The use of long-term opioid therapy (LTOT) has increased dramatically in recent decades. More than 500,000 Veterans are treated with opioid pain medications in spite of inadequate evidence of long-term benefit and growing evidence of harm. Overdose deaths due to opioid medications are now the leading cause of adult injury death in the United States, surpassing motor vehicle accidents. The risk of overdose increases in a dose-dependent manner. It is therefore possible that opioid dose reduction, or opioid tapering, may prevent opioid-related adverse events without negatively impact pain or quality of life. To this end, the Opioid Safety Initiative promotes opioid dose reduction, or opioid tapering, in several high-risk scenarios and instructs VHA networks to establish "safe and effective tapering programs". However, several important evidence gaps must first be addressed. First, evidence-based, effective protocols to guide tapering are lacking, especially in primary care settings where the majority of chronic pain is managed. Second, patient outcomes in opioid tapering are not well characterized. Opioid tapering may reduce risk and improve quality of life. Alternatively, opioid tapering may adversely impact pain, function and substance use. This proposal addresses these research gaps by adapting a collaborative care intervention to provide Veteran-centered, Veteran-driven opioid tapering support in VA primary care.
Aim 1: Describe the prevalence and correlates of Veterans' desire to taper long-term opioid therapy.
Aim 2: Adapt a collaborative care intervention to support opioid tapering in VA primary care.
Aim 3: Conduct a single arm pilot feasibility study to support opioid tapering in a VA primary care setting.
In Aim 1, we will conduct a structured phone interview among 300 Veterans to measure patient-reported desire to taper LTOT and examine its association with patient engagement and other patient and medication characteristics.
In Aim 2, we will adapt existing intervention components (medication management, patient education, collaborative care, longitudinal support) by incorporating tapering-specific elements (Motivational Interviewing, goal setting, multidisciplinary care, peer support). We will use the Nominal Group Technique to achieve Veteran and provider consensus.
In Aim 3, we will conduct a single arm pilot feasibility study to support opioid tapering in a VA primary care setting. We will recruit 40 Veterans on LTOT. We will measure the intervention's feasibility and acceptability and collect pilot data on patient-reported outcomes.
Not yet available.
This work is critically important to Veterans and VA healthcare systems nationally. It is well-aligned with the VA's National Pain Management Strategy with its emphasis on primary care-based programs to promote Veteran-centered pain care. Career development activities will build the applicant's expertise in 1) patient-reported outcome measurement; 2) behavior change intervention development; 3) pragmatic clinical trial design. This will be facilitated by mentorship, coursework, and seminars to leverage resources within the Denver-Seattle COIN, the University of Colorado and the VA's national pain research community. The mentorship, training, and protected time afforded by this award will ensure the applicant's development as an independent investigator and leader in the development and implementation of Veteran-centered, Veteran-driven, effective pain care.
- Kennedy LC, Binswanger IA, Mueller SR, Levy C, Matlock DD, Calcaterra SL, Koester S, Frank JW. "Those Conversations in My Experience Don't Go Well": A Qualitative Study of Primary Care Provider Experiences Tapering Long-term Opioid Medications. Pain medicine (Malden, Mass.). 2018 Nov 1; 19(11):2201-2211.
- Frank JW, Lovejoy TI, Becker WC, Morasco BJ, Koenig CJ, Hoffecker L, Dischinger HR, Dobscha SK, Krebs EE. Patient Outcomes in Dose Reduction or Discontinuation of Long-Term Opioid Therapy: A Systematic Review. Annals of internal medicine. 2017 Aug 1; 167(3):181-191.
- Nugent SM, Dobscha SK, Morasco BJ, Demidenko MI, Meath THA, Frank JW, Lovejoy TI. Substance Use Disorder Treatment Following Clinician-Initiated Discontinuation of Long-Term Opioid Therapy Resulting from an Aberrant Urine Drug Test. Journal of general internal medicine. 2017 Oct 1; 32(10):1076-1082.
- Busse JW, Craigie S, Juurlink DN, Buckley DN, Wang L, Couban RJ, Agoritsas T, Akl EA, Carrasco-Labra A, Cooper L, Cull C, da Costa BR, Frank JW, Grant G, Iorio A, Persaud N, Stern S, Tugwell P, Vandvik PO, Guyatt GH. Guideline for opioid therapy and chronic noncancer pain. CMAJ: Canadian Medical Association Journal = Journal De L'Association Medicale Canadienne. 2017 May 8; 189(18):E659-E666.
- Lovejoy TI, Morasco BJ, Demidenko MI, Meath TH, Frank JW, Dobscha SK. Reasons for discontinuation of long-term opioid therapy in patients with and without substance use disorders. Pain. 2017 Mar 1; 158(3):526-534.
- Frank JW, Levy C, Matlock DD, Calcaterra SL, Mueller SR, Koester S, Binswanger IA. Patients' Perspectives on Tapering of Chronic Opioid Therapy: A Qualitative Study. Pain medicine (Malden, Mass.). 2016 Oct 1; 17(10):1838-1847.
- Frank JW, Gilmartin HM. Pain Management and Opioid Safety. https://www.hsrd.research.va.gov/news/podcasts/listen.cfm?ID=28; 2018 May 4. Available from: https://www.hsrd.research.va.gov/news/podcasts/listen.cfm?ID=28.
Substance Abuse and Addiction, Health Systems
Treatment - Efficacy/Effectiveness Clinical Trial