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Publication Briefs

Study Shows Increases in Opioid Dosing of 20% or Greater were Not Associated with Improvements in Pain among Veterans

Due to the development of tolerance and inadequate control of pain, opioid dose escalation is a common decision that prescribers must consider for patients on chronic opioid therapy. Unfortunately, limited evidence exists to guide appropriate opioid dose increases among patients with chronic pain. The Numeric Rating Scale (NRS) is one of the most common ratings of pain intensity, with a single item that asks patients to rate their pain on a scale of 0 (no pain) to 10 (the most severe pain). This study examined the influence of opioid dose escalation on NRS pain scores recorded in the VA electronic medical record among patients on chronic opioid therapy for chronic non-cancer pain. Using VA data from 2008 to 2015, investigators identified Veterans with chronic pain (arthritis, back pain, neck pain, neuropathic pain, or headache/migraine) who had received chronic opioid therapy for at least two consecutive 180-day periods. Investigators matched 19,358 dose escalators with 19,358 dose maintainers with nearly equivalent demographic profiles, comorbidities, healthcare visits, medication use (i.e., antidepressants, skeletal muscle relaxants, non-opioid analgesics), baseline pain scores, and opioid use characteristics (i.e., schedule, duration).


  • Increases in opioid dose of 20% or greater were not associated with improvements in pain scores.
  • In the follow-up period, dose escalators had higher average morphine milligram equivalents (MME) when compared to dose maintainers (45 MME vs. 28 MME) and were more likely to use long-acting opioids in combination with a short-acting opioid (18% vs. 8%, respectively).
  • The sample consisted mostly of men that were on average 56 years old and most commonly suffered from back pain or arthritis. A little more than half had one or more mental health diagnoses and reported an average pain rating of about 5 on the NRS at baseline.


  • Clinicians should carefully evaluate increasing opioid doses, regardless of the current dose. When determining whether to escalate the dose, considerations should focus less on the potential benefit to improve pain intensity and more on the balance of other potential benefits and harms.


  • Variation in administration of the NRS may have impacted validity of this rating scale.
  • Information on opioid use outside VA was not available to investigators.

Drs. Hayes and Hudson are part of HSR&D’s Center for Mental Healthcare and Outcomes Research (CeMHOR), North Little Rock, AR. Dr. Krebs is part of HSR&D’s Center for Care Delivery and Outcomes Research (CCDOR), Minneapolis, MN.

PubMed Logo Hayes C, Krebs E, Hudson T, et al. Impact of Opioid Dose Escalation on Pain Intensity: A Retrospective Cohort Study. Pain. January 7, 2020; ePub ahead of print.

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HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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