Long-term opioid therapy trajectories in Veteran patients with and without substance use disorder

Abstract: Introduction: Previous research on veteran patient populations has identified distinct long-term opiod therapy (LTOT) dose trajectories. Recipients of these trajectories were clinically distinguishable from each other by types of pain, pain scores, prevalence of AUD and smoking, and incidence of opiod use disorder (OUD). Further, higher and escalating dose trajectories were found to be associated with higher odds of opioid overdose compared to a low, stable dose trajectory. This work increases the understanding that dose trajectory, not just dose, is important for health outcomes and has clinical implications. However, it has yet to be determined if and how a veteran’s substance use disorder (SUD) diagnosis is associated with a particular LTOT dosage trajectory. Thus, in this retrospective cohort study using data from health records of 285,772 patients seen at any VA facility between 2010 and 2017, we aimed to examine if membership in previously described LTOT trajectories differs with the presence of a SUD. We hypothesized that trajectory membership would differ by SUD status demonstrating that veterans with SUD were prescribed LTOT at higher doses compared to veterans without SUD. Data and participants: We conducted a retrospective cohort study using data from the Corporate Data Warehouse (CDW), which houses clinical and pharmacy data for every patient seeking care at the VHA. Patients at least 18 years of age, actively engaged in care at the VHA (defined as ≥ 2 outpatient visits or ≥ 1 inpatient admission in the year prior to cohort entry) with incident LTOT between 2010 and 2017 were included. Incident LTOT was defined as 90 consecutive days of opioid receipt, allowing for a 30-day gap. Results: The final analytic sample included 285,772 patients, which were majority male (93 %) and white (77 %), with a mean age of 64.04 (14.09) years. At time of LTOT initiation, 19 % (53,505) of the sample had a SUD diagnosis. Patients with SUD were slightly younger in age, on average (p < 0.001). While most patients in the sample were white, there were statistically significant differences by race and SUD status (p < 0.001). Discussion: This retrospective cohort study examined LTOT trajectory membership in VHA patients with and without SUD. Patients with SUD had significantly higher odds of being in any other higher-dose trajectory compared to the low-dose/stable trajectory. This study’s finding that patients with SUD are at greater odds of experiencing a higher-dose LTOT trajectory reflects findings from previous research examining longitudinal opioid prescribing to patients with SUD. Rentsch and colleagues similarly found Conclusions: Overall, we found patients with SUD had higher odds of membership in riskier LTOT trajectories. These analyses, which used a large national dataset, build upon previous research related to LTOT trajectories by highlighting the unique risks patients with SUD may face in receiving higher-dose trajectories compared to those without SUD. Veterans on LTOT with SUD may require interdisciplinary care to manage symptoms and improve opioid-related outcomes; current VA initiatives incorporating addiction

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