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Study Shows Discontinuation of Long-Term Opioid Therapy among Veterans is Overwhelmingly Initiated by VA Clinicians


BACKGROUND:
The 2009 American Pain Society and 2010 VA/DoD clinical practice guidelines recommend discontinuation of opioid therapy under several circumstances, including patient behaviors that heighten the risk of opioid overdose and death. The 2016 CDC Guidelines for Prescribing Opioids for Chronic Pain further emphasize a risk-benefit evaluation. Patients with substance use disorder (SUD) are at increased risk of experiencing opioid-related adverse events. The aim of this retrospective study was to compare reasons for discontinuation of long-term opioid therapy (LTOT) between Veterans with (n=300) and without SUD (n=300) receiving care within the VA healthcare system in the years following release of the 2009 and 2010 clinical practice guidelines. Investigators reviewed patients' medical records to determine the reasons for LTOT discontinuation during 2012. For this study, LTOT was defined as having been prescribed opioid therapy for the entirety of 2011, allowing prescription opioid refill gaps of no more than 30 days between the completion of an opioid prescription and a refill. Investigators also assessed patient demographics, rural vs. urban residence, service-connected disability status, and comorbidities.

FINDINGS:

  • The majority of Veterans (85%) discontinued opioid use because their clinician stopped prescribing, rather than the patients deciding to stop. For patients whose clinicians initiated discontinuation, 75% were discontinued due to opioid-related aberrant behaviors (i.e., suspected substance abuse at 51% and aberrant urine drug test at 44%). Veterans with SUD diagnoses were more likely to discontinue LTOT due to aberrant behaviors, particularly abuse of alcohol or other substances, compared to Veterans without SUD (81% vs. 68%).
  • High proportions of patients received diagnoses for mental health disorders in the year prior to discontinuation of LTOT, including PTSD (31%), anxiety disorders other than PTSD (25%), and depressive disorders (25%).

IMPLICATIONS:

  • Increasing rates of opioid discontinuation are likely to occur due to policies and programs that encourage close monitoring of Veterans on LTOT for opioid misuse behaviors. Integrating non-opioid pain therapies and SUD treatment into multiple settings such as primary care and specialty SUD care is one possible approach to enhance their care.

LIMITATIONS:

  • Investigators randomly selected patients with SUD and matched patients without SUD. Subjects may thus represent more "complex" patients than in the general population of VA patients who discontinue LTOT.
  • Veterans who were discontinued and then subsequently restarted opioid therapy within a year were not captured and may represent a selection bias.

AUTHOR/FUNDING INFORMATION:
This study was funded by HSR&D, and Drs. Lovejoy and Frank are supported by HSR&D Career Development Awards. All authors, except Dr. Frank, are part of HSR&D's Center to Improve Veteran Involvement in Care (CIVIC), Portland, OR.


PubMed Logo Lovejoy T, Morasco B, Demidenko M, Meath T, Frank J, and Dobscha S. Reasons for Discontinuation of Long-Term Opioid Therapy in Patients with and without Substance Use Disorders. Pain. March 2017;158(3):526-34.

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What are HSR&D Publication Briefs?

HSR&D requires notification by HSR&D-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR&D 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&D 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&D published articles. Visit the HSR&D citations database for a complete listing of HSR&D articles and presentations.