September 2021

In This Issue: Helping Veterans Cope with and Conquer Pain
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Chronic Pain Management Following Discontinuation of Long-Term Opioid Therapy

Feature Article

Takeaway: This study will provide VA with information that will describe opioid discontinuation from the patient’s perspective. These perspectives will inform best practices for discontinuing opioid therapy, when clinically indicated, while mitigating any associated negative consequences. Findings also will help engage and empower Veterans in managing chronic pain with evidence-based non-opioid treatment options.

Nearly 900,000 Veterans were dispensed opioid medication at the prescribing peak in 2012, with rates of opioid prescribing in VA subsequently declining year-over-year to fewer than 700,000 Veterans dispensed opioid medication in 2016. These downward trends are likely to continue with more widespread implementation of the VA Opioid Safety Initiative, additional efforts at local VA hospitals to enhance opioid risk mitigation and safe opioid prescribing practices, and recently released CDC and VA/DoD evidence-based opioid prescribing guidelines that discourage long-term opioid therapy (LTOT) for chronic non-cancer pain. Despite steady rates of opioid discontinuation in VA, little is known about consequences—positive or negative—of opioid discontinuation.

The objectives of this ongoing study (November 2018 – October 2022) are to characterize VA patients’ experiences with the opioid discontinuation process – and to identify ways they subsequently manage their pain through VA and non-VA resources. This prospective cohort study also is examining patient-centered outcomes such as quality of life, pain, substance use, and mental health symptom severity following opioid discontinuation. Study investigators have three specific aims:

• Compare acute, intermediate (6-month), and long-term (12-month) quality-of-life and pain outcomes between patients who discontinue vs those who remain on LTOT;
• Test the moderating effect of gender and race/ethnicity on changes in outcomes between patients who discontinue vs those who remain on LTOT; and
• Use qualitative methods to augment quantitative findings on patients’ quality-of-life and pain outcomes, identify patient experiences with the opioid discontinuation process, and characterize the impact of discontinuation on patient-clinician relationships.

Methodology

Study investigators enrolled 1,367 VA patients randomly selected from the population of VA patients who were prescribed long-term opioid therapy. All patients completed a mailed or online survey at baseline – and will complete up to four additional follow-up assessments at 6-, 12-, 18-, and 24-months that assess quality of life, pain, substance use, and mental health symptoms. Additional clinical and pharmacy data will be extracted from patients’ VA electronic health record. Investigators will monitor patients in the cohort for reductions in opioid dose and complete opioid discontinuation. Patients who discontinue opioid therapy will complete an additional survey to assess acute patient outcomes following opioid discontinuation.

A subset of patients who discontinue opioid therapy will participate in semi-structured interviews over the telephone immediately following discontinuation, as well as 6 and 12 months post-discontinuation. Interviews will ascertain patients’ experiences with the opioid discontinuation process, pain treatment approaches used within and outside VA, and patient outcomes following discontinuation. To date, 37 patients have completed the post-opioid discontinuation interview and continue to be followed for future interviews. The integration of results from both quantitative and qualitative data will characterize patients’ experiences with, and outcomes following opioid discontinuation.

Findings

Nothing to report at this time.

Anticipated Impact

This study will provide VA with information that characterizes opioid discontinuation from the patient’s perspective. These perspectives will inform best practices for discontinuing opioid therapy, when clinically indicated, while mitigating any associated negative consequences. Findings also will help engage and empower Veterans in managing chronic pain with non-opioid treatment options.

Principal Investigator

Travis Lovejoy, PhD, MPH, is an investigator with HSR&D’s Center to Improve Veteran Involvement in Care (CIVIC) in Portland, OR.

View study abstract