Opioid Discontinuation Among Patients Receiving High-Dose Long-Term Opioid Therapy in the Veterans Health Administration
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Partnered Evidence-based Policy Resource Center, VA Boston Healthcare System, , MABoston, USA; 2Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA, USA; 3Bouvé College of Health Sciences, Northeastern University, Boston, MA, USA; 4VA Office of Mental Health and Suicide Prevention, VA Program Evaluation and Resource Center, VA Palo Alto Healthcare System, Menlo Park, CA, USA; 5VA Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA, USA; 6Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Cambridge, MA, USA.
BACKGROUND: Prior opioid discontinuation studies have focused on one of two characteristics of opioid prescribing, its duration (long term vs not) or dosage (high vs low). Questions remain about the experience of patients with highdose, long-term opioid therapy (HLOT) prescriptions who are likely to be at the highest risk for adverse events. OBJECTIVE: We address the following questions among the Veterans Health Administration (VHA) patients receiving HLOT: 1), How has the prevalence of discontinuation of opioids changed over time? 2), How do patient characteristics vary between those who do and do not discontinue? And 3), how does the prevalence of discontinuation vary geographically? DESIGN: A retrospective observational study of VHA patients with HLOT between fiscal year (FY) 2014 and FY2018. PARTICIPANTS: We identified 1,281,330 patients from VHA outpatient opioid prescription data with at least a 1-day opioid supply between FY2014 and FY2018. We identified and excluded those receiving palliative care or diagnosed with metastatic cancer. MAIN MEASURES: For a given patient and month, a patient having a 3-month moving average of ≥ 90 daily morphine milligram equivalent (MME) was defined as having HLOT. Similarly, we used a three-month average MME of zero as discontinuation. KEY RESULTS: The prevalence of discontinuation among patients with HLOT increased from 6.3% in FY2014 to 7.8% in FY2018. Across the years, patients who discontinued were younger, less likely to be married, and more likely to have comorbidities related to substance use disorders compared with patients who continued to receive HLOT. Incidence of discontinuation among those with HLOT increased in more than half (64%) of the 129 VHA medical centers. Prior Presentations AcademyHealth Annual Research Meeting June 2– 4, 2019 Electronic supplementary material The online version of this article (https://doi.org/10.1007/s11606-020-06252-9) contains supplementary material, which is available to authorized users. Received February 3, 2020 Accepted September 17, 2020
CONCLUSION: Prevalence of patients receiving HLOT in the VHA decreased as the incidence of discontinuation increased. Further research is needed to understand the process by which patients are discontinued and to assess the relationship between discontinuation and health outcomes. KEY WORDS: opioid; long-term high-dose opioid therapy; taper; discontinuation; Veterans He
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