Correlates of Prescription Opioid Initiation and Long-term Opioid Use in Veterans With Persistent Pain

Abstract

Objectives Little is known about how opioid prescriptions for chronic pain are initiated. We sought to describe patterns of prescription opioid initiation, identify correlates of opioid initiation, and examine correlates of receipt of chronic opioid therapy (COT) among veterans with persistent non-cancer pain. Methods Using Veterans Affairs (VA) administrative data, we identified 5,961 veterans from the Pacific Northwest with persistent elevated pain intensity scores who had not been prescribed opioids in the prior 12 months. We compared veterans not prescribed opioids over the subsequent 12 months to those prescribed any opioid and to those prescribed COT (≥90 consecutive days). Results During the study year, 34% of the sample received an opioid prescription, and 5% received COT. Most first opioid prescriptions were written by primary care clinicians. Veterans prescribed COT were younger, had greater pain intensity, and high rates of psychiatric and substance use disorders (SUDs) compared to veterans in the other two groups. Among patients receiving COT, 29% were prescribed long-acting opioids, 37% received one or more urine drug screens, and 24% were prescribed benzodiazepines. Adjusting for age, sex, and baseline pain intensity, major depression (OR 1.24 [1.10–1.39]; 1.48 [1.14–1.93]) and nicotine dependence (1.34 [1.17–1.53]; 2.02 [1.53–2.67]) were associated with receiving any opioid prescription and with COT, respectively. Discussion Opioid initiations are common among veterans with persistent pain, but most veterans are not prescribed opioids long-term. Psychiatric disorders and SUDs are associated with receiving COT. Many Veterans receiving COT are concurrently prescribed benzodiazepines and many do not receive urine drug screening; additional study regarding practices that optimize safety of COT in this population is indicated.

Trends in Prevalent and Incident Opioid Receipt: an Observational Study in Veterans Health Administration 2004–2012

“…Dobscha et al 38 studied a cohort of 17,126 patients defined by persistent elevated pain, in which only 5,961 (35 %) had not received any opioid in the12 months prior to the index date. Among the opioid-naïve patients, 13.2 % (273 of 1,797) who received any opioids went on to receive long-term opioid therapy.…”

Correlates of prescription opioid therapy in Veterans with chronic pain and history of substance use disorder

“…To identify correlates of prescription opioid therapy, we categorized participants into three groups: (1) no opioid therapy (NOT) in the past 90 d (n = 134), (2) SOT (<90 d duration; n = 31), or (3) LOT (90 d duration; n = 49). Similar definitions of SOT and LOT have been used in prior studies [8,20,[41][42].…”

“…We next conducted a hierarchical multinomial logistic regression analysis to identify clinical and pain-related variables most strongly associated with NOT versus SOT versus LOT in the past 90 d. The goal of this analysis was to test the hypothesized correlates of prescription opioid therapy. The first step of this model controlled for demographic characteristics that have demonstrated associations with receipt of prescription opioid therapy in prior studies (age, sex, race) [8][9]19]. In the second step, we included depression symptom severity, PTSD diagnosis, and active SUD diagnosis.…”

“…High rates of past and current alcohol and other substance use disorders (SUDs) have also been observed in patients with chronic pain [6][7]. Prescription opioid therapy is commonly used to treat chronic pain in both Veteran and non-Veteran patients [8][9][10]. However, controversy surrounds this practice because recent studies indicate that fewer than half of patients prescribed opioids will experience a clinically significant reduction in pain intensity in the short term, with little improvement in physical function long-term [11][12].…”

“…These include younger age, male sex, white race, mental health diagnoses (e.g., depressive disorders and posttraumatic stress disorder [PTSD]), specific pain diagnoses (e.g., low back pain, neck or joint pain, arthritis), and greater perceived pain intensity [8][9][19][20]. Notably, Veterans with comorbid chronic pain and SUD, relative to Veterans with chronic pain and no SUD, are also more likely to be prescribed SOT and LOT at high doses [2,8,13,[21][22]. No studies, however, have identified correlates of prescription opioid therapy within samples composed exclusively of patients with lifetime SUD histories, and it is unclear whether correlates of opioid therapy identified in previous studies that recruited heterogeneous patient samples will extend to SUD populations.…”