September 2018

In This Issue: Improving Opioid Safety
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Effects of VHA Opioid Policy on Prescribing and Patient-Centered Outcomes

Feature Article

Chronic pain is an important public health problem and among the most prevalent and disabling of chronic diseases. VA has been a national leader in pain management—including early initiatives to promote greater awareness of pain, efforts to expand access to a stepped-care model of pain treatment, and responses to the emerging epidemic of serious opioid-related harms. Recent VA opioid policies include the Opioid Safety Initiative, the mandatory Informed Consent for Long-Term Opioid Therapy for Pain, and system-wide opioid safety goals to increase the use of opioid risk management tools and to decrease high-risk prescribing (e.g., high-dose opioid therapy). Research using administrative data suggests these initiatives have reduced the rates and intensity of opioid prescribing in VA. If fully successful, these initiatives also will improve pain and quality of life (QOL) outcomes among Veterans with chronic pain.

The main objective of this ongoing (2015–2019) HSR&D study is to understand patient-centered outcomes of opioid prescribing changes among Veterans treated with opioids for chronic pain. The project has enrolled a nationally-representative sample of VA primary care patients receiving long-term opioid therapy, and investigators are collecting patient-reported pain outcomes data using a longitudinal mixed-mode (mail and telephone) survey design. Specific aims are to examine:

• The relationship between changes in prescribed opioids and changes in patient-reported pain and QOL outcomes; and
• Associations of patient, provider, and facility factors with changes in patient-reported pain and QOL, primarily through their influence on opioid prescribing and use of non-pharmacological pain therapies.

Veterans participating in this study are asked to complete three annual questionnaires. Patient-reported data are merged with VA administrative data for analyses.

Findings:

Of 14,029 VA primary care patients contacted in the initial survey wave, 9,253 (66%) completed a questionnaire or interview and were included in the cohort. Baseline results from this national cohort demonstrate moderate-severe pain, poor quality of life, and low perceived pain treatment effectiveness among VA patients on long-term opioid therapy for chronic pain. For example:

• The mean average pain severity (range 0-10; higher = worse) was 6.8.
• On the Veterans RAND 12-item Health Survey (VR-12©) quality-of-life measure (range 0-100; higher = better), the mean physical health score was 25 and the mean mental health score was 39.
• Of the Veterans participating in the study, 13% rated the effectiveness of their pain treatment as very good or excellent, and 26% rated the quality of VA pain care as very good or excellent.
• When asked where they would go if they could get their pain care anywhere, 44% of Veterans reported they would choose VA care, 33% were unsure, and 23% would choose non-VA care.

Data analysis and 24-month follow-up data collection are currently in progress.

Impact:
By examining patient-reported pain and quality of life outcomes associated with changes in treatment during follow-up, this research will allow for a fuller understanding of the effects of VA opioid and pain management initiatives on Veterans receiving opioid therapy for chronic pain. Study findings will contribute to identifying successful approaches and targeting potential gaps in VA efforts to achieve patient-centered pain management and opioid safety goals.

Principal Investigator: Erin Krebs, MD, MPH, is part of HSR&D’s Center for Chronic Disease Outcomes Research (CCDOR) in Minneapolis, MN, and is a former HSR&D Career Development Awardee.

Additional Resources

• VHA Pain Management. Opioid Safety Initiative Toolkit.
• Veterans Crisis Line 1-800-273-8255 (press 1) or Text message to 838255.