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Complexities and Comorbidities in Patients with Chronic Non-Cancer Pain: Suicidal Behaviours and Pharmaceutical Opioid Use

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Complexities and Comorbidities in Patients with Chronic Non-Cancer Pain: Suicidal Behaviours and Pharmaceutical Opioid Use Complexities and comorbidities in patients with chronic non-cancer pain: Suicidal behaviours and pharmaceutical opioid use Gabrielle Campbell Masters of Criminology A thesis in fulfilment of the requirements for the degree of Doctor of Philosophy National Drug and Alcohol Research Centre School of Public Health and Community Medicine Faculty of Medicine University of New South Wales January 2016 THE UNIVERSITY OF NEW SOUTH WALES Thesis/Dissertation Sheet Surname or Family name: Campbell (Szytkiel) First name: Gabrielle Other name/s: Abbreviation for degree as given in the University calendar: PhD School: Medicine Faculty: School of Public Health and Community Medicine Title: Complexities and comorbidities in patients with chronic non-cancer pain: Suicidal behaviours and pharmaceutical opioid use Abstract: Chronic non-cancer pain (CNCP) is a worldwide, common complaint and has a major impact on the individual and community in terms of social, financial and health costs. To date, research has been limited in a number of areas, including the association of CNCP with suicidality, the nature of pharmaceutical opioid use in people with CNCP and the prevalence of Borderline Personality Disorder (BPD) in people with CNCP, and associations with suicidality and problematic opioid use. This thesis aimed to address the gaps in previous literature using two data sources; firstly, the 2007 Australian National SuNey of Mental Health and Well-being and secondly, data from a large, na tional community suNey, the Pain and Opioids IN Treatment (POINT) study. The studies included in this thesis aimed to: 1) examine the association of CNCP with suicidality in the Australia population; 2) describe the formation of the POINT cohort to examine prescription opioid use in CNCP; 3) examine the characteristics of CNCP patients prescribed pharmaceutical opioids; 4) examine characteristics associated with pharmaceutical opioid dose and pharmaceutical opioid dependence in the POINT cohort; 5) determine the prevalence of suicidality and contribution of general and pain-specific risk factors to suicidality in the POINT cohort and 6) explore BPD in the POINT cohort and associations with problematic pharmaceutical opioid use and suicidality. There were a number of significant findings from th is thesis. Firstly, there was large proportion of the cohort consuming opioids in the high range (over 90mg of oral morphine equivalents per day) and this was associated with more problematic opioid use. Secondly, suicidality was common in people with CNCP, especially in people prescribed opioids for CNCP. An individual's confidence in coping with their pain was the only independent factor that was predictive of past 12 month elevation from ideation to suicide attempt. Finally, the presence of BPD was high amongst this sample and was associated with pharmaceutical opioid dependence and suicidality. Clinical and research implications are discussed in terms of the need for a multidisciplinary approach to CNCP and the need for appropriate screening for the use of pharmaceutical opioids in the treatment of CNCP. Declaration relating to disposition of project thesis/dissertation 1 hereby grant to the University of New South Wales or its agents the right to archive and to make available my thesis or dissertation in whole or in part in the University libraries in all forms of media. now or here after known, subject to the provisions of the Copyright Act 1968. I retain all property rights, such as patent rights. I also retain the rig ht to use in future works (such as articles or books) all or part of this thesis or dissertation. 1 also authorise University Microfilms to use the 350 word abstract of my thesis in Dissertation Abstracts International (this is applicable to doctoral theses only). I Signature · · ··· · ···· · ··· · · · · ~W itness · · ·· · Date The University recognises that there may be exceptional circumstances requiring restrictions on copying or conditions on use. Requests for restriction for a period of up to 2 years must be made in writing. Requests for a longer period of restriction may be considered in exceptional circumstances and re uire the a roval of the Dean of Graduate Research . FOR OFFICE USE ONLY Date of completion of requirements for Award: THIS SHEET IS TO BE GLUED TO THE INSIDE FRONT COVER OF THE THESIS DECLARATIONS Originality statement I hereby declare that this submission is my own work and to the best of my knowledge it contains no materials previously published or written by another person, or substantial proportions of material which have been accepted for the award of any other degree or diploma at UNSW or any other educational institution, except where due acknowledgement is made in the thesis. Any contribution made to the research by others, with whom I have worked at UNSW or elsewhere, is explicitly acknowledged in the thesis. I also declare that the intellectual content of this thesis is the product of my own work, except to the extent that assistance from others in the project's design and conception or in style, presentation and linguistic expression is acknowledged. Gabrielle Campbell January 2016 ii Copyright I hereby grant the University of New South Wales or its agents the right to archive and to make available my thesis or dissertation in whole or part in the University libraries in all forms of media, now or here after known, subject to the provisions of the Copyright Act 1968. I retain all proprietary rights, such as patent rights. I also retain the right to use in future works (such as articles or books) all or part of this thesis or dissertation. I also authorise University Microfilms to use the 350 word abstract of my thesis in Dissertation Abstract International (this is applicable to doctoral theses only). I have either used no substantial portions of copyright material in my thesis or I have obtained permission to use copyright material; where permission has not been granted I have applied/will apply for a partial restriction of the digital copy of my thesis or dissertation. Gabrielle Campbell January 2016 Authenticity statement I certify that the Library deposit digital copy is a direct equivalent of the final officially approved version of my thesis. No emendation of content has occurred and if there are any minor variations in formatting, they are the result of the conversion to digital format. Gabrielle Campbell January 2016 iii ACKNOWLEDGMENTS First and foremost I would like to give my sincerest thanks to my supervisors, Louisa Degenhardt (supervisor), Shane Darke (joint-supervisor) and Raimondo Bruno (co- supervisor). I feel honoured and privileged to have been supervised by individuals who are so highly regarded in their respective fields. To Louisa, you are inspiring and your passion is what led me to appreciate research in the first place. Your generosity and support (and pushing) throughout the years have been greatly appreciated, and I am eternally grateful for all the opportunities you share with me. To Shane, thank you for the support you have given me over the years we have worked together. Your door has always been open whenever I have needed to talk. Through you; I have learnt to appreciate the English language. To Raimondo, I have immensely enjoyed working with you. You kept me grounded throughout my thesis, and your passion for statistics has inspired me. Finally, to my unofficial mentor Briony Larance. Thank you for your support and wisdom. You are always there for a chat (whether you want to or not), you make me laugh, and that has kept me going throughout the years. Thank you to the POINT participants who were willing to share their experiences. I hope that this research may be of some assistance in the understanding of CNCP and the difficulties that you often experience. Thanks to the Chief Investigators of the POINT study, Louisa Degenhardt, Wayne Hall, Richard Mattick, Suzanne Nielsen, Briony Larance, Raimondo Bruno, Nicholas Lintzeris, Milton Cohen, Fiona Shand and Michael Farrell. I have enjoyed being challenged and am thankful for the opportunity to work with you all on a project that is of great importance. Thanks to the POINT study team, Jessica Belcher, Bianca Hoban, Sarah Freckleton, Anika Martin, Ranira Moodley, Teleri Moore, Kimberley Smith, and Rachel Urquhart- Secord. Your dedication to the project is greatly appreciated. Without your hard work this project would not be possible. v Thank you to and friends and parents. Natasha Winsley, thank you for always being available to listen, you have endured this PhD with me. To my fellow PhD students, Elizabeth Whittaker and Amanda Roxburgh, I am grateful to have undertaken this journey with you. To my mum, thank you for coming and helping at home so that I was able to concentrate on my PhD. To my dad, thank you for your comments on my thesis. That you had to read my thesis, whilst in hospital, on opioids and in pain must have been insightful. Thank you to my family for their continual support throughout this journey. To my step-son Robbie, I know you have been missing my cooking and must be grateful this journey is now coming to a close. Thank you to my husband, Geo, for your support and managing the family, house and animals whilst I have been working on my PhD many a weekend. It will be nice to be able to do things as a family again. Finally, to my baby girl, Louella. You have been my main motivator for completing this PhD. Without you, I would have been a major procrastinator, time spent working on my thesis was time away from you, therefore not a minute was wasted. vi ABSTRACT Chronic non-cancer pain (CNCP) is a worldwide, common complaint and has a major impact on the individual and community in terms of social, financial and health costs. To date, research has been limited in a number of areas, including the association of CNCP with suicidality, the nature of pharmaceutical opioid use in people living with CNCP, the prevalence of Borderline Personality Disorder (BPD) in people living with CNCP, and associations between suicidality (i.e.
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