Discontinuation of Chronic Opioids in Veterans Varies
Phoenix—A new study has confirmed that the reasons
veterans discontinue their chronic opioid therapy are as heterogeneous
as the veterans themselves. Factors associated with discontinuation were
younger age, mental health or substance use disorders and taking lower
doses of opioids.
Mark Sullivan, MD, PhD, professor, Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, and several co-investigators found in a previous study that Medicaid and commercially insured individuals were less likely to discontinue long-term opioid therapy if they were receiving high daily doses of opioids—at least 120 mg of a morphine-equivalent dose (MED)—and appeared to be misusing opioids (J Gen Intern Med 2011;26:1450-1457).
Dr. Sullivan and his colleagues sought to find out whether the same is true in the veteran population, a group in which long-term opioid use is prevalent. The researchers focused on data from individuals who visited a Veterans’ Health Administration (VHA) facility as an outpatient at least twice during fiscal years (FY; beginning of October to end of September) 2009, 2010 and 2011, and received at least a 90-day supply of opioids. They excluded individuals who resided in a VHA nursing home or long-term care facility, had a cancer diagnosis other than nonmelanoma skin cancer, had incomplete records, were on methadone maintenance, had not used VA services in the 90 days after discontinuation—indicating the investigators could not verify whether they had truly stopped the opioids—or died between 2009 and 2011.
The team was unable to determine the causes of opioid discontinuation in the patients, but their assumption was that, similar to the results from their previous study, most discontinuations were not due to reduction in pain, but rather to side effects and aberrant behaviors.
In all, 546,043 individuals were included in the analysis and were split evenly among those treated in FY 2009, FY 2010 and FY 2011. The mean ages of the patients in the three years were 57.9, 57.9 and 58 years, respectively; more than 92% were men; and 70.9%, 70.3% and 69.8%, respectively, were white. Furthermore, mean MED was 33.49, 32.96 and 32.36, respectively. Hydrocodone products were the most commonly prescribed opioids, followed by tramadol or tapentadol (Nucynta, Janssen) products, and then oxycodone. The three groups also had similar proportions of different mental health diagnoses such as anxiety, major depressive disorder and post-traumatic stress disorder, and of substance use disorders.
Overall, approximately 75% of the patients continued their opioids. The mean time to discontinuation was 547 days and the median time to discontinuation was 488 days.
Dr. Sullivan’s team constructed a Cox proportional hazards model to uncover factors associated with discontinuation. These ranged from age 18 to 30 years, with a hazard ratio (HR) of 1.63—representing a 63% higher probability of discontinuation than among individuals aged 50 to 65—to those with a traumatic brain injury, who had a 12% higher probability of discontinuation (HR, 1.12). Higher daily opioid doses were associated with a lower probability of discontinuation, with an HR of 0.65 among individuals taking MEDs of at least 100 mg versus those with MEDs of 0 to 20 mg, and an HR of 0.79 among those taking MEDs of 20 to 100 mg versus 0 to 20 mg.
Kaplan-Meier curves confirmed these results, and also yielded supplementary information. Having one or more types of chronic pain reduced the odds of discontinuation, whereas having more than one type of mental health disorder or substance use disorder increased the probability of discontinuation.
The results were presented at the American Academy of Pain Medicine’s 2014 annual meeting (poster 120).
“A second analysis not presented on the poster confirmed that, for each additional mental health or substance use category that a subject had, they had a progressively higher chance of discontinuation,” said Erik Vanderlip, MD, a fellow working with Dr. Sullivan.
Jeffrey Katz, MD, professor in anesthesiology, Feinberg School of Medicine, Northwestern University, Chicago, who was not involved in the study, said the results are difficult to interpret because, as the authors stated, discontinuation of opioids in this population was most likely the result of noncompliance or lack of efficacy, rather than the result of improvement in the pain condition.
“For example, when they state that the presence of substance abuse and/or mental health disorders was associated with higher rates of opioid discontinuation, it was not because these patients are more likely to improve,” Dr. Katz told Pain Medicine News, “but rather that they are more likely to have opioids discontinued for reasons of inappropriate use or lack of efficacy.”
—Rosemary Frei, M
Mark Sullivan, MD, PhD, professor, Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, and several co-investigators found in a previous study that Medicaid and commercially insured individuals were less likely to discontinue long-term opioid therapy if they were receiving high daily doses of opioids—at least 120 mg of a morphine-equivalent dose (MED)—and appeared to be misusing opioids (J Gen Intern Med 2011;26:1450-1457).
Dr. Sullivan and his colleagues sought to find out whether the same is true in the veteran population, a group in which long-term opioid use is prevalent. The researchers focused on data from individuals who visited a Veterans’ Health Administration (VHA) facility as an outpatient at least twice during fiscal years (FY; beginning of October to end of September) 2009, 2010 and 2011, and received at least a 90-day supply of opioids. They excluded individuals who resided in a VHA nursing home or long-term care facility, had a cancer diagnosis other than nonmelanoma skin cancer, had incomplete records, were on methadone maintenance, had not used VA services in the 90 days after discontinuation—indicating the investigators could not verify whether they had truly stopped the opioids—or died between 2009 and 2011.
The team was unable to determine the causes of opioid discontinuation in the patients, but their assumption was that, similar to the results from their previous study, most discontinuations were not due to reduction in pain, but rather to side effects and aberrant behaviors.
In all, 546,043 individuals were included in the analysis and were split evenly among those treated in FY 2009, FY 2010 and FY 2011. The mean ages of the patients in the three years were 57.9, 57.9 and 58 years, respectively; more than 92% were men; and 70.9%, 70.3% and 69.8%, respectively, were white. Furthermore, mean MED was 33.49, 32.96 and 32.36, respectively. Hydrocodone products were the most commonly prescribed opioids, followed by tramadol or tapentadol (Nucynta, Janssen) products, and then oxycodone. The three groups also had similar proportions of different mental health diagnoses such as anxiety, major depressive disorder and post-traumatic stress disorder, and of substance use disorders.
Overall, approximately 75% of the patients continued their opioids. The mean time to discontinuation was 547 days and the median time to discontinuation was 488 days.
Dr. Sullivan’s team constructed a Cox proportional hazards model to uncover factors associated with discontinuation. These ranged from age 18 to 30 years, with a hazard ratio (HR) of 1.63—representing a 63% higher probability of discontinuation than among individuals aged 50 to 65—to those with a traumatic brain injury, who had a 12% higher probability of discontinuation (HR, 1.12). Higher daily opioid doses were associated with a lower probability of discontinuation, with an HR of 0.65 among individuals taking MEDs of at least 100 mg versus those with MEDs of 0 to 20 mg, and an HR of 0.79 among those taking MEDs of 20 to 100 mg versus 0 to 20 mg.
Kaplan-Meier curves confirmed these results, and also yielded supplementary information. Having one or more types of chronic pain reduced the odds of discontinuation, whereas having more than one type of mental health disorder or substance use disorder increased the probability of discontinuation.
The results were presented at the American Academy of Pain Medicine’s 2014 annual meeting (poster 120).
“A second analysis not presented on the poster confirmed that, for each additional mental health or substance use category that a subject had, they had a progressively higher chance of discontinuation,” said Erik Vanderlip, MD, a fellow working with Dr. Sullivan.
Jeffrey Katz, MD, professor in anesthesiology, Feinberg School of Medicine, Northwestern University, Chicago, who was not involved in the study, said the results are difficult to interpret because, as the authors stated, discontinuation of opioids in this population was most likely the result of noncompliance or lack of efficacy, rather than the result of improvement in the pain condition.
“For example, when they state that the presence of substance abuse and/or mental health disorders was associated with higher rates of opioid discontinuation, it was not because these patients are more likely to improve,” Dr. Katz told Pain Medicine News, “but rather that they are more likely to have opioids discontinued for reasons of inappropriate use or lack of efficacy.”
—Rosemary Frei, M
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