VOL. 15, NO. 4
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n clinical n
© Managed Care &
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the effect of pain on process and outcome measures of diabetes care is
unknown. In addition, no study has specifically examined the effect of
opioid therapy on the quality of care for unrelated chronic conditions,
but there is reason to believe that opioid therapy may impart more com-
plexity and challenge than pain alone.32
has varied depending on the diagnoses, the clinician and patient, and
the clinical environment. Seeking to harmonize these mixed results
into a unifying theory, Piette and Kerr10 proposed that symptomatic
conditions may have a greater effect on quality of care than asymptom-
atic conditions and that conditions with dissimilar management goals
(“discordant conditions”) may have a greater effect than those with
similar goals (“concordant conditions”).
By this reasoning, chronic pain could have a considerable adverse
effect on quality of care for unrelated conditions. Pain is highly symp-
tomatic, and pain management is discordant with the management of
other conditions.11 While the use of opioids to treat chronic noncancer
pain is increasingly accepted,12 opioid therapy may present additional
challenges due to the potential for abuse, dependence, and diversion and
due to conflicts over appropriate dosages.13-19 However, opioid therapy
could also facilitate care for unrelated conditions. Patients receiving
opioids may visit the clinic more often, allowing more opportunities for
medical management.10 Adequate treatment of pain may improve the
patient’s functional status and quality of life,12 allowing greater focus on
Diabetes mellitus, a common, costly, and highly morbid condition,20,21
is a good condition in which to examine this possibility. Adequate man-
agement of diabetes requires collaboration among clinicians and the pa-
tient within a system of care,22-27 and explicit guidelines and diabetes
performance targets exist with which to examine the adequacy of dia-
betes care.28-30 Krein et al31 showed that among patients with diabetes,
chronic pain is a barrier to the completion of self-care activities such as
taking medications, exercising, and pursuing a prudent diet. However,
nderstanding the role of clinical complexity as a determi-
nant of quality of care is a major research goal.1 In previous
studies,2-9 the effect of clinical complexity on quality of care
To clarify whether the net effect
of opioid therapy is to promote or im-
pede care for diabetes, we analyzed a
large database of patients with diabe-
tes in the US Department of Veterans
In this issue
Take-Away Points / p222
Full text and PDF
Does Opioid Therapy Affect Quality of Care
for Diabetes Mellitus?
Adam J. Rose, MD, MSc; John A. Hermos, MD; Susan M. Frayne, MD, MPH;
Leonard M. Pogach, MD, MBA; Dan R. Berlowitz, MD, MPH; and Donald R. Miller, ScD
Objective: To examine whether veterans who re-
ceived chronic opioid therapy had worse diabetes
performance measures than patients who did not
Study Design: Retrospective cohort study.
Methods: We identified all patients with diabetes
mellitus receiving care in US Department of Veter-
ans Affairs facilities during 2004. Cases received
at least 6 prescriptions for chronic opioids during
2004, while controls were randomly selected
from among patients with diabetes who received
no opioids. We compared process measures
(glycosylated hemoglobin and low-density
lipoprotein cholesterol levels tested and an eye
examination performed) and outcome measures
(glycosylated hemoglobin level <9.0% and low-
density lipoprotein cholesterol level <130 mg/dL)
Results: Cases (n = 47,756) had slightly worse
diabetes performance measures than controls
(n = 220,912) after adjustment for covariates. For
example, 86.4% of cases and 89.0% of controls
had a glycosylated hemoglobin test during fiscal
year 2004 (adjusted odds ratio, 0.69; P <.001).
Among cases, receipt of higher-dose opioids was
associated with additional decrement in diabetes
performance measures, with a dose-response
Conclusions: Chronic opioid therapy among
patients within the Veterans Affairs system is
associated with slightly worse diabetes perfor-
mance measures compared with patients who do
not receive opioids. However, patients receiving
higher dosages of opioids had additional decre-
ments in diabetes performance measures; these
patients may be appropriate targets for interven-
tions to improve their care for pain and diabetes.
(Am J Manag Care. 2009;15(4):217-224)
For author information and disclosures,
see end of text.
n www.ajmc.com n?
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