Clinical characteristics of veterans prescribed high doses of opioid medications for chronic non-cancer pain

Abstract

Little is known about patients prescribed high doses of opioids to treat chronic non-cancer pain, though these patients may be at higher risk for medication-related complications. We describe the prevalence of high-dose opioid use and associated demographic and clinical characteristics among veterans treated in a VA regional healthcare network. Veterans with chronic non-cancer pain prescribed high doses of opioids (>=180 mg/day morphine equivalent; n=478) for 90+ consecutive days were compared to two groups with chronic pain: Traditional-dose (5-179 mg/day; n=500) or no opioid (n=500). High-dose opioid use occurred in 2.4% of all chronic pain patients and in 3.4% of all chronic pain patients prescribed opioids long-term. The average dose in the high-dose group was 324.9 (SD=285.1) mg/day. The only significant demographic difference among groups was race (p=0.03) with black veterans less likely to receive high doses. High-dose patients were more likely to have four or more pain diagnoses and the highest rates of medical, psychiatric, and substance use disorders. After controlling for demographic factors and VA facility, neuropathy, low back pain, and nicotine dependence diagnoses were associated with increased likelihood of high-dose prescriptions. High-dose patients frequently did not receive care consistent with treatment guidelines: there was frequent use of short-acting opioids, urine drug screens were administered to only 40.8% of patients in the prior year, and 32.0% received concurrent benzodiazepine prescriptions, which may increase risk for overdose and death. Further study is needed to identify better predictors of high-dose usage, as well as the efficacy and safety of such dosing.

Chronic Opioid Therapy Urine Drug Testing in Primary Care: Prevalence and Predictors of Aberrant Results

“…44 Our hypothesis that males would have more illicit drug results was not confirmed; findings in previous studies were mixed. 16,18 Consistent with prior studies, 18,20 we found no significant association between opioid regimen characteristics and illicit drugs.…”

“…20 Marijuana is the most commonly used recreational drug. 43 An estimated 7.3 % of the U.S. population uses marijuana, with approximately 7.6 million Americans using marijuana daily or almost daily.…”

“…17,18 Among veterans, UDT detection of illicit substances (including THC) was more common for those with SUD diagnoses. 19 Studies in diverse settings 18,20 found no significant association between opioid regimen characteristics and UDT detection of illicit drugs.…”

Adherence to Clinical Guidelines for Opioid Therapy for Chronic Pain in Patients with Substance Use Disorder

“…A portion of these data have been reported in a report of factors associated with prescriptions for high doses of opioids. 26 We created an index date for all patients to be used as a reference for data collection. The index date was the earliest date in 2008 at the beginning of a 90 consecutive day episode of opioid use.…”

“…Each opioid prescription was converted to a morphine equivalent. 26 We extracted medical utilization data from services considered important in management with opioid therapy for one year after the index date. This included data from primary care, physical therapy, orthopedics, mental health, and substance abuse treatment.…”