to identify patients at risk for prescription opioid abuse. Am J Manag Care.2009;15(12):897.
8.
OfratS, KruegerRF, EatonNR, . Nonmedical prescription drug use comorbidity: developing a cohesive risk model. J Psychopathol Behav Assess.2014;36(3):371–379.
9.
CochranG, RubinsteinJ, BacciJL, YliojaT, TarterR. Screening community pharmacy patients for risk of prescription opioid misuse. J Addict Med.2015;9(5):411–416.
10.
MartinsSS, KeyesKM, StorrCL, ZhuH, ChilcoatHD. Pathways between nonmedical opioid use/dependence and psychiatric disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Drug Alcohol Depend.2009;103(1–2):16–24.
11.
BogdanowiczKM, StewartR, BroadbentM, . Double trouble: psychiatric comorbidity and opioid addiction—all-cause and cause-specific mortality. Drug Alcohol Depend.2015;148:85–92.
12.
HanB, ComptonWM, BlancoC, CraneE, LeeJ, JonesCM. Prescription opioid use, misuse, and use disorders in US adults: 2015 National Survey on Drug Use and Health. Ann Intern Med.2017;167(5):293–301.
13.
PietrzakRH, GoldsteinRB, SouthwickSM, GrantBF. Medical comorbidity of full and partial posttraumatic stress disorder in US adults: results from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions. Psychosom Med.2011;73(8):697.
14.
SchnurrPP, SpiroIIA, ParisAH. Physician-diagnosed medical disorders in relation to PTSD symptoms in older male military veterans. Health Psychol.2000;19(1):91.
15.
OuimetteP, GoodwinE, BrownPJ. Health and well being of substance use disorder patients with and without posttraumatic stress disorder. Addict Behav.2006;31(8):1415–1423.
16.
GeisserME, RothRS, BachmanJE, EckertTA. The relationship between symptoms of post-traumatic stress disorder and pain, affective disturbance and disability among patients with accident and non-accident related pain. Pain1996;66(2–3):207–214.
17.
BeckJG, FreemanJB, ShipherdJC, HamblenJL, LacknerJM. Specificity of stroop interference in patients with pain and PTSD. J Abnorm Psychol.2001;110(4):536.
18.
PhiferJ, SkeltonK, WeissT, . Pain symptomatology and pain medication use in civilian PTSD. Pain.2011;152(10):2233–2240.
19.
OuimetteP, ReadJP, WadeM, TironeV. Modeling associations between posttraumatic stress symptoms and substance use. Addict Behav.2010;35(1):64–67.
20.
SealKH, ShiY, CohenG, . Association of mental health disorders with prescription opioids and high-risk opioid use in US veterans of Iraq and Afghanistan. JAMA.2012;307(9):940–947.
21.
MorascoBJ, LovejoyTI, LuM, TurkDC, LewisL, DobschaSK. The relationship between PTSD and chronic pain: mediating role of coping strategies and depression. Pain.2013;154(4):609–616.
22.
MeierA, Lambert-HarrisC, McGovernMP, XieH, AnM, McLemanB. Co-occurring prescription opioid use problems and posttraumatic stress disorder symptom severity. Am J Drug Alcohol Abuse.2014;40(4):304–311.
23.
TurkDC, SwansonKS, GatchelRJ. Predicting opioid misuse by chronic pain patients: a systematic review and literature synthesis. Clin J Pain.2008;24(6):497–508.
24.
GrattanA, SullivanMD, SaundersKW, CampbellCI, Von KorffMR. Depression and prescription opioid misuse among chronic opioid therapy recipients with no history of substance abuse. Ann Fam Med.2012;10(4):304.
25.
WasanAD, ButlerSF, BudmanSH, BenoitC, FernandezK, JamisonRN. Psychiatric history and psychologic adjustment as risk factors for aberrant drug-related behavior among patients with chronic pain. Clin J Pain.2007;23(4):307–315.
26.
EdlundMJ, MartinBC, FanM-Y, DevriesA, BradenJB, SullivanMD. Risks for opioid abuse and dependence among recipients of chronic opioid therapy: results from the TROUP Study. Drug Alcohol Depend.2010;112(1–2):90–98.
27.
KatonWJ. Epidemiology and treatment of depression in patients with chronic medical illness. Dialogues Clin Neurosci.2011;13(1):7.
28.
BaumeisterH, KnechtA, HutterN. Direct and indirect costs in persons with chronic back pain and comorbid mental disorders-a systematic review. J Psychosom Res.2012;73(2):79.
29.
BairMJ, RobinsonRL, KatonW, KroenkeK. Depression and pain comorbidity: a literature review. Arch Intern Med.2003;163(20):2433–2445.
30.
HammackSE, CooperMA, LezakKR. Overlapping neurobiology of learned helplessness and conditioned defeat: implications for PTSD and mood disorders. Neuropharmacology.2012;62(2):565–575.
31.
GriffithsM. A ‘components’ model of addiction within a biopsychosocial framework. J Subst Use.2005;10(4):191–197.
32.
BucknerJD, HeimbergRG, EckerAH, VinciC. A biopsychosocial model of social anxiety and substance use. Depress Anxiety.2013;30(3):276–284.
33.
ChungMC, DennisI, EasthopeY, WerrettJ, FarmerS. A multiple-indicator multiple-cause model for posttraumatic stress reactions: personality, coping, and maladjustment. Psychosom Med.2005;67(2):251–259.
34.
MueserKT, RosenbergSD, GoodmanLA, TrumbettaSL. Trauma, PTSD, and the course of severe mental illness: an interactive model. Schizophr Res.2002;53(1–2):123–143.
35.
KesslerRC, CrumRM, WarnerLA, NelsonCB, SchulenbergJ, AnthonyJC. Lifetime co-occurrence of DSM-III-R alcohol abuse and dependence with other psychiatric disorders in the National Comorbidity Survey. Arch Gen Psychiatry.1997;54(4):313–321.
36.
CottlerLB, ComptonWM, MagerD, SpitznagelEL, JancaA. Posttraumatic stress disorder among substance users from the general population. Am J Psychiatry.1992;149(5):664.
37.
AlschulerKN, OtisJD. Coping strategies and beliefs about pain in veterans with comorbid chronic pain and significant levels of posttraumatic stress disorder symptoms. EJP.2012;16(2):312–319.
38.
FayersPM, HjermstadMJ, KlepstadP, . The dimensionality of pain: palliative care and chronic pain patients differ in their reports of pain intensity and pain interference. Pain.2011;152(7):1608–1620.
39.
NersesyanH, SlavinKV. Current aproach to cancer pain management: availability and implications of different treatment options. Ther Clin Risk Manag.2007;3(3):381.
40.
ZechDF, GrondS, LynchJ, HertelD, LehmannKA. Validation of World Health Organization Guidelines for cancer pain relief: a 10-year prospective study. Pain.1995;63(1):65–76.
41.
DowellD, HaegerichTM, ChouR. CDC guideline for prescribing opioids for chronic pain - United States, 2016. MMWR Recomm Rep.2016;65(1):1.
42.
KniselyJS, WunschMJ, CropseyKL, CampbellED. Prescription Opioid Misuse Index: a brief questionnaire to assess misuse. J Subst Abuse Treat.2008;35(4):380–386.
43.
Villalobos-GallegosL, Pérez-LópezA, Mendoza-HasseyR, Graue-MorenoJ, Marín-NavarreteR. Psychometric and diagnostic properties of the Drug Abuse Screening Test (DAST): comparing the DAST-20 vs. the DAST-10. Salud Mental.2015;38(2):89–94.
44.
YudkoE, LozhkinaO, FoutsA. A comprehensive review of the psychometric properties of the Drug Abuse Screening Test. J Subst Abuse Treat.2007;32(2):189–198.
45.
BohnM, BaborT, KranzlerH. Validity of the Drug Abuse Screening Test (DAST-10) in inpatient substance abusers. Problems Drug Depend.1991;119:233–235.
46.
de Meneses-GayaC, ZuardiAW, LoureiroSR, CrippaJ. Alcohol Use Disorders Identification Test (AUDIT): an updated systematic review of psychometric properties. Psychol Neurosci.2009;2(1):83.
47.
BushK, KivlahanDR, McDonellMB, FihnSD, BradleyKA. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. Arch Intern Med.1998;158(16):1789–1795.
48.
DawsonDA, GrantBF, StinsonFS, ZhouY. Effectiveness of the derived alcohol use disorders identification test (AUDIT‐C) in screening for alcohol use disorders and risk drinking in the US general population. Alcohol Clin Exp Res.2005;29(5):844–854.
49.
KroenkeK, SpitzerRL, WilliamsJB. The Patient Health Questionnaire-2: validity of a two-item depression screener. Med Care.2003;41(11):1284–1292.
50.
LöweB, KroenkeK, GräfeK. Detecting and monitoring depression with a two-item questionnaire (PHQ-2). J Psychosom Res.2005;58(2):163–171.
51.
CameronRP, GusmanD. The primary care PTSD screen (PC-PTSD): development and operating characteristics. Prim Care Psych.2003;9(1):9–14.
52.
WareJEJr, KosinskiM, BjornerJB, Turner-BowkerDM, GandekB, MaruishME. SF-36v2® Health Survey: Administration Guide for Clinical Trial Investigators. Lincoln, RI: QualityMetric Incorporated; 2008.
53.
MaruishME, DeRosaMA. A Guide to the Integration of Certified Short Form Survey Scoring and Data Quality Evaluation Capabilities. Lincoln, RI:QualityMetric Incorporated; 2009.
54.
BrazierJE, RobertsJ. The estimation of a preference-based measure of health from the SF-12. Med Care.2004;42(9):851–859.
55.
WareJEJr, KosinskiM, KellerSD. A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care.1996;34(3):220–233.
56.
StataCorp. Stata Statistical Software: Release 14.2. College Station, TX: StataCorp LP. 2015.
57.
HayesAF. Introduction to Mediation, Moderation, and Conditional Process Analysis: A Regression-Based Approach. 2nd edition. New York, NY: Guilford Press; 2018.
58.
CorpI. IBM SPSS Statistics for Windows. Version 24.0. Released 2016.
59.
WasanAD, RossEL, MichnaE, . Craving of prescription opioids in patients with chronic pain: a longitudinal outcomes trial. J Pain.2012;13(2):146–154.
60.
ChouR, TurnerJA, DevineEB, . The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop effectiveness and risks of long-term opioid therapy for chronic pain. Ann Intern Med.2015;162(4):276–286.
61.
BowmanS, EisermanJ, BeletskyL, StancliffS, BruceRD. Reducing the health consequences of opioid addiction in primary care. Am J Med.2013;126(7):565–571.
62.
SehgalN, ManchikantiL, SmithHS. Prescription opioid abuse in chronic pain: a review of opioid abuse predictors and strategies to curb opioid abuse. Pain Physician.2012;15(3 Suppl):ES67–ES92.
63.
BrownR, DeyoB, RileyC, . Screening in Trauma for Opioid Misuse Prevention (STOMP): study protocol for the development of an opioid risk screening tool for victims of injury. Addict Sci Clin Pract.2017;12(1):28.
64.
MooreTM, JonesT, BrowderJH, DaffronS, PassikSD. A comparison of common screening methods for predicting aberrant drug‐related behavior among patients receiving opioids for chronic pain management. Pain Med.2009;10(8):1426–1433.
65.
SAMHSA. Results from the 2015 National Survey on Drug Use and Health: Detailed Tables. Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services; 2015.
ChainDrugStoresN. 2011–2012 Chain Pharmacy Industry Profile. Alexandria, VA: National Association of Chain Drug Stores; 2011.
68.
CochranG, FieldC, LawsonK. Pharmacists who screen and discuss opioid misuse with patients: future directions for research and practice. J Pharm Pract2014;28(4):404–412.
69.
CochranG, FieldC, LawsonK, EricksonC. Pharmacists’ knowledge, attitudes and beliefs regarding screening and brief intervention for prescription opioid abuse: a survey of Utah and Texas pharmacists. J Pharm Health Serv Res.2013;4(2):71–79.
70.
DhitalR, WhittleseaCM, NormanIJ, MilliganP. Community pharmacy service users’ views and perceptions of alcohol screening and brief intervention. Drug Alcohol Rev.2010;29(6):596–602.
71.
CochranG, GordonAJ, FieldC, . Developing a framework of care for opioid medication misuse in community pharmacy. Res Social Adm Pharm.2016;12(2):293–301.
72.
CochranG, FieldC, KarpJ, . A community pharmacy intervention for opioid medication misuse: a pilot randomized clinical trial. J Am Pharm Assoc.2018;58(4):395.
73.
NovakSP, Herman-StahlM, FlanneryB, ZimmermanM. Physical pain, common psychiatric and substance use disorders, and the non-medical use of prescription analgesics in the United States. Drug Alcohol Depend.2009;100(1–2):63–70.
74.
NovakSP, Herman-StahlM, FlanneryB, ZimmermanM. Physical pain, common psychiatric and substance use disorders, and the non-medical use of prescription analgesics in the United States. Drug Alcohol Depend.2009;100(1–2):63–70.
