Studies Show Chronic Use Common after Prescription
By Brenda L. Mooney
MINNEAPOLIS — A new initiative to reduce the use of opioids at the VA already is demonstrating some success at eight launch sites in Minnesota, where high-dose use of the painkillers has been reduced more than 50%.
The initiative, the Opioid Safety Initiative (OSI), emphasizes patient education, intensive patient-monitoring with frequent feedback and complementary and alternative medicine practices such as acupuncture to lower dependency on opioids. Involved in the initiative at each VAMC are interdisciplinary pain medicine specialty teams and consult services, facility pain committees, pharmacy staff and primary care/patient aligned care team (PACT) participants.
“We have developed and implemented joint pain management guidelines which encourage the use of other medications and therapies in lieu of habit-forming opiates,” said Secretary of Veterans Affairs Eric K. Shinseki. “Early results give us hope that we can reduce the use of opioids for veterans suffering with chronic pain and share these best practices across our healthcare networks.”
Announcement of the initiative, which launched in October 2013, came a few weeks after new studies presented at the 30th Annual Meeting of the American Academic of Pain Medicine described the scope of opioid use at the VA. Most of the nearly 1 million veterans prescribed opioids for painful conditions continued to use them chronically or beyond 90 days, according to presentations at the conference.1, 2
With funding from the National Institute on Drug Abuse, researchers from the University of Washington in Seattle, the University of Arkansas Medical Sciences in Little Rock, AR, and the Research Triangle Institute in Research Triangle Park, NC, sought to determine how addiction and abuse issues develop in veterans. Using VA data and limiting the study to veterans who had at least two outpatient visits at a VHA facility in 2009, they identified 959,226 veterans who had received an opioid prescription for at least 90 days in a 180-day period.
With opioid discontinuation defined as no use for at least six months, they determined that 502,634, or 52.4%, of the group used opioids chronically. Among the factors linked to chronic opioid use were post-traumatic stress disorder (PTSD), tobacco use, being married, having multiple chronic pain conditions, the use of multiple opioids and opioid dose above 100 mg per day.
Noting that veterans have high rates of painful conditions and show elevated levels rates of chronic opioid use, the researchers said, “Understanding rates and predictors of discontinuation will clarify the risks for opioid abuse and dependence among this population.”
The results did not completely track previous research, however.
“Unlike other samples, it appears that mental-health disorders and substance-use disorders are associated with increased rates of discontinuation in the VA,” said lead author Mark Sullivan, MD, PhD. “The exception is tobacco use, which is associated with a decreased likelihood of discontinuation.”
In examining how to predict opioid discontinuation, the researchers looked at demographic and clinical characteristics as well as treatment choices. Pain characteristics and diagnoses related to medical conditions, mental health and substance abuse were taken into consideration along with other medications used by the patients, such as non-opioid pain relievers and those used to treat mental-health disorders.
Results indicated that chronic opioid users took the painkillers for an average of 242.08 days, compared with 29.22 days among nonchronic users. The mean daily dose among chronic users, meanwhile, was 38 mg morphine equivalent dose (MED), compared with 22 mg among nonchronic users. Only 5% of patients were found to have a mean daily dose greater than 90 mg MED.
The study noted that substance use disorders were diagnosed in 23% of chronic users and 20% of nonchronic users, although, among nonchronic users in FY 2009, 16.6% used opioids chronically in FY 2010.
The researchers said they lacked reliable or interpretable data to look at pain levels as predictors of opioid discontinuation or why some patients had received high doses of opioids, Sullivan said.
“Chronic opioid use is very common among veterans, but mean doses are modest. In contrast to other samples, no increase in rates of chronic opioid use were found in those with diagnosed substance use disorders,” the authors concluded.
In addition to the most recent initiative, the VA has directed significant resources toward management of pain and the drugs used to treat it. For example, Pain Coach is a pain-management application available for download by patients receiving pain-management treatments, and, also online, veterans have access to a Patient/Family Management Toolkit, and resources for pain management on My HealtheVet.
“The Opioid Safety Initiative is an example of VHA’s personalized, proactive and patient-centered approach to healthcare. We are also using a full range of support treatments for Veterans, including Complementary and Alternative Medicine,” said Robert Petzel, MD, VA’s Under Secretary for Health. “We are delivering healthcare with the patient’s long-term personal health goals at the forefront.”
1 Sullivan M, Hudson T, Bradley CM, Edlund M, Fortney J, et.al. National Analysis of Opioid Use Among Veterans. Poster session presented at: the 30th Annual Meeting of the American Academic of Pain Medicine; 2014 March 6-9, Phoenix, AZ.
2 Sullivan M, Hudson T, Bradley CM, Edlund M, Fortney J, et.al.. National Study of Discontinuation of Chronic Opioid Therapy Among Veterans. Poster session presented at: the 30th Annual Meeting of the American Academy of Pain Medicine; 2014 March 6-9, Phoenix, AZ.