Why Opioids Are Discontinued in VHA Patients

PORTLAND, OR — Discontinuation of opioids can be accelerated for several reasons, according to a new study, including lack of information about the long-term effectiveness of opioids for chronic pain, heightened awareness about opioid-related adverse events, closer monitoring of patients for opioid-related aberrant behaviors, and greater restrictions around opioid prescribing.

That’s especially the case in patients considered “high risk,” noted the article published recently in the journal Pain.1

The study led by researchers from the Center to Improve Veteran Involvement in Care at the VA Portland, OR, Healthcare System sought to compare reasons for discontinuation of long-term opioid therapy (LTOT) between patients with and without substance use disorder (SUD) diagnoses receiving care within the VHA.

The retrospective cohort study involved a cohort of veteran patients prescribed opioid therapy for at least 12 consecutive months who subsequently discontinued opioid therapy for at least 12 months. From the cohort, researchers randomly selected 300 patients with SUD diagnoses and propensity score-matched 300 patients without SUD diagnoses.

Used to determine reasons for LTOT discontinuation was a comprehensive manual review of patients’ medical records. Results indicated that most patients (85%) were discontinued because of clinician, rather than patient, decisions.

For patients whose clinicians initiated discontinuation, 75% were discontinued because of opioid-related aberrant behaviors. Compared to patients without SUD diagnoses, those with SUD diagnoses were more likely to discontinue LTOT because of aberrant behaviors — 81% vs. 68% — usually abuse of alcohol or other substances.

“This is the first study to document reasons for discontinuation of LTOT in a sample of patients with and without SUD diagnoses,” study authors wrote. “Treatments that concurrently address SUD and chronic pain are needed for this high-risk population.”

  1. 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;158(3):526-534. doi: 10.1097/j.pain.0000000000000796. PubMed PMID: 28192376.

Comments (5)

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  1. Wayne Hachey says:

    While it is reassuring that great efforts are being made to counter opioid misuse many veterans are then subject to substandard care and ineffective pain management. The study cited above includes some 25% of the study population without aberrant behaviors in whom their provider discontinued pain medications. The same diligence should be applied to address appropriate and effective pain management rather than often draconian measures targeting meeting a goal of decreased opioid use.

  2. Micha Smith-Hammond says:

    This article about “reasons for discontinuation” is not very informative and raises more questions than answers about the actual patients that suffer from chronic pain. In no way can a clinician apply this article to their practice.

    Questions to think about:
    1. So, are these patients still in pain?
    2. Were they switched to another non-opioid med?
    3. Are the patients satisfied with their care?
    4. Are they now receiving proper pain management?
    5. Without the opioids for pain are these patients with SUD turning to more harmful substances?
    6. Did benefits outweigh the risks of stopping opioid with this diagnosis?
    7. What was the timeframe for follow-up after stopping opioid therapy?
    8. Was mental health evaluated properly in this population?
    9. What was the patient’s severity of pain after stopping opioid treatment?

    • Daniel says:

      I’d like to answer:

      1. Yes
      2. Yes. We are given the option of Tylenol or Motrin, along with other forms of therapy such as, I shit you not, nerve stimulation therapy (externally like a tens unit or internally, meaning surgery and still no guarantee of success) or alternative medicine like, wait for it, acupuncture.
      3. Absolutely not
      4. See above
      5. They absolutely are, meaning a vast array of measures, including suicide (see Operation Zero)
      6. Many veterans have been on, or a combination of, these medications for decades who have had very little or no dangers associated with continued use. The va continually monitors patients on opioids including quarterly urine and blood draws to test for other banned substances and liver enzyme tests. These veterans had no history past or present to indicate any issues or complications with these medications. They were just discontinued
      7. Va policy for follow-up appointments is 3 months.
      8. Most of these patients have seen or are seen by mental health professionals for at minimum a post-service mental health evaluation. Depending on the duration of time between that appointment and the initiation of opioid medication, a new evaluation would be ordered. However, many of these veterans begin using these medications after a physical trauma, from simple surgery to loss of limbs from combat. Thanks to the va’s stellar record of seeing patients in a timely fashion, a badly traumatized Veterans could go years from the date of initiation of opioid medicine to seeing a mental health professional.
      9. If you know anyone who has ever been a heroin addict, you’d understand. Lots of us do. This is the same equivalent to immediately and abruptly stopping opioid treatment. They’ve condemned these men and women. They have spent years treating them and turning them into addicts, then suddenly saying “that’s it. No more” and letting them to their own devices. No counseling, no post medicine-cycle therapy, no rehab, to medication that is proven it’s value to those who have had addictions in the past, nothing. The va loves filling your meds on your last day as well. So you get so close to the end you start to stress about it. Then you start to wonder if there’s a problem. So you call different offices and people trying to get answers, which are always strangely non-specific. But it usually does come and you can relax a bit for about 3 weeks, then rinse, wash, and repeat. Until now. So the day we’ve all been waiting for and worrying about because some people abuse their medication and other illicit drugs finally comes, and your offered acupuncture. It’s the most humiliating and demeaning thing they can tell you. We trusted you with multi-million dollar equipment. You trusted us with the safety and security of this very nation. We’ve sweat, bled, died, and some come home battered, bruised, and scarred. You promised you’d help us. You swore we’d be taken care of. You made us swear. We believed you. We trusted you. Then you treat us like this. It’s obscene.

      You should all be ashamed of yourself.

      “To care for him who shall have borne the battle and for his widow, and for his orphan.” -Abraham Lincoln

  3. M Jarrett says:

    This is totally laughable !!! It is blatantly obvious these days that when those that are in charge, from the President down to the pharmacist want the opioids to go away unless the patient has cancer they will go away !!!

  4. Sam says:

    Its amazing that these so called “Experts” in their field most probably have never felt what “severe chronic pain” is nor do they factor into their little arguments the one question that is actually written in Title 38 USC 1701, (look it up). Which is also in the VA/DOD Guideline on Long Term Opioid Use for Severe Chronic Pain and Lower Back Pain.
    Does the opioid improve the veterans quality of life and extend his life activity?
    That should be the question that is on the minds of the “Experts” who are playing with peoples lives.

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