Running head: INTEGRATIVE REVIEW 1

Integrative Review

Shaila Ellis

Bon Secours Memorial College of Nursing

Arlene Holowaychuk EdD, MSN, RN, CNE

Nursing Research NUR 4122

April 17, 2019

Honor Code: “I Pledge…”

INTEGRATIVE REVIEW 2

Abstract

The purpose of this integrative review is to examine research literature that evaluates long-term

opioid use in chronic pain that could lead to opioid misuse disorder (OUD). Previous research

indicates that opioid use for patients with chronic pain is often associated with the development

of OUD. The PICO question under consideration is: Does long-term opioid use influence the risk

of opioid use disorder in patients who have chronic pain? The research design is an integrative

review of the literature. The database that was used for this research included Google Scholar to

locate the research articles selected for the integrative review. The results of the search yielded

17,500 articles and five of those were selected, due to them meeting the inclusion criteria. The

limitations to this review include a limited number of articles, an inexperience researcher, and

limited time to complete this research assignment. The five articles are up to date which is

evident by them not being more than five years old. The results of the research indicated that

there are several factors that play a role for OUD in patients taking opioids to manage their

chronic pain. Furthermore, the results yielded taking opioids for management of chronic pain

place patients at an increased risk for OUD. Implications of the studies’ findings suggested that

the results of the data could help lead to the development of preventative interventions that

decrease OUD. Recommendations for new research include utilizing clinicians to help with the

validity and reliability of client’s use of opioids.

INTEGRATIVE REVIEW 3

Integrative Review

The purpose of this integrated review is to examine research literature that evaluates how

long-term opioid use in patients with chronic pain, could lead to opioid misuse disorder (OUD).

OUD is common among patients of all age groups who have been diagnosed with chronic pain,

but it is more prevalent in individuals that are experiencing psychiatric symptoms (Martel,

Dolman, Edwards, Jamison, & Wasan, 2014). Previous research has consistently shown that

long-term use of opioids in patients with chronic pain increases the risk of OUD (Hser et al.,

2017). Long-term opioid use for chronic pain has been a growing concern for years due to the

risk of opioid abuse and the opioid epidemic crisis. Additionally, previous research indicates that

there is a variety of factors that influence the risk of OUD in patients with chronic pain (Martel et

al., 2014). The findings of this study can help with the opioid crisis by identifying patients that

are at an increased risk for OUD, when being treated for their chronic pain in the clinical setting.

The aim of this literature review is to examine and discuss previous research data as it relates to

the researcher’s PICO question: Does long-term opioid use influence the risk of opioid use

disorder in patients who have chronic pain?

Design and Search Methods

The research design is an integrative review of the literature. The articles were achieved

by using one database known as Google Scholar. The search terms included, ‘chronic pain’,

‘opioid use with chronic pain,’ ‘opioid use disorder,’ and ‘prescription opioid misuse.’ The

results yielded 17,500 articles from Google Scholar. The articles were filtered out to only list

research articles that was published in English between 2014-2019 to ensure the data was

acceptable, up to date and not contradicting of any new data.

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The research articles were inspected for relevancy of the PICO question set forth by the

researcher, “Does long-term opioid use influence the risk of opioid use disorder in patients who

have chronic pain?” If the article that was being evaluated did not have enough information or

did not include OUD or chronic pain, it was excluded from the research. Therefore, if it was

excluded from the research, it did not meet the criteria and it was not used for the integrative

review. Based upon evaluation of several articles that was yielded from the research, five peer-

reviewed quantitative studies were selected and referenced for this integrative review.

Findings and Results

The findings and results of the five studies that were reviewed indicated that the use of

long-term opioids in patients with chronic pain increase the risk of OUD (Hser et al., 2017,

Martel et al., 2014, McHugh, et al., 2016, Mojtabai, Amin-Esmaeili, Nejat, & Olfson, 2019, &

Vest, Reynolds, & Tragesser, 2016). A summary of each article is attached via Appendix 1. This

review is structured based upon the following themes found among patients with OUD and

chronic pain: substance misuse disorder, psychological distress, and impulsivity.

Substance Misuse disorder

Two out of the five articles incorporated outcomes linking illegal substance abuse

disorders with OUD in patients experiencing chronic pain (Hser et al., 2017 & Mojtabai et al.,

2019). This non-experimental descriptive correlational quantitative study by Hser et al. (2017)

examined the relationship among patients diagnosed with OUD who are experiencing chronic

pain (Schmidt & Brown, 2015). Also, the authors of this research assessed the prevalence of

other comorbidities in the subjects by comparing the subjects with other substance use disorders

(SUD). Initially, the researchers of this study had about 4.6 million individuals in the electronic

healthcare record. After each patient in the healthcare record were assessed for the OUD
INTEGRATIVE REVIEW 5

diagnosis, the ending results were only 5,307 participants with a diagnosis of OUD. The methods

for this study included utilizing an electronic health care record (HER) data base from a large

Los Angeles health system. The researchers used healthcare data from the subjects from the

years of 2006-2015. The records were thoroughly assessed for the patients’ demographics,

clinical diagnoses, prescribed medications, and laboratory testing that was done within the

clinical setting. The participants were spilt up into four groups based upon their first diagnosis

and pain condition: no chronic pain, OUD prior to chronic pain, OUD and chronic pain at the

same time, and chronic pain prior to OUD. The data was analyzed by using a multinomial

logistic regression analysis for each variable to test for group differences. Additionally, linear

test was used if the groups had a significant difference and they tested on equivalence of

coefficients between the pair of groups. Finally, the results supported and indicated that patients

with chronic pain and SUD are at a higher risk of OUD than any other group.

In the study completed by Mojtabai et al. (2019), the authors examined the prevalence

and risk factors for self-reported misuse of prescribed opioids in the general population of the

United States, such as substance abuse disorder (SUD) and psychological distress. This non-

experimental descriptive correlational quantitative study had a sample size of 31, 068 adult

participants (Schmidt & Brown, 2015). The data of the participants were obtained from the

National Survey on Drug Use and Health (NSDUH) from 2015-2016. The patients met the

inclusion criteria if they used opioids in the past year. The data was analyzed by utilizing

multivariable logistic regression and boosted regression model to assess the prevalence of OUD.

The data of the study concluded that participants who misused prescribed opioids also had a

significant substance misuse profile. Initially, the multivariable logistic regression model

indicated that SUD and psychological distress have a positive correlation with OUD.
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Furthermore, the researchers used a boosted regression analysis to see if the results were

consistent with one another. The results indicated that both of the analyses yielded the same

results that SUD and psychological distress are one of the most influential factors of OUD

because of the excessive use of unprescribed medications and inability to control impulsive

behavior.

Psychological Distress

Three of the five research articles utilized for this review were quantitative studies. The

studies examined the relationship between opioid misuse in patients with chronic pain

experiencing negative affect and distress intolerance (Martel et al., 2014, McHugh et al., 2016 &

Mojtabai et al., 2019). In the cross-sectional study conducted by Martel et al. (2014), the authors

conducted a quantitative study that researched the factors that underlie the relationship between

negative affect and prescription opioid misuse disorder. The researchers examined the role of

opioid craving and the association between negative affect and prescription misuse disorder. This

quantitative study sampled 82 adult participants with chronic musculoskeletal pain with or

without radicular symptoms (Schmidt & Brown, 2015). The methods of research for this study

included that the patients were also in a larger randomized clinical trial study for a behavioral

intervention designed to improve prescription opioid compliance in patients experiencing chronic

pain. The subjects’ data was collected at the beginning of the study for a base line and followed

throughout the study. During the study, the subjects were observed and directed to complete

multiple self-report questionnaires. The 17-item self-report current opioid misuse measure

(COMM) was used to determine and examine the relationship among negative affect and OUD.

Additionally, the researchers used the electronic diary questionnaire to assess for anxiety and

depression and opioid craving, and the results were converted to a numerical scale of 0-100.
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These questionnaires were analyzed using Pearson correlations and Steiger’s Z-test. The results

indicated that patients experiencing psychological distress, such as anxiety and depression have a

significant relationship with increasing the risk of prescription opioid misuse. Also, the results

showed a significant positive correlation between negative affect and opioid cravings. These

findings suggested that negative affect with opioid cravings place the chronic pain patient at a

higher risk for OUD.

In the second quantitative study completed by McHugh et al. (2016), the authors

conducted cross-sectional study examining whether distress intolerance is associated with OUD

in patients with chronic pain. This study sampled 51 participants that attended a pain

management clinic at a large urban academic hospital. The methods of research for this study

included several self-report questionnaires, Computerized Mirror Tracing Persistence that is used

to produce frustration, and psychological testing done by the study staff. The psychological

testing was performed via a noninvasive procedure that assessed the subjects’ pain threshold.

The series of self-report questionnaires included the COMM, Addiction Behavior Checklist, and

the Distress Intolerance Index, and they were placed into a multisource method to assess for the

risk of OUD. The self-report questionnaires were collected using a series of logistic regression

models. The regression model examined the relationship between distress intolerance and OUD,

and it analyzed OUD status as the dependent variable. The outcome of the regression model

indicated a significant relationship between distress intolerance and OUD. The study found that

self-report of distress intolerance is a major factor that places chronic pain patients at higher risk

for of OUD.

In the third cross-sectional quantitative study conducted by Martel et al. (2014), the

authors examined the relationship amongst patients taking prescribed opioids for chronic pain
INTEGRATIVE REVIEW 8

and psychological distress. The article mentioned that most of the participants who misused

opioids had a distinct mental health profile. The research indicated that patients misusing

prescribed opioids suffered from psychological distress by experiencing a depressive episode in

the past year and had some suicidal thoughts. The results yielded that patients with chronic pain

taking prescribed opioids are at an increased risk of OUD.

Impulsivity

Two of the five research articles revealed a significant connection between impulsivity in

patients taking opioids for chronic pain (Martel et al., 2014 & Vest et al., 2016). The quantitative

study done by Martel et al., (2016), examined how drug cravings increase the likelihood of drug

misuse in patients with chronic pain. The items were rated on a 0-100 VAS and based upon the

Cocaine Craving Scale. The data was downloaded from the diary questionnaire and placed into

the participants portfolio during the study. Initially, the researchers used Pearson correlations to

assess the univariate relationship between opioid craving and OUD. Furthermore, a multiple

mediation analysis was used to further assess the association of opioid cravings, negative affect,

and OUD. The results indicated that there was a significant positive correlation among self-

reports of patients with negative affect and opioid cravings. This finding supports the data that

opioid craving places the patient at higher risk of OUD.

Finally, Vest et al., (2016) completed a non-experimental descriptive quantitative study

that examined the relationship amongst the four facets of impulsivity and the risk for prescription

opioid misuse, current misuse of prescription, and OUD symptoms. The four facets included

sensation seeking, lack of premeditation, lack of perseverance, and urgency. The study sampled

143 volunteers who was referred to a multimodal chronic pain treatment facility for management

of chronic pain. The patients had to be referred to the clinic, over the age of 18, and able to read
INTEGRATIVE REVIEW 9

English at the eighth-grade level to meet the inclusion criteria. The method of research for this

study included a 45-item UPPS Impulsive Behavior Scale that measured the four facets of

impulsivity. The items were recorded and rated from one to four, with one being strongly agree

and four being strongly disagree. The risk of prescription opioid misuse was measured using the

Revised Screener and Opioid Assessment for patients with pain (SOAPP-R), and the Opioid use

disorder symptoms were assessed using data from the National Survey on Drug Use and Health

(NSDUH). The NSDUH measured the consequences of using opioid pain medication and the

dependence symptoms. Additionally, the current misuse of opioid misuse disorder was measured

using the Prescription Opioid Misuse Index (POMI). The multi-regression model was used to

determine the relationship amongst the four facets of impulsivity and OUD. The results indicated

that sensation seeking does not place chronic pain patients at a higher risk for opioid misuse

disorder but found a significant relationship with current prescription opioid misuse. In addition

to the results found, urgency was the only significant impulsivity predictor that placed chronic

pain patients at risk for OUD.

Discussion and Implications

The articles selected for this integrative review provides significant information about the

major concern of opioid misuse in patients with chronic pain. The PICO question, does long-

term opioid use influence the risk of opioid use disorder in patients who have chronic pain, was

revealed and consistent based on the findings in each article. The quantitative studies conducted

by Hser et al., (2017), Martel et al., (2014), McHugh et al., (2016), Mojtabai et al., (2019), and

Vest et al., (2016) concluded that there are many factors that can influence a chronic pain patient

taking opioids at higher risk for OUD. Psychological distress, substance abuse disorder, and

impulsivity played a big role in the articles and the results indicated that each variable increases
INTEGRATIVE REVIEW 10

the risk for OUD in chronic pain patients. The authors highlighted how the results of each article

are consistent with previous data, which can help identify people who are at risk for OUD in the

clinical setting. The researchers suggest that identifying patients at high risk of OUD can help

end the opioid epidemic by decreasing the frequency of prescribed opioids for chronic pain,

without trying alternative pain managements first. For further studies, repetitive researchers

should include clinicians for reliability of the client’s use of opioids. Many of the authors from

the article highlighted how self-reports could be deemed unreliable and can introduce bias into

the study. Implications of the studies’ findings suggested that the results of the data could help

lead to the development of preventative interventions that decrease OUD.

Limitations

Foremost, the researcher for conducting this integrative review is inexperienced. The

researcher was only limited to five articles to review for a class assignment, which makes it not

an exhaustive review. All the articles in this integrative review was published within the past five

years. The researcher only used quantitative research articles for this study which limits lived

experiences and the quality of life experiences from participants.

The authors did not clearly indicate the power analysis in any of the articles which helps

determine if the acceptable sample size will affect the outcome variable. Three out of the five

articles by Hser et al., (2017), Mojtabai et al., (2019), and Vest et al., (2016), were non-

experimental designs which are considered the weakest quantitative design because it is prone to

threats of validity and reliability. All of the articles utilized some sort of self-report

questionnaires which can introduce bias and unreliable data into the study. Each of the authors

from the studies highlighted that more research needs to be conducted to assess the risk of OUD

in patients taking opioids for management of chronic pain. Four out of the five articles by Hser et
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al., (2017), Martel et al., (2014), McHugh et al., (2016), and Vest et al., (2016) acknowledged

that their research needed to have more generalizability in the study.

Conclusion

The findings in the integrative review emphasizes the relationship between chronic pain

and OUD which directly relates to the PICO question. The results indicate that there are many

factors that can influence the risk of OUD in patients with chronic pain. Psychological distress,

SUD, and impulsivity all increase the risk of OUD in patients experiencing chronic pain. The

findings of this study implicate that the results of the data could help lead to the development of

preventative interventions that decrease OUD, especially in the clinical setting. The authors of

each article acknowledged that further research needs to be completed to further assess the risk

of opioid misuse in patients with chronic pain.

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References

Hser, Y. I., Mooney, L. J., Saxon, A. J., Miotto, K., Bell, D. S., & Huang, D. (2017). Chronic

pain among patients with opioid use disorder: Results from electronic health records data.

Journal of substance abuse treatment, 77, 26-30. doi: 10.1016/j.jsat.2017.03.006

Martel, M. O., Dolman, A. J., Edwards, R. R., Jamison, R. N., & Wasan, A. D. (2014). The

Association between negative Affect and prescription opioid misuse in patients with

chronic pain: the mediating role of opioid craving. The Journal of Pain, 15(1), 90-100.

doi: 10.1016/j.jpain.2013.09.014

McHugh, R. K., Weiss, R. D., Cornelius, M., Martel, M. O., Jamison, R. N., & Edwards, R. R.

(2016). Distress intolerance and prescription opioid misuse among patients with chronic

pain. The Journal of Pain, 17(7), 806-814. doi: 10.1016/j.jpain.2016.03.004

Mojtabai, R., Amin‐Esmaeili, M., Nejat, E., & Olfson, M. (2019, February 05). Misuse of

prescribed opioids in the united states. Retrieved from

https://onlinelibrary.wiley.com/doi/abs/10.1002/pds.4743

Schmidt, N. A., & Brown, J. M. (2015). Evidence-based practice for nurses: Appraisal and

application of research. Burlington, MA: Jones & Bartlett Learning.

Vest, N., Reynolds, C. J., & Tragesser, S. L. (2016). Impulsivity and risk for prescription opioid

misuse in a chronic pain patient sample. Addictive Behaviors, 60, 184-190.

doi: 10.1016/j.addbeh.2016.04.015
INTEGRATIVE REVIEW 13

Appendix 1: Article Summary Evaluation Tables

Article Reference Hser, Y. I., Mooney, L. J., Saxon, A. J., Miotto, K., Bell, D. S., &
Huang, D. (2017). Chronic pain among patients with opioid use
disorder: Results from electronic health records data. Journal of
substance abuse treatment, 77, 26-30. doi
10.1016/j.jsat.2017.03.006
Intext citation: (Hser, et al., 2017)
Background/Problem Intro/Background: The purpose of this study was to examine the
Statement prevalence of comorbid chronic pain among patients with opioid
use disorder (OUD) and to compare other comorbidities
[substance abuse, mental health disorders, health disease
conditions into four categories, such as having no chronic pain,
OUD prior to pain, OUD and pain at the same time, and pain
condition prior to OUD.
Problem Statement: OUD is associated with excess mortality and
morbidity, and other adverse health and social interactions. OUD
is common among individuals with chronic pain conditions, and
chronic pain is common among individuals with OUD. The
recognition of the national epidemic of non-prescribed opioid
misuse in the United States makes prescription opioid misuse a
critical public health concern.
This article supports the PICO question.
Conceptual/theoretical No conceptual frame work was listed in the article
Framework
Design/ Design: Non-experimental Descriptive Correlational Quantitative
Method/Philosophical Study [Page 187]
Underpinnings Method: The study used health record data from a healthcare
system
The was not any Philosophical Underpinnings

Sample/ Setting/Ethical Sample size: The electronic healthcare record had around 4.6
Considerations million patients in the system, and only 5307 had an OUD
diagnosis. Most of the patients were male, white, and had private
insurance or paid their healthcare bills themselves. The sampling
size was adequate for this study.
Study sample: any patient over the age of 18 that was diagnosed
with OUD during their inpatient or outpatient visits during 2006-
2015.
Ethical considerations: The study was approved by the UCLA
institutional Review Board.
INTEGRATIVE REVIEW 14

Major Variables Major variables: Patient characteristics, chronic pain, health or

Studied (and their disease diagnoses, psychiatric/substance misuse diagnoses.
definition), if 1. Patient characteristics Sociodemographic variables
appropriate included: sex, race, age, employment, and health insurance
2. Chronic pain codes of conditions that causes chronic
pain follow the list provided by the CDC.
3. Health or disease diagnoses Major diseases include heart
disease/hypertension/stroke, respiratory disease, sleep
disorders, liver disease, cancer, diabetes, sexually
transmitted diseases, HIV, HCV.
4. Psychiatric and substance misuse disorders mental
disorders include psychotic disorders, bipolar disorders,
depressive disorder, anxiety disorder, and other mental
health disorders. Substance use disorders includes
dependence on tobacco, and both abuse and dependence on
alcohol, cannabis, amphetamine, cocaine, hallucinogens,
sedatives/hypnotics/anxiolytics, and other drugs.
Measurement Tool/Data Measurement tools: No pain, OUD first, OUD and pain at the
Collection Method same time, Pain first
Data collection method: The data was collected from an
electronic health record
Data Analysis - Continuous variables were conducted by t-test and
categorical variables were conducted by chi-square tests to
examine group differences on demographics.
- Separate multinomial logistic regression analysis was
conducted for each diagnostic measure to test group
differences.
- When group differences were significant, linear test on
equivalence of coefficients between pair of groups were
conducted.
Findings/Discussion - Patient characteristics most of the patients exhibited that
they had chronic pain before OUD. Most of the patients in
the study were male, white, and used private insurance or
paid for healthcare bills on their own.
- Chronic pain conditions most of the patients stated that
they had pain first before having OUD
- Co-morbid of substance abuse and psychiatric disorders
The patients with chronic and OUD had highest prevalence
rates for alcohol, cocaine, and other drugs. 70% of the
sample had a co-morbid mental health disorder.
- Health conditions OUD patient without chronic pain and
patients with chronic pain demonstrated the higher rates of
physical health conditions or diseases, including heart
disease with 70% among patients that experienced pain
first before OUD
INTEGRATIVE REVIEW 15

Appraisal/Worth to The results of this study supported the hypothesis from the
practice literature review that stated that people with chronic pain
conditions with OUD would be associated with greater prevalence
of mental health disorders and physical health conditions than that
among OUD patients without chronic pain.
INTEGRATIVE REVIEW 16

Article Reference Martel, M. O., Dolman, A. J., Edwards, R. R., Jamison, R. N., &
Wasan, A. D. (2014). The Association between negative Affect
and prescription opioid misuse in patients with chronic pain: the
mediating role of opioid craving. The Journal of Pain, 15(1), 90-
100. doi: 10.1016/j.jpain.2013.09.014
Intext citation: (Martel, Dolman, Edwards, Jamison, & Wasan,
2014)
Subsequent: (Martel et al., 2014)
Background/Problem Intro/background: This examined the factors that underlie the
Statement association between negative affect (NA) and prescription opioid
misuse among patients with chronic pain.
Problem Statement: There has been a substantial rise in the use
of opioids for the treatment of chronic noncancerous pain.
This article was appropriate for the PICO question.
Conceptual/theoretical No conceptual theoretical framework was stated in the article.
Framework
Design/ Design: Randomized controlled trial (RCT) Quantitative Study
Method/Philosophical Method: observation and self-report questionnaires
Underpinnings Philosophical Underpinnings: there were no philosophical
underpinnings
Sample/ Setting/Ethical Sample: 82 patients with chronic musculoskeletal pain
Considerations Ethical Considerations: They researchers obtained informed
consent from all the of the participants.

Major Variables Major Variables: Pain intensity, negative affect, opioid craving,
Studied (and their prescription opioid misuse
definition), if 1. Pain intensity self-reports of pain
appropriate 2. Negative affect (NA) anxiety and depression
3. Opioid craving the need or desire to consume certain
drugs or illicit substances.
4. Prescription opioid misuse
Measurement Tool/Data Measurement tools: demographic questionnaire, screening for
Collection Method substance use disorders (M.I.N.I), current opioid misuse measure
(COMM), self-report measures of pain intensity, NA, and craving,
Data Collection:
Data Analysis - t-test for descriptive data
- chi-square test was used for descriptive data for categorical
variables
- after removing the COMM items related to
emotional/psychiatric issues and more aberrant behaviors,
the Cronbach’s alpha remained greater than 0.70.
- bootstrap meditation analysis
INTEGRATIVE REVIEW 17

Findings/Discussion - Analysis revealed no significant sex differences in age,

pain intensity, NA, opioid craving, opioid misuse, or
average daily opioid dose.
- 73.2% (60/82) of the sample reported at least 1
prescription opioid misuse behavior within the past month.
- Correlational analyses revealed that both depression and
anxiety is significantly associated with prescription opioid
misuse and opioid craving.
- Higher levels of NA were associated with higher scores on
the COMM, a self-report measure designed to assess
prescription opioid misuse.
- Positive correlation was found between NA and self-
reports of opioid craving patients with higher levels of
NA reported higher levels of opioid cravings
- Higher levels of pain intensity were associated with
increase rates of opioid misuse. This is not consistent with
all current data due to them may be experiencing pseudo-
addiction.
- Higher levels of opioid cravings increase the risk for
opioid misuse.

Appraisal/Worth to The findings of this article are consistent with those of previous
practice studies that have examined the association between measures of
NA and prescription opioid misuse. More research needs to be
done to determine the psychological and neurobiological factors
that may contribute to opioid misuse.
INTEGRATIVE REVIEW 18

Article Reference McHugh, R. K., Weiss, R. D., Cornelius, M., Martel, M. O.,
Jamison, R. N., & Edwards, R. R. (2016). Distress intolerance and
prescription opioid misuse among patients with chronic pain. The
Journal of Pain, 17(7), 806-814. Retrieved from
http://dx.doi.org/10.1016/j.jpain.2016.03.004
Intext citation: (McHugh, et al., 2016).
Background/Problem Intro/Background: The purpose of this study is to examine
Statement whether distress intolerance is associated with opioid misuse in
those with chronic pain.
Problem Statement: The risk of misuse of opioid medications is a
significant challenge in the management if chronic pain.
This article supports the PICO question.
Conceptual/theoretical No conceptual frame work was listed in the article
Framework
Design/ Design: Experimental Time Series Quantitative Study [Page 183]
Method/Philosophical Method: series of self-report questionnaires and psychological
Underpinnings testing
The was not any Philosophical Underpinnings

Sample/ Setting/Ethical Sample size: The sample size consisted of 51 participants

Considerations The sampling size was adequate for this study.
Study sample: These participants were prescribed opioid
analgesics for chronic back or neck pain. All participants were
recruited from the pain management clinic of a large, urban
academic hospital.
Ethical considerations: All study procedures were approved by
the McLean Hospital institutional review board and informed
consent was obtained from the participants.
Major Variables Major variables: Distress intolerance and opioid muse
Studied (and their 5. Distress intolerance defined as the perceived or actual
definition), if inability to handle aversive somatic or emotional stress.
appropriate 6. Opioid misuse not taking medications as prescribed by
their healthcare provider
Measurement Tool/Data Measurement tools:
Collection Method - The Current Opioid Misuse Measure 17-item self-report
measure of prescription opioid misuse
- The Addiction Behaviors Check-list 20 item measure of
addiction-like behaviors that was developed to measure
prescription opioid addiction in chronic pain patients.
- Pain severity self-report Brief Pain inventory
- Distress Intolerance Index 10-item self-report
measurement of distress intolerance
INTEGRATIVE REVIEW 19

- Computerizing Mirror Testing Tracing Persistence Task

computer-based distress intolerance measure
- Quantitative Sensory Testing mechanical pain thresholds
were evaluated using a digital pressure algometer.
Data collection method: completed battery of self-report
questionnaires and behavioral measure of distress intolerance and
psycho-physical testing
Data Analysis - Participants with or without opioid misuse was compared
on sociodemographic and clinical variables using t-tests
and x2 test.
- Logistic regression models
- Correlations for continuous variables
- T-tests were used for independent samples (dichotomous
variables)
- Nonparametric tests were used for any variable with
evidence if significant skewness.
Findings/Discussion - Of the 51 participants recruited, 31 of them met the criteria
for opioid misuse.
- Data concluded that higher levels of distress intolerance
were associated with more severe opioid misuse.
- The results indicated a strong and significant association
between distress intolerance and opioid misuse behaviors.
Appraisal/Worth to This study demonstrated that distress in tolerance and opioid
practice misuse has a strong relationship among patients with chronic pain.
INTEGRATIVE REVIEW 20

Article Reference Mojtabai, R., Amin‐Esmaeili, M., Nejat, E., & Olfson, M. (2019,
February 05). Misuse of prescribed opioids in the United States.
Retrieved from
https://onlinelibrary.wiley.com/doi/abs/10.1002/pds.4743
Intext citation: (Mojtabai, Amin-Esmaeili, Nejat, & Olfson, 2019)
- Subsequent: (Mojtabai et al., 2019)
Background/Problem Intro/Background: The purpose is to assess the prevalence and
Statement correlates of self-reported misuse of prescribed-opioid
medications in the United States general population.
Problem Statement: there is a growing concern about the misuse
of prescription opioid medications in the United States and its role
in the development of opioid use disorder (OUD) and other
adverse health outcomes.
This article did not fully support the PICO question but had great
information retaining to OUD.
Conceptual/theoretical No conceptual frame work was listed in the article
Framework
Design/ Design: Non-Experimental Descriptive Correlational Quantitative
Method/Philosophical Study [Page 187].
Underpinnings Method: The study used series of questionnaires and surveys
The was not any Philosophical Underpinnings

Sample/ Setting/Ethical Sample size: the sample size was 31,068 adult participants of the
Considerations National Survey on Drug Use and Health (NSDUH) from 2015-
2016 who reported using opioids in the past year. The study size
was appropriate for this study
Ethical considerations: The study was approved by the
Institutional Review Board at RTI International.
Major Variables Major variables: Benzodiazepine misuse; Heroin, alcohol,
Studied (and their prescription opioid and other drug use disorders; illegal activities;
definition), if chronic medical conditions; healthcare visits, medical marijuana,
appropriate psychological distress, major depressive episodes, suicidal
ideations, plans, and suicide attempts.
7. Benzodiazepine misuse used in “greater amount,” “more
often,” or “for longer” than prescribed or without
prescription in the past year
8. Drug use disorders structured interviews based upon the
Diagnostic and Statistical Manual of Mental Disorders,
Fourth edition (DMS-IV). If they met the criteria of the
DSM-IV, they met the diagnostic criteria.
9. Illegal activities have they done anything illegal while
consuming drugs, such as driving while intoxicated, stole
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something worth more than $50, sold illegal drugs, or

violated parole.
10. Chronic conditions ask about any chronic conditions and
assess for burden of the illness.
11. Healthcare visits number of times they visited the doctor
or any other healthcare physician.
12. Medical marijuana ask about use of marijuana
prescribed by doctor
13. Psychological distress frequency of experiencing
psychological distress
14. Major depressive episode interviewed based on the
DSM-IV criteria
15. Suicide attempting to harm self or thinking about it
Measurement Tool/Data Measurement tools: DSM IV, series of questionnaires based off
Collection Method the variable, structured interview instrument, Nicotine dependence
scale, K6 covering the past 30 days, and National Comorbidity
Survey Replication (NCS-R).
Data collection method: the data was collected from the National
Survey on Drug use and health (NSDUH)
Data Analysis - Multivariable logistic-regression models and the machine-
learning method of boosted regression were used to
identify the correlates of misuse
Findings/Discussion - A total of 1728 (4.4%) of the 30,813 adult participants who
reported using prescription opioid or 1.6% of the total
adult population surveyed reported using their prescribed
medication not as prescribed by their healthcare provider.
The percentage corresponds to approximately 3.9 million
adults misusing prescribed opioids out of over 89.7 million
using these drugs each year.
- Most of the participants who misused prescribed opioids
also had a distinct mental health and substance use profile.
Also, misuse of prescribed opioids was more common
among those with more than two chronic medical
conditions than those without the conditions.
- In the boosted regression analysis, misuse of prescription
opioids without a prescription, misuse of prescribed
benzodiazepines, other substance use disorders, illegal
activities, and psychological distress has the most
influential factors associated with prescribed opioid
misuse.
Appraisal/Worth to The results of this study did not fully support the PICO question.
practice The information in this article has some significant findings about
factors that can influence OUD but was not mostly on chronic
pain.
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Article Reference Vest, N., Reynolds, C. J., & Tragesser, S. L. (2016). Impulsivity
and risk for prescription opioid misuse in a chronic pain
patient sample. Addictive Behaviors, 60, 184-190. doi:
10.1016/j.addbeh.2016.04.015
Intext citation: (Vest, Reynolds, & Tragesser, 2016).
Subsequent: (Vest et al., 2016)

Background/Problem Intro/background: The purpose of this study was to examine

Statement associations between the four facets of impulsivity and risk for
prescription opioid misuse, current prescription opioid misuse, and
OUD symptoms.
Problem statement: The misuse of prescription opioid pain
relievers is a growing concern, in both non-clinical samples and
chronic pain patients receiving opioid analgesic therapy. This
article was appropriate for the PICO question.
Conceptual/theoretical The theoretical framework is based upon the Five Factor model by
Framework Whiteside and Lynam.
Design/ Design: Non-experimental Descriptive Quantitative Study [Page
Method/Philosophical 186]
Underpinnings Method: series of self-reporting questionnaires
There was not any Philosophical Underpinnings.
Sample/ Setting/Ethical Sample size: 143 volunteers who was referred to a treatment
Considerations facility for management of chronic pain. There was an adequate
amount of sampling size.
Ethical Considerations: All study procedures received IRB
approval from both the funding university and the hospital that
manages clinic.
Major Variables Major variables: urgency, sensation seeking, lack of
Studied (and their premeditation, and lack of perseverance.
definition), if 1. Urgency refers to the tendency to act impulsivity while
appropriate experiencing negative emotions.
2. Lack of premeditation refers to reacting impulsively
without accounting for future consequences.
3. Lack of perseverance refers to an inability to focus or
persist on challenging or boring tasks
4. Sensation seeking  refers to the tendency to initiative
activities that are exciting and thrilling.

Measurement Tool/Data Measurement tools: pain variables [chronic pain duration,

Collection Method number of pain conditions, severity, interference], UPPS, Opioid
variables [number of opioid prescriptions, SOAPP-R, POMI,
OUD Symptoms]
Data Collection: Series of self-reporting questionnaires
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Data Analysis Possible covariates were determined by multiple regression model

and bivariate correlation were tabulated between age, gender,
BMI, duration of chronic pain, number of pain conditions, pain
severity and interference, impulsivity, subscales, number of opioid
prescriptions, SOAPP, POMI, and opioid use disorder symptoms.
Findings/Discussion Significant positive correlations for two of the major variables
which were sensation seeking and urgency. Urgency was found to
be associated with all three prescription opioid outcome variables.
Sensation seeking was not found to be correlated with risk of
OUD.
UPPS lack of premeditation and UPPS lack of perseverance were
excluded from the study due to it not showing any association with
any of the outcome measurements.
The data indicated that patients with who react to impulsivity to
negative moods and craving are especially at higher risk of opioid
misuse disorder.
Appraisal/Worth to The results of this study were linked back to the literature review
practice and fits with previous research published, and they found that it
was consistent with the current data. These data include that
patients who react impulsivity to negative mood states and
cravings may be especially prone to developing unusual use of
patterns when taking prescription opioids.