Papers by Jennifer Braden
The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry, 2008
Mental health disorders commonly co-occur in patients with chronic pain, but little is known abou... more Mental health disorders commonly co-occur in patients with chronic pain, but little is known about the role of chronic pain in mental health service use. In this study, the authors explored the role of chronic pain in mental health service use by adults according to age group. The authors conducted a cross-sectional analysis of survey data from the second wave of the Health Care for Communities telephone survey collected in 2000-2001. Participants consisted of U.S. civilian adults (N = 6629) from randomly selected U.S. households. Common mental disorders were assessed using the short-form versions of the World Health Organization's Composite International Diagnostic Interview. Chronic pain conditions and mental health services received were identified by self-report. Physical and mental functioning was assessed using the Short Form-12. Adults older than age 60 had higher rates of chronic pain and lower rates of mental health service use compared with those aged 18-60 years. In m...
Psychiatric Services, 2008
Objective-We sought to examine the independent and interactive effects of common mental health di... more Objective-We sought to examine the independent and interactive effects of common mental health disorders and chronic pain conditions on employment and work outcomes among individuals younger than 65 years of age.
Pain Medicine, 2010
To estimate recent age- and sex-specific changes in long-term opioid prescription among patients ... more To estimate recent age- and sex-specific changes in long-term opioid prescription among patients with chronic pain in two large American Health Systems. Analysis of administrative pharmacy data to calculate changes in prevalence of long-term opioid prescription (90 days or more during a calendar year) from 2000 to 2005, within groups based on sex and age (18-44, 45-64, and 65 years and older). Separate analyses were conducted for patients with and without a diagnosis of a mood disorder or anxiety disorder. Changes in mean dose between 2000 and 2005 were estimated, as were changes in the rate of prescription for different opioid types (short-acting, long-acting, and non-Schedule 2). Enrollees in HealthCore (N = 2,716,163 in 2000) and Arkansas Medicaid (N = 115,914 in 2000). Within each of the age and sex groups, less than 10% of patients with a chronic pain diagnosis in HealthCore, and less than 33% in Arkansas Medicaid, received long-term opioid prescriptions. All age, sex, and anxiety/depression groups showed similar and statistically significant increases in long-term opioid prescription between 2000 and 2005 (35-50% increase). Per-patient daily doses did not increase. No one group showed especially large increases in long-term opioid prescriptions between 2000 and 2005. These results argue against a recent epidemic of opioid prescribing. These trends may result from increased attention to pain in clinical settings, policy or economic changes, or provider and patient openness to opioid therapy. The risks and benefits to patients of these changes are not yet established.
PAIN, 2008
Opioids are widely prescribed for non-cancer pain conditions (NCPC), but there have been no large... more Opioids are widely prescribed for non-cancer pain conditions (NCPC), but there have been no large observational studies in actual clinical practice assessing patterns of opioid use over extended periods of time. The TROUP (Trends and Risks of Opioid Use for Pain) study reports on trends in opioid therapy for NCPC in two disparate populations, one national and commercially insured (HealthCore Blue Cross and Blue Shield plans) and one state-based and publicly-insured (Arkansas Medicaid) population over a six year period (2000)(2001)(2002)(2003)(2004)(2005). We track enrollees with the four most common NCPC conditions: arthritis/joint pain, back pain, neck pain, headaches, as well as HIV/AIDS. Rates of NCPC diagnosis and opioid use increased linearly during this period in both groups, with the Medicaid group starting at higher rates and the HealthCore group increasing more rapidly. The proportion of enrollees receiving NCPC diagnoses increased (HealthCore 33%, Medicaid 9%), as did the proportion of enrollees with NCPC diagnoses who received opioids (HealthCore 58%, Medicaid 29%). Cumulative yearly opioid dose (in mg. morphine equivalents) received by NCPC patients treated with opioids increased (HealthCore 38%, Medicaid 37%) due to increases in number of days supplied rather than dose per day supplied. Use of short-acting Drug Enforcement Administration Schedule II opioids increased most rapidly, both in proportion of NCPC patients treated (HealthCore 54%, Medicaid 38%) and in cumulative yearly dose (HealthCore 95%, Medicaid 191%). These trends have occurred without any significant change in the underlying population prevalence of NCPC or new evidence of the efficacy of long-term opioid therapy and thus likely represent a broad-based shift in opioid treatment philosophy.
PAIN, 2010
The use of chronic opioid therapy (COT) for chronic non-cancer pain (CNCP) has increased dramatic... more The use of chronic opioid therapy (COT) for chronic non-cancer pain (CNCP) has increased dramatically in the past two decades. There has also been a marked increase in abuse of prescribed opioids and in accidental opioid overdose. Misuse of prescribed opioids may link these trends, but has thus far only been studied in small clinical samples. We therefore sought to validate an administrative indicator of opioid misuse among large samples of recipients of COT and determine the demographic, clinical, and pharmacological risks associated with possible and probable opioid misuse. 21,685 enrollees in commercial insurance plans and 10,159 in Arkansas Medicaid who had at least 90 days of continuous opioid use 2000-5 were studied for one year. Criteria were developed for possible and probable opioid misuse using administrative claims data concerning excess days supplied of shortacting and long-acting opioids, opioid prescribers and opioid pharmacies. We estimated possible misuse at 24% of COT recipients in the commercially insured sample and 20% in the Medicaid sample and probable misuse at 6% in commercially insured and at 3% in Medicaid. Among non-modifiable factors, younger age, back pain, multiple pain complaints and substance abuse disorders identify patients at high risk for misuse. Among modifiable factors, treatment with high daily dose opioids (especially>120mg MED per day) and short-acting Schedule II opioids appears to increase risk of misuse. The consistency of the findings across diverse patient populations and varying levels of misuse suggests that these results will generalize broadly, but awaits confirmation in other studies.
Journal of Pain and Symptom Management, 2010
Although opioids are increasingly used for chronic noncancer pain (CNCP), we know little about op... more Although opioids are increasingly used for chronic noncancer pain (CNCP), we know little about opioid dosing patterns among individuals with CNCP in usual care settings, and how these are changing over time. To investigate the distribution of mean daily dose and mean days supply among patients with CNCP in two disparate populations, one national and commercially insured population (HealthCore) and one state based and publicly insured (Arkansas Medicaid), for years 2000 and 2005. For individuals with any opioid use, we calculated the distribution of mean daily dose (in milligram morphine equivalents), mean days supply in a year, mean annual dose, and patient characteristics associated with heavy utilizers of opioids. Between 2000 and 2005, across all percentiles, there was little change in the mean daily opioid dose. In HealthCore, mean days supply increased most rapidly at the top end of the days supply distribution, whereas in Arkansas Medicaid, the greatest increases were near the median of days supply. In HealthCore, the top 5% of users accounted for 70% of total use (measured in milligram morphine equivalents), and the top 5% of Arkansas Medicaid users accounted for 48% of total use. The likelihood of heavy opioid utilization was increased among individuals with multiple pain conditions, and in HealthCore, among those with mental health and substance use disorders. Opioid use is heavily concentrated among a small percent of patients. The characteristics of these high utilizers need to be further established, and the benefits and risks of their treatment evaluated.
The Journal of Pain, 2012
Pain complaints are commonly reported symptoms among postmenopausal women and can have significan... more Pain complaints are commonly reported symptoms among postmenopausal women and can have significant effects on health-related quality of life. We sought to identify medical and psychosocial factors that predict changes in pain and overall physical functioning over a three-year period among post-menopausal women with recurrent pain conditions. We examined data from postmenopausal women age 50-79 with recurrent pain conditions (low back pain, neck pain, headache or migraines, or joint pain or stiffness) over a three-year period using the Women's Health Initiative Observational Study Cohort (N=67,963). Multinomial logistic regression models controlling for demographic and clinical characteristics were used to identify baseline predictors of change in the SF-36 subscales for pain and physical functioning between baseline and three year follow-up. BMI was associated with worsening of pain (OR [95% CI] 1.54 [1.45-1.63] for BMI ≥30) and physical functioning (1.83 [1.71-1.95] for BMI≥30). A higher reported number of non-pain symptoms, higher medical comorbidity and a positive screen for depression (1.13 [1.05-1.22] for worsened pain) were also associated with worsening of pain and physical functioning. Baseline prescription opioid use was also associated with lack of improvement in pain (OR 0.42, 95% CI 0.36-0.49) and with worsened physical functioning (1.25 [1.04-1.51]).
The Journal of Pain, 2008
ABSTRACT The use of prescription opioids for chronic non-cancer pain is becoming an increasingly ... more ABSTRACT The use of prescription opioids for chronic non-cancer pain is becoming an increasingly more common treatment strategy, and rates of use have increased significantly. We sought to examine trends in opioid prescribing for individuals with chronic non-cancer pain conditions (arthritis, back pain, neck pain, headaches, HIV/AIDS), by type and number of pain diagnoses. Data were obtained from claims records for the years 2000 through 2005 from two health plans: Wellpoint (N=3,768,223) and Arkansas Medicaid (N=154,371). Doses from opioid prescriptions dispensed were converted to morphine equivalents, and the total per patient per year was compared across years and pain types. The percent of enrollees with any opioid use, days supply and mean total opioid dose increased between 2000 and 2005 for all pain diagnosis types and with increasing number of pain diagnoses. Among Arkansas Medicaid enrollees in 2005, mean days supply by pain type ranged from 84.6 (HIV/AIDS) to 134.2 (neck pain), and total mean opioid dose ranged from 5352.7 (HIV/AIDS) to 8575.7 (neck pain) mg morphine equivalents. Mean days supply increased from 69.4 for one pain diagnosis to 191.1 for four pain diagnoses, and the corresponding mean total opioid dose increased from 3827.9 to 11,974.4 mg morphine equivalents. Among Wellpoint enrollees in 2005, mean days supply by pain type ranged from 54.4 (arthritis) to 78.8 (headaches), and mean total opioid dose ranged from 3537.6 (arthritis) to 5041.8 (back pain) mg morphine equivalents. Mean days supply increased from 36.4 for one pain diagnosis to 147.7 for four pain diagnoses, and the corresponding mean total opioid dose increased from 2111.0 to 9332.3 mg morphine equivalents. The greatest percent increases in mean days supply and dose between 2000 and 2005 in both plans occurred among those with back and/or neck pain, and three or four pain diagnoses.
The Journal of Pain, 2008
ABSTRACT The TROUP (Trends and Risks of Opioid Use for Pain) study is designed to assess trends i... more ABSTRACT The TROUP (Trends and Risks of Opioid Use for Pain) study is designed to assess trends in and risks of opioid therapy for chronic non-cancer pain in contrasting pain populations. Data from a national privately insured population (WellPoint, 2005 enrollees N= 3,768,223) are compared with a state-based publicly-insured population (Arkansas Medicaid, 2005 enrollees N=154,371). We assess trends from 2000 to 2005 in opioid use for common chronic non-cancer pain (CNCP): arthritis/joint pain, back pain, neck pain, headaches/migraines, HIV/AIDS. The proportion of the samples with these CNCP conditions, and the proportion of these who received opioids increased linearly over the six years. Between 2000 and 2005, the proportion of Wellpoint enrollees with CNCP receiving any opioids increased 58% from 5.4% to 8.6%, while the proportion of Medicaid enrollees increased 34% from 17.3% to 23.1%. Among WellPoint enrollees receiving any opioids for CNCP, the total dose (in mg. morphine equivalents) increased 38% from 2473 to 3406 mg per year, while among Medicaid enrollees, the total dose increased 29% from 4610 to 5935 mg per year. In both samples, this was due to an increase in days supplied since dose/days supplied did not increase. The proportion of CNCP patients using short-acting DEA Schedule II opioids increased 54% in WellPoint and 41% in Medicaid. Mean dose among those using these short-acting Schedule II opioids increased 95% in WellPoint and 167% in Medicaid. The proportion of CNCP patients using long-acting DEA Schedule II opioids increased 11% in WellPoint and 28% in Medicaid. Mean dose among those using these long-acting Schedule II opioids increased 39% in WellPoint and 20% in Medicaid. Among patients with CNCP, the proportion using opioids, the dose supplied, and the potency are all rapidly increasing. The WellPoint sample increased more rapidly, but the Medicaid sample started at a higher level of use.
The Journal of Pain, 2008
ABSTRACT Prior studies have suggested an increased risk for suicidal thoughts and behaviors in in... more ABSTRACT Prior studies have suggested an increased risk for suicidal thoughts and behaviors in individuals with chronic pain conditions, but most of these have been focused on a discrete subset of individuals with chronic pain and/or not adequately adjusted for socio-demographic and psychiatric risk factors for suicide. We sought to examine whether chronic pain is independently associated with an increased risk for suicidal ideation, plan, or attempts after adjusting for other risk factors and whether risk differs by specific type of chronic pain. We analyzed data from the National Co-morbidity Survey Replication, a household survey of U.S. civilian adults carried out between 2001 and 2003. Chronic pain conditions and suicidal history were obtained by self report. DSM-IV mood, anxiety and substance use disorders were assessed using the World Health Organization's Composite International Diagnostic Interview (CIDI). In logistic regression analyses, the presence of any chronic pain condition remained significantly associated with lifetime suicidal ideation, plan or attempt after controlling for other covariates (OR for suicidal ideation 1.4 [1.1-1.8]). When examining subtypes of chronic pain, associations remained for severe or frequent headaches and other' chronic pain, but not for back/neck pain or arthritis. Results highlight the importance of identifying and treating co-morbid mental disorders and suggest that other factors specific to chronic pain serve as additional risk factors for suicidal thoughts and behaviors, particularly in those with chronic pain conditions other than arthritis and back/neck pain.
The Journal of Pain, 2008
We sought to examine whether the presence of a noncancer pain condition is independently associat... more We sought to examine whether the presence of a noncancer pain condition is independently associated with an increased risk for suicidal ideation, plan, or attempt after adjusting for sociodemographic and psychiatric risk factors for suicide and whether risk differs by specific type of pain. We analyzed data from the National Comorbidity Survey Replication, a household survey of U.S. civilian adults age 18 years and older (n ؍ 5692 respondents). Pain conditions, nonpain medical conditions, and suicidal history were obtained by self-report. DSM-IV mood, anxiety, and substance use disorders were assessed using the World Health Organization's Composite International Diagnostic Interview. Antisocial and borderline personality traits were assessed with the International Personality Disorder Examination screening questionnaire. In unadjusted logistic regression analyses, the presence of any pain condition was associated with lifetime and 12-month suicidal ideation, plan, and attempt. After controlling for demographic, medical, and mental health covariates, the presence of any pain condition remained significantly associated with lifetime suicidal ideation (odds ratio, 1.4; 95% confidence interval, 1.1-1.8) and plan. Among pain subtypes, severe or frequent headaches and "other" chronic pain remained significantly associated with lifetime suicidal ideation and plan; "other" chronic pain was also associated with attempt.
The Journal of Pain, 2008
Use of prescription opioids for non-cancer pain has increased significantly in recent years, but ... more Use of prescription opioids for non-cancer pain has increased significantly in recent years, but it is not known if trends differ among the most common non-cancer pain conditions. We examined trends in opioid prescribing for the years 2000 through 2005 for individuals with arthritis/joint pain, back pain, neck pain, and headaches by type and number of pain diagnoses, using data from claims records from two health insurers: HealthCore commercially insured members (N=3,768,223) and Arkansas Medicaid (N=127,866). Rates of headache, back pain, and neck pain diagnoses increased significantly in Arkansas Medicaid enrollees, but more modestly among HealthCore enrollees. Rates of opioid use increased in both groups, with long term use (>90 days supply per year) increasing at twice the rate of any use. Rates of opioid use did not differ widely between non-cancer pain conditions, but long-term opioid use rates doubled with each additional pain diagnosis. Mean days supply and cumulative yearly dose increased between 2000 and 2005 for all pain types and with increasing number of pain diagnoses, but dose per day supply remained relatively stable. The greatest increases in dose among all the pain conditions were seen in short-acting DEA Schedule II opioids.
Journal of General Internal Medicine, 2013
BACKGROUND: Opioids are increasingly prescribed, but there are limited data on opioid receipt by ... more BACKGROUND: Opioids are increasingly prescribed, but there are limited data on opioid receipt by HIV status. OBJECTIVES: To describe patterns of opioid receipt by HIV status and the relationship between HIV status and receiving any, high-dose, and long-term opioids. DESIGN: Cross-sectional analysis of the Veterans Aging Cohort Study. PARTICIPANTS: HIV-infected (HIV+) patients receiving Veterans Health Administration care, and uninfected matched controls. MAIN MEASURES: Pain-related diagnoses were determined using ICD-9 codes. Any opioid receipt was defined as at least one opioid prescription; high-dose was defined as an average daily dose ≥120 mg of morphine equivalents; long-term opioids was defined as ≥90 consecutive days, allowing a 30 day refill gap. Multivariable models were used to assess the relationship between HIV infection and the three outcomes. KEY RESULTS: Among the HIV+ (n = 23,651) and uninfected (n=55,097) patients, 31 % of HIV+ and 28 % of uninfected (p<0.001) received opioids. Among patients receiving opioids, HIV+ patients were more likely to have an acute pain diagnosis (7 % vs. 4 %), but less likely to have a chronic pain diagnosis (53 % vs. 69 %). HIV+ patients received a higher mean daily morphine equivalent dose than uninfected patients (41 mg vs. 37 mg, p=0.001) and were more likely to receive high-dose opioids (6 % vs. 5 %, p<0.001). HIV+ patients received fewer days of opioids than uninfected patients (median 44 vs. 60, p<0.001), and were less likely to receive long-term opioids (31 % vs. 34 %, p< 0.001). In multivariable analysis, HIV+ status was associated with receipt of any opioids (AOR 1.40, 95 % CI 1.35, 1.46) and high-dose opioids (AOR 1.22, 95 % CI 1.07, 1.39), but not long-term opioids (AOR 0.94, 95 % CI 0.88, 1.01).
Journal of General Internal Medicine, 2011
OBJECTIVE: To report chronic opioid therapy discontinuation rates after five years and identify f... more OBJECTIVE: To report chronic opioid therapy discontinuation rates after five years and identify factors associated with discontinuation. METHODS: Medical and pharmacy claims records from January 2000 through December 2005 from a national private health network (HealthCore), and Arkansas (AR) Medicaid were used to identify ambulatory adult enrollees who had 90 days of opioids supplied. Recipients were followed until they discontinued opioid prescription fills or disenrolled. Kaplan Meier survival models and Cox proportional hazards models were estimated to identify factors associated with time until opioid discontinuation. RESULTS: There were 23,419 and 6,848 chronic opioid recipients followed for a mean of 1.9 and 2.3 years in the HealthCore and AR Medicaid samples. Over a maximum follow up of 4.8 years, 67.0% of HealthCore and 64.9% AR Medicaid recipients remained on opioids. Recipients on high daily opioid dose (greater than 120 milligrams morphine equivalent (MED)) were less likely to discontinue than recipients taking lower doses: HealthCore hazard ratio (HR) = 0.66 (95%CI: 0.57-0.76), AR Medicaid HR=0.66 (95%CI: 0.50-0.82). Recipients with possible opioid misuse were also less likely to discontinue: HealthCore HR =0.83 (95%CI: 0.78-0.89), AR Medicaid HR=0.78 (95%CI: 0.67-0.90). CONCLUSIONS: Over half of persons receiving 90 days of continuous opioid therapy remain on opioids years later. Factors most strongly associated with continuation were intermittent prior opioid exposure, daily opioid dose ≥ 120 mg MED, and possible opioid misuse. Since high dose and opioid misuse have been shown to increase the risk of adverse outcomes special caution is warranted when prescribing more than 90 days of opioid therapy in these patients.
Journal of General Internal Medicine, 2010
BACKGROUND: Opioids have been linked to increased risk of fractures, but little is known about ho... more BACKGROUND: Opioids have been linked to increased risk of fractures, but little is known about how opioid dose affects fracture risk.
Drug and Alcohol Dependence, 2010
Objective-To estimate the prevalence of and risk factors for opioid abuse/dependence in longterm ... more Objective-To estimate the prevalence of and risk factors for opioid abuse/dependence in longterm users of opioids for chronic pain, including risk factors for opioid abuse/dependence that can potentially be modified to decrease the likelihood of opioid abuse/dependence, and non-modifiable risk factors for opioid abuse/dependence that may be useful for risk stratification when considering prescribing opioids.
The Clinical Journal of Pain, 2013
Increasing rates of opioid use disorders (OUDs) (abuse and dependence) among patients prescribed ... more Increasing rates of opioid use disorders (OUDs) (abuse and dependence) among patients prescribed opioids are a significant public health concern. We investigated the association between exposure to prescription opioids and incident OUDs among individuals with a new episode of a chronic noncancer pain (CNCP) condition. We utilized claims data from the HealthCore Database for 2000 to 2005. The dataset included all individuals aged 18 and over with a new CNCP episode (no diagnosis in the prior 6 mo), and no opioid use or OUD in the prior 6 months (n=568,640). We constructed a single multinomial variable describing prescription on opioid days supply (none, acute, and chronic) and average daily dose (none, low dose, medium dose, and high dose), and examined the association between this variable and an incident OUD diagnosis. Patients with CNCP prescribed opioids had significantly higher rates of OUDs compared with those not prescribed opioids. Effects varied by average daily dose and days supply: low dose, acute (odds ratio [OR]=3.03; 95% confidence interval [CI], 2.32, 3.95); low dose, chronic (OR=14.92; 95% CI, 10.38, 21.46); medium dose, acute (OR=2.80; 95% CI, 2.12, 3.71); medium dose, chronic (OR=28.69; 95% CI, 20.02, 41.13); high dose, acute (OR=3.10; 95% CI, 1.67, 5.77); and high dose, chronic (OR=122.45; 95% CI, 72.79, 205.99). Among individuals with a new CNCP episode, prescription opioid exposure was a strong risk factor for incident OUDs; magnitudes of effects were large. Duration of opioid therapy was more important than daily dose in determining OUD risk.
Archives of Internal Medicine, 2010
Background: Therehasbeenanincreaseinoverdosedeaths and emergency department visits (EDVs) involvi... more Background: Therehasbeenanincreaseinoverdosedeaths and emergency department visits (EDVs) involving use of prescription opioids, but the association between opioid prescribing and adverse outcomes is unclear.
General Hospital Psychiatry, 2009
More than half of all outpatient visits are trigged by physical symptoms which, in turn, are not ... more More than half of all outpatient visits are trigged by physical symptoms which, in turn, are not adequately explained by medical disorders at least half of the time. Further, the presence and severity of somatic symptoms often correlate more strongly with psychological, cognitive and behavioral factors than with physiological or biological findings. Finally, our understanding of the etiology, evaluation, and management of somatic symptoms and functional syndromes is less advanced than our knowledge of many defined medical and psychiatric disorders. This special section, edited by Kurt Kroenke, M.D., will highlight original studies that advance the science and clinical care of somatic symptoms.
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Papers by Jennifer Braden