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2019 HSR&D/QUERI National Conference Abstract

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1014 — Outcomes of Prescription Opioid Dose Escalation for the Treatment of Chronic Pain: Results from a Prospective Cohort Study

Lead/Presenter: Benjamin Morasco,  COIN - Portland
All Authors: Morasco BJ (Center to Improve Veteran Involvement in Care, VA Portland Health Care System), Smith N (Center for Health Research, Kaiser Permanente), Dobscha SK (Center to Improve Veteran Involvement in Care, VA Portland Health Care System) Deyo RA (Oregon Health & Science University) Hyde S (Center to Improve Veteran Involvement in Care, VA Portland Health Care System) Yarborough BJH (Center for Health Research, Kaiser Permanente)

Objectives:
Long-term opioid therapy for chronic pain is common, yet data on long-term outcomes, especially after dose escalation, are sparse. We conducted a two-year prospective cohort study to examine potential benefits and harms associated with prescription opioid dose escalation.

Methods:
Participants were recruited from a VA medical center and a private integrated health network. All participants (n = 517) were receiving a stable dose of long-term opioid therapy (LTOT) at baseline. They completed self-report measures of pain, function, depression, and potential adverse effects at baseline and every six months for two years. We reviewed electronic health record data weekly to identify episodes of prescription opioid dose escalation; participants who increased their dose were seen for an additional research visit within one month of dose escalation.

Results:
At baseline, the average opioid dose in all participants was 36.2 mg MED (SD = 27.8). Over the two-year period, 19.5% of participants had an increase in prescription opioid dose of 15% or more of baseline dose. After controlling for covariates, there were no significant changes in pain intensity, pain interference, depression severity, or sleep functioning over time. Dose escalation status was not associated with changes in these outcomes. Statistically significant improvements were found on measures of medication-related side effects and risk for prescription opioid misuse; sexual functioning significantly worsened over time. Across all outcome measures, the only variable that significantly differed based on dose escalation status was risk for prescription opioid misuse; the average score in the dose escalation group was 2.4 points lower at the end of the two-year observation window compared with the non-escalation group (p = 0.018).

Implications:
In sum, patients who are prescribed a stable dose of LTOT demonstrate few changes in key pain-related outcomes over time, and prescription opioid dose escalation status is unrelated to most clinical outcomes.

Impacts:
Prescription opioid dose escalation was not associated with significant improvements in pain or functioning among patients receiving LTOT, suggesting the need to find alternative strategies to improve pain-related outcomes.