Background: Chronic pain is an important public health problem and among the most prevalent and disabling of chronic diseases. After two decades of sustained prescribing increases, opioid analgesics are the most commonly prescribed medications for chronic pain; however, evidence for long-term opioid effectiveness is insufficient. Now, an emerging public health epidemic of opioid-related harms-especially abuse and overdose-has triggered a new era in opioid attitudes and policies, in which opioid prescribing trends are being actively reversed. The Veterans Health Administration (VHA) has been a national leader in pain management-in early initiatives to promote greater awareness of pain, in efforts to expand access to a stepped care model of pain treatment, and in responses to the emerging epidemic of serious opioid-related harms. Recent VHA opioid policies include mandatory written informed consent for long-term opioid therapy and system-wide opioid safety goals to increase use of opioid risk management tools and decrease high-risk prescribing (e.g., high-dose opioid therapy). Because these VHA mandates are being implemented in a larger context of markedly changed attitudes towards opioids and because they are modeled on prior policies that have effectively reduced opioid prescribing, they are anticipated to substantially reduce rates and intensity of opioid prescribing in VHA. If successful, VHA initiatives will reduce potentially hazardous and excessive prescribing of opioids and improve pain and quality of life (QOL) outcomes among Veterans with chronic pain. Objectives: The main objective is to understand patient-centered outcomes of opioid prescribing changes among Veterans treated with opioids for chronic pain. The project will survey a nationally-representative sample of VA primary care patients receiving long-term opioid therapy to collect longitudinal patient-reported pain outcomes data.
Specific aims are to examine, among patients receiving long-term opioid therapy, 1) the relationship between changes in opioid daily dose and changes in patient-reported pain and QOL outcomes; and 2) associations of patient, provider, and facility factors with changes in patient-reported pain and health- related QOL, primarily through their influence on opioid daily dose and use of non-pharmacological pain therapies. Methods: Existing data from VHA datasets will be used to identify VA patients prescribed long-term opioids (defined as = 6 consecutive months) for chronic pain. From this population, a nationally representative sample of 13,675 VA primary care patients receiving long-term opioid therapy will be identified using a multi-stage random sampling strategy. Patients included in the sample will be invited to participate in a longitudinal survey and complete brief questionnaires at three time points (baseline, 12 months, and 24 months). Following established methods for maximizing response to mailed surveys, eligible patients will be contacted multiple times by mail for each data collection time point, with a final telephone follow-up for non-responders. Questionnaires will assess pain-related function and health-related QOL as the primary outcomes and will assess pain characteristics, patient perception of treatment, and aspects of the patient-provider relationship as covariates. VHA administrative data will be used to assess patient use of non-pharmacological pain therapies and patient, provider, and facility covariates. Prospective patient-reported survey data will be merged with administrative data for analyses to address the specific aims.
Chronic pain is among the most prevalent and disabling of chronic diseases. Opioids are the most commonly prescribed medications for chronic pain, but are associated with important harms, including addiction and accidental overdose. Current VHA policies aim to reduce excessive prescribing of opioid medications and increase availability of effective non-opioid pain treatments. This study will survey a nationally-representative sample of Veterans who have been prescribed long-term opioid therapy for chronic pain to understand how changes in opioid prescribing may affect their pain and quality of life. Findings will contribute to identification of successful approaches and potential gaps in VHA efforts to achieve patient-centered pain management and opioid safety goals for Veterans with chronic pain. 1
