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Reasons for discontinuation of long-term opioid therapy in patients with and without substance use disorders

Lovejoy, Travis I.; Morasco, Benjamin J.; Demidenko, Michael I.; Meath, Thomas H.A.; Frank, Joseph W.; Dobscha, Steven K.

doi: 10.1097/j.pain.0000000000000796
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Abstract: Several factors may accelerate opioid discontinuation rates, including lack of information about the long-term effectiveness of opioids for chronic pain, heightened awareness about opioid-related adverse events, closer monitoring of patients for opioid-related aberrant behaviors, and greater restrictions around opioid prescribing. Rates of discontinuation may be most pronounced in patients deemed to be at “high risk.” The purpose of this study was to compare reasons for discontinuation of long-term opioid therapy (LTOT) between patients with and without substance use disorder (SUD) diagnoses receiving care within a major U.S. health care system. This retrospective cohort study assembled a cohort of Veterans Health Administration patients prescribed opioid therapy for at least 12 consecutive months who subsequently discontinued opioid therapy for at least 12 months. From this cohort, we randomly selected 300 patients with SUD diagnoses and propensity score–matched 300 patients without SUD diagnoses. A comprehensive manual review of patients' medical records ascertained reasons for LTOT discontinuation. Most patients (85%) were discontinued as a result of clinician, rather than patient, decisions. For patients whose clinicians initiated discontinuation, 75% were discontinued because of opioid-related aberrant behaviors. Relative to patients without SUD diagnoses, those with SUD diagnoses were more likely to discontinue LTOT because of aberrant behaviors (81% vs 68%), most notably abuse of alcohol or other substances. This is the first study to document reasons for discontinuation of LTOT in a sample of patients with and without SUD diagnoses. Treatments that concurrently address SUD and chronic pain are needed for this high-risk population.

Patients with substance use disorders were more likely than patients without substance use disorders to be discontinued from long-term opioid therapy due to aberrant behaviors.

aCenter to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA

bDepartment of Psychiatry, Oregon Health & Science University, Portland, OR, USA

cSchool of Public Health, Oregon Health & Science University, Portland, OR, USA

dCenter for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR, USA

eCenter of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Denver, CO, USA

fDivision of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA

Corresponding author. Address: Center to Improve Veteran Involvement in Care, VA Portland Health Care System, 3710 SW U.S. Veterans Hospital Rd, Mail Code: R&D 66, Portland, OR 97239, USA. Tel.: 503-220-8262 x57744; fax: 503-402-2952. E-mail address: travis.lovejoy@va.gov (T. I. Lovejoy).

Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.painjournalonline.com).

Received May 25, 2016

Received in revised form October 21, 2016

Accepted October 27, 2016

© 2017 International Association for the Study of Pain
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