Prescription opioids, drugs once reserved for the treatment of end-of-life cancer pain, have recently become a mainstay in the treatment of chronic non-cancer pain (CNCP), a trend that is increasingly controversial. Limited data exist to support the safety and efficacy of chronic opioid therapy (i.e., long-term opioid use), and risk for misuse is elevated in patients with psychiatric illness and substance use disorders. Despite these concerns, prescriptions for CNCP continue to rise, as evidenced by the substantial growth in retail pharmacy sales in recent years: from 1997 to 2006, the number of opioid prescriptions dispensed in the U.S. increased by 48%, and the amount of medication dispensed per person rose by 368% (from 74 to 369 milligrams per capita, according to the U.S. Drug Enforcement Agency). Mirroring these trends has been a rise in unintentional overdose deaths and unprecedented levels of addiction to prescription drugs. These data underscore the need for clinician adherence to evidence-based opioid treatment guidelines, first introduced in 1997 to promote the safe and efficacious use of prescription opioids for CNCP management. The overall objective of this proposal is to describe clinician adherence to evidence-based opioid treatment guidelines and to examine the association between guideline adherence and patient safety, among HIV+ and HIV- patients. We hypothesize that clinicians are not delivering guideline concordant care, which is putting patients and the public at risk. To test this hypothesis, we will carryout three specific aims: 1) describe clinician adherence to guidelines for the provision of chronic opioid therapy;2) examine, using survival regression models, the longitudinal association between guideline adherence and patient deaths (all-cause, overdose, and violent);and 3) explore the moderating effects of psychiatric and substance use disorders on this relationship. To accomplish these aims, we will conduct a secondary analysis of data from the Veterans Aging Cohort Study (VACS): an observational, prospective study of HIV+ and HIV- veterans. With this data, we will have access to clinical, administrative, and pharmacy data on a vulnerable patient group for which CNCP, psychiatric illness, and substance use disorders are prevalent. This project has implications for clinician education and training, which federal agencies have identified as a top priority for addressing the country's fastest-growing drug problem, opioid abuse. This research is also aligned with NIDA's recent initiative to support clinical research to protect against opioid abuse and addiction. Finally, this work is consistent with NIDA's mission to address HIV, and co-occurring conditions, in the context of substance abuse.

Public Health Relevance

Prescription opioids now account for more overdose deaths than from heroin and cocaine combined, and, according to the Centers for Disease Control and Prevention, overdose deaths from prescription drug poisonings now rival those from motor vehicle accidents. Opioids are also implicated in a number of non-overdose deaths, such as those caused by falls and other accidents. In an effort to address persistent and growing questions surrounding the role played by clinicians in opioid-related deaths, we aim with this study to examine the impact of quality of opioid treatment on patient safety and public health.

National Institute of Health (NIH)
National Institute on Drug Abuse (NIDA)
Predoctoral Individual National Research Service Award (F31)
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Special Emphasis Panel (ZRG1-AARR-C (22))
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Kahana, Shoshana Y
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Yale University
Public Health & Prev Medicine
Schools of Medicine
New Haven
United States
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Gaither, Julie R; Goulet, Joseph L; Becker, William C et al. (2014) Guideline-concordant management of opioid therapy among human immunodeficiency virus (HIV)-infected and uninfected veterans. J Pain 15:1130-40