Clinical Characteristics of Veterans Prescribed High Doses of Opioid Medications for Chronic Non-Cancer Pain

Mental Health and Clinical Neurosciences Division, Portland VA Medical Center, Department of Psychiatry, Oregon Health & Science University, Portland, OR 97239, USA.
Pain (Impact Factor: 5.21). 12/2010; 151(3):625-32. DOI: 10.1016/j.pain.2010.08.002
Source: PubMed


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 8.2% 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 25.7% 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.

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    • "Our findings on the medical characteristics of people with LTOT agree with a Danish study (Ekholm et al., 2014) in which LTOT was more frequently prescribed to women and older people. In line with US studies, male gender (Dunn et al., 2010; Kobus et al., 2012) and mental health diagnoses (Dunn et al., 2010; Morasco et al., 2010; Kobus et al., 2012) were associated with high-dose opioid use. In contrast to a US (Kobus et al., 2012) and Norwegian study (Højsted et al., 2013), we did not find an association with co-prescriptions of sedative-hypnotics, but of anticonvulsants. "
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    ABSTRACT: Background: No data are available on the prevalence and predictors of (high-dose) long-term opioid therapy (LTOT) and on abuse/addiction of prescribed opioids by patients with chronic non-cancer pain (CNCP) outside North America and Scandinavia. Methods: We analysed randomly selected claims records of 870,000 persons (10% of insureds) in a large German medical health insurance organization during the fiscal year 2012. Results: The prevalence of LTOT prescriptions (defined by at least one opioid prescription per quarter for at least three consecutive quarters) for CNCP was 1.3% of all insureds. The mean daily dosage of LTOT was 58 (SD 79; minimum 0.3, maximum 2010) mg morphine equivalent/day. The percentage of insureds with high-dose opioid prescriptions (≥100 mg morphine equivalent/day) among LTOT insureds was 15.5%. High-dose LTOT (compared to traditional dose) prescription was associated with younger age, male gender, diagnoses of chronic pain disease, somatoform pain disorder, depression and prescription of anticonvulsants. The pooled 1-year prevalence of abuse/addiction of prescribed opioids (defined by hospital stays because of mental and behavioural disorders due to alcohol, opioids, tranquilizers, multiple substances and intoxications by narcotic agents) was 0.008%. Abuse/addiction of prescribed opioids was associated with younger age, diagnoses of somatoform pain disorder, depression and prescription of tranquilizers. Conclusions: The study found no signals of an 'opioid epidemic' in Germany. However, careful selection of patients with CNCP considered for LTOT and continuous evaluation during LTOT are warranted.
    Full-text · Article · Oct 2015 · European journal of pain (London, England)
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    • "duty [8]. A recent study among veterans treated in a Veterans Administration regional health care network also found that LBP was significantly associated with increased risk of high-dose opioid use [38]. Moreover, in fiscal year 2010 (October 1, 2009, through September 30, 2010), approximately 70,000 individuals were recruited into the U.S. Army [39]. "
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    ABSTRACT: BACKGROUND CONTEXT: Effective strategies for preventing low back pain (LBP) have remained elusive, despite annual direct health care costs exceeding $85 billion dollars annually. In our recently completed Prevention of Low Back Pain in the Military (POLM) trial, a brief psychosocial education program (PSEP) that reduced fear and threat of LBP reduced the incidence of health care–seeking for LBP. PURPOSE: The purpose of this cost analysis was to determine if soldiers who received psychosocial education experienced lower health care costs compared with soldiers who did not receive psychosocial education. STUDY DESIGN/SETTING: The POLM trial was a cluster randomized trial with four intervention arms and a 2-year follow-up. Consecutive subjects (n54,295) entering a 16-week training program at Fort Sam Houston, TX, to become a combat medic in the U.S. Army were considered for participation. METHODS: In addition to an assigned exercise program, soldiers were cluster randomized to receive or not receive a brief psychosocial education program delivered in a group setting. The Military Health System Management Analysis and Reporting Tool was used to extract total and LBP-related health care costs associated with LBP incidence over a 2-year follow-up period. RESULTS: After adjusting for postrandomization differences between the groups, the median total LBP-related health care costs for soldiers who received PSEP and incurred LBP-related costs during the 2-year follow-up period were $26 per soldier lower than for those who did not receive PSEP ($60 vs. $86, respectively, p5.034). The adjusted median total health care costs for soldiers who received PSEP and incurred at least some health care costs during the 2-year follow-up period were estimated at $2 per soldier lower than for those who did not receive PSEP ($2,439 vs. $2,441, respectively, p5.242). The results from this analysis demonstrate that a brief psychosocial education program was only marginally effective in reducing LBP-related health care costs and was not effective in reducing total health care costs. Had the 1,995 soldiers in the PSEP group not received PSEP, we would estimate that 16.7% of them would incur an adjusted median LBP-related health care cost of $517 compared with the current 15.0% soldiers incurring an adjusted median cost of $399, which translates into an actual LBP-related health care cost savings of $52,846 during the POLM trial. However, it is likely that the unaccounted for direct and indirect costs might erase even these small cost savings. CONCLUSION: The results of this study will help to inform policy- and decision-making regarding the feasibility of implementing psychosocial education in military training environments across the services. It would be interesting to explore in future research whether cost savings from psychosocial education could be enhanced given a more individualized delivery method tailored to an individual’s specific psychosocial risk factors.
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