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Prescription Opioids Associated with Lower Likelihood of Sustained Improvement in Pain among Older Veterans


BACKGROUND:
Chronic pain is especially common among Veterans, but little is known about the factors associated with outcomes related to pain and its treatment among older patients. This issue is particularly important because 44% of Veterans are age 65 and older, and 21% are 75 years and older – and these proportions are expected to increase in the coming years. As part of its National Pain Strategy, VA collects pain intensity scores from Veterans during routine care; Veterans are administered the single-item 11-point Numeric Rating Scale (NRS) pain intensity measure during outpatient visits. This observational study sought to identify patient factors associated with improvements in pain intensity in a national cohort of Veterans 65 years or older with chronic pain (Veterans with cancer diagnoses were excluded). Specifically, investigators examined the percentage change over 12 months in average pain intensity scores relative to average baseline pain intensity scores – and time to sustained improvement in average pain scores, defined as a 30% reduction in 3-month scores compared to baseline. Investigators included 12,924 Veterans receiving VA treatment with persistently elevated NRS scores in 2010, who had not been prescribed opioids in the prior 12 months. Investigators also examined patient demographics, VA service-connected disability, in addition to mental health diagnoses.

FINDINGS:

  • On average, Veterans prescribed an opioid during the 12-month follow-up period were less likely to demonstrate sustained improvement in pain intensity scores compared to Veterans who were not prescribed opioids.
  • Overall, average relative improvement in pain intensity scores from baseline ranged from 25% to 29%; almost two-thirds of Veterans met criteria for sustained improvement during follow-up.
  • Higher baseline pain intensity and older age were associated with a greater likelihood of improvement in pain intensity scores over time, while VA service-connected disability status, mental health conditions, chronic low back pain, neuropathy, fibromyalgia/myofascial pain diagnoses, and being prescribed an opioid were associated with lower likelihood of improvement.

IMPLICATIONS:

  • Findings call for further characterization of heterogeneity in pain outcomes in older adults, as well as further analysis of the relationships between prescription opioids and treatment outcomes.

LIMITATIONS:

  • Prior studies suggest that the accuracy of the NRS score in measuring pain as administered during routine VA care is modest.
  • There is no gold standard for identifying chronic pain using large administrative datasets. Measures of function are highly recommended, but they are not currently available in national VA datasets.
  • The observational nature of this study precludes determinations about causality, and the analyses did not adjust for variables that might contribute to provider decisions to prescribe opioids.

AUTHOR/FUNDING INFORMATION:
Drs. Dobscha, Lovejoy, and Morasco are part of HSR&D's Center to Improve Veteran Involvement in Care (CIVIC), Portland, OR. Dr. Lovejoy is supported by an HSR&D Career Development Award.


PubMed Logo Dobscha S, Lovejoy T, Morasco B, et al. Predictors of Improvements in Pain Intensity in a National Cohort of Older Veterans with Chronic Pain. Journal of Pain. July 2016;17(7):824-35.

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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.