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2019 HSR&D/QUERI National Conference Abstract

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4123 — Ambivalence toward opioid tapering among Veterans on long-term opioid therapy

Lead/Presenter: Anne Hale,  COIN - Seattle/Denver
All Authors: Hale AL (Seattle-Denver COIN, VA Eastern Colorado Health Care System), Evan Carey, PhD (Saint Louis University, VA Eastern Colorado Health Care System), Lindsay Miller (Seattle-Denver COIN, VA Eastern Colorado Health Care System) Charlotte Nolan, MPA (Seattle-Denver COIN, VA Eastern Colorado Health Care System) Agnes Jensen (Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System) Erin Krebs, MD, PhD (Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, University of Minnesota) Joseph W. Frank, MD, PhD (Seattle-Denver COIN, VA Eastern Colorado Health Care System, University of Colorado)

Objectives:
There is inadequate evidence of benefit from long-term opioid therapy (LTOT) and growing evidence of harms. Expert guidelines recommend reduction or discontinuation of LTOT ("opioid tapering") when risks exceed benefits. Many patients on LTOT report ambivalence about opioid medications but patient perspectives on opioid tapering are not well understood. We examined patient reported importance, readiness, and confidence in their ability to taper LTOT.

Methods:
We conducted a cross-sectional survey within a national prospective cohort study of Veterans on LTOT, for which 9,253 Veterans completed a baseline survey in 2015. We randomly selected 600 Veterans who, at baseline, were prescribed > = 50mg morphine equivalent daily dose (MED) and completed a mail survey. We conducted structured phone interviews at the 18-month time point to examine Veterans' self-reported past year experience of opioid tapering or discontinuation. We assessed ambivalence using 11-point scales of importance, readiness and confidence. Data on demographics, medications and diagnoses were obtained from electronic health records.

Results:
The study sample (N = 316, 58% response rate) was 73% age > = 60 years, 92% male and 87% White. Opioid medication doses at baseline were 50-99mg MED (53%) and 100+mg MED (47%). Overall, 68% reported fair or poor health status, and 51% reported pain severity that was slightly or much worse than 1 year ago. A majority (190/316, 60%) reported tapering in the past year or discontinuing opioid medications. The mean scores for the sample for the importance of, confidence to, and readiness to taper were: 5.1, 3.7, and 3.0, respectively. Measures of importance (5.6 vs. 4.1, p = .001), confidence (4.2 vs. 3.2, p = .031), and readiness scales (3.5 vs. 2.3, p = .008) were significantly higher among individuals reporting past year opioid tapering compared to individuals who had not tapered.

Implications:
Veterans on LTOT report ambivalence about opioid tapering or discontinuation. Measures of importance, readiness, and confidence are associated with prior opioid tapering experience.

Impacts:
Study findings suggest that behavior change techniques already supported in VA, such as Motivational Interviewing, may have a role in supporting patient-centered opioid tapering. Future studies should examine the relationship between patient-reported ambivalence and subsequent opioid tapering outcomes.