Context Chronic pain and opioid dependence confer substantial individual and societal burdens and are notoriously difficult to treat effectively. Their comorbid presentation further complicates effective treatment through complex physiological and environmental interactions. Objectives (1) What are the clinical characteristics and treatment outcomes associated with comorbid chronic pain in ORT patients? (2) Does the patient-attributed direction of the causal relationship in the development of opioid dependence and chronic pain identify two clinically-distinct treatment populations? (3) What is the incidence of iatrogenic opioid dependence or abuse following opioid analgesic treatment? (4) Is there evidence of opioid-induced hyperalgesia in humans? Methods Primary data Participants were 467 treatment-seeking, opioid-dependent patients. Materials comprised standardised instruments – focusing on illicit substance use and mental health characteristics – completed by medical staff at study inception, and extracts of routinely-collected clinical datasets spanning the follow-up period. Procedures involved the use of a health informatics approach. Electronic linkage of data collected at study inception with routinely-collected clinical datasets spanning the 5-year follow-up period. Secondary data Systematic searches were undertaken using six electronic research databases, supplemented by manual searches. Study quality was assessed using instruments developed by NIH. Data synthesis using random effects models (DerSimonian-Laird method) generated: (1) a pooled incidence of iatrogenic dependence or abuse following opioid analgesic treatment; and (2) a pooled effect of opioid exposure on the development of opioid-induced hyperalgesia. Additional analyses included assessment of heterogeneity in study effects, within- and between-study risk of bias and sensitivity analyses. Results A total of 246 (53%) patients reported comorbid chronic pain. This ‘comorbid’ group was associated with increased mortality, physical and mental health problems, service utilisation and illicit drug use, specifically benzodiazepines and cannabinoids. Within the ‘comorbid’ group, patients who reported a causal impact of opioid dependence on the development of pain were associated with increased illicit drug use and psychiatric morbidity. Secondary data analyses revealed a 4.7% incidence estimate of iatrogenic dependence or abuse following opioid analgesic treatment, and evidence of the development of opioid-induced hyperalgesia following therapeutic opioid exposure. Conclusions Elevated mortality, morbidity and illicit drug use in opioid-dependent patients with comorbid chronic pain reflects a patient population with substantial health burdens. The dynamic relationship between these severe and chronic conditions necessitates complex, multimodal treatment strategies and multiagency collaboration, including general psychiatric intervention. Whilst a substantial proportion reported that opioid dependence developed as a consequence of pain problems, there is evidence to suggest that the assumed risk of iatrogenic opioid dependence and abuse may be an overestimate; however, therapeutic opioids may lead to other problems that impact on treatment effectiveness, such as opioid-induced hyperalgesia.

Opioid abuse costs affect the majority of the adult population in our society directly or indirectly. The current prevailing medical treatment for opioid addiction is methadone maintenance treatment (MMT). MMT reduces infectious disease spread, illicit drug use, criminal activity, and overdose potential. MMT is only as effective as the length of time a client remains active and compliant with the program. In previous studies, therapeutic alliance (TA) has been shown to positively influence the effectiveness of substance abuse treatment. However, a gap exists in research in regards to the impact of TA on the effectiveness of MMT outcomes. The theoretical framework of this study is based on therapeutic alliance, which guided an examination on whether therapeutic alliance (as measured by the Session Rating Scale) influenced MMT retention and compliance (drug screens and session attendance). Archival data from 264 clients receiving MMT for opioid dependence were reviewed from a nonprofit community-based agency in Arizona. Logistic regression results revealed that TA did not significantly affect retention or compliance. However, issues were noted such as how the SRS was administered, a lack of understanding by clients regarding scoring the SRS, and unique social desirability demands when clients are in MMT. The finding that TA alone did not significantly affect retention and compliance does not decrease the need to find effective means to improve MMT outcomes. Rather, the findings suggest a critical need to identify and utilize measures more appropriate for clients receiving MMT. In doing so, positive social change may be achieved by assisting clinical staff in developing a strong therapeutic alliance with MMT clients as they focus on problem solving as a joint venture when challenges in the recovery process arise.

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Bakgrund och syfte. Opioidberoende medför flera risker för individen varav utanförskap, sämre upplevd livssituation och dödsfall är exempel på några av dessa risker. Denna studie genomfördes som en litteraturstudie med syfte att undersöka främjande eller hindrande faktorer som påverkar en opioidberoende individs användningsmönster och även utforska dennes uppfattningar kring sin livssituation.  Metod. Studien grundar sig i metoden litteraturstudie och genom litteratursökningar har fem kvalitativa vetenskapliga artiklar granskats, analyserats och diskuterats. Det teoretiska ramverket för diskussionen har varit empowerment.  Resultat. I resultatet framträdde nyckelsaspekter som kan verka främjande eller hindrande i en förändringsprocess gällande opioidanvändning. Upplevt stöd och förståelse hos individen från omgivningen gällande opioidberoendet kan främja för en förändring i användningsmönstret, samtidigt som att uppleva motsatsen kan vara ett hinder för förändringsprocessen. Resultatet antyder också att en opioidberoende individs livssituation är fylld med negativa upplevelser i form av bland annat bristande egenmakt och stigma till följd av sin beroendeproblematik.  Slutsats. En ökad kunskap i samhället kan tänkas bidra till ett minskat stigma för individer med beroendeproblematik vilket i sin tur även kan främja en förändringsprocess gällande användningsmönster. / Background and aim. Opioid dependence entails several risks for the individual with the dependence, of which crime, exclusion, poorer perceived life situation and death are examples of some of these risks. This study was conducted as a literature study with the aim of examining promoting or hindering factors that affect an opioid-dependent individual's pattern of use and explore the perceptions about their life situation. Method. The study is based on the method literature study and through literature searches five qualitative scientific articles have been reviewed, analyzed, and discussed. The theoretical framework for the discussion has been empowerment. Results. Key aspects that can have a promoting or hindering effect in the change of process regarding opioid use emerged in the results. Perceived support and understanding from the environment regarding their opioid dependency can promote a change in the pattern of opioid use, at the same time perceiving the opposite can be hindering in the process of change. The results also indicates that a life with opioid dependency is filled with negative experiences in the form of, amongst other things, lack of autonomy and stigma because of the dependency. Conclusion. An increased knowledge in society regarding opioid dependency can possibly contribute to a reduced sense of stigma for individuals with dependency problems, which also promote a process of change regarding the pattern of use.