The use of chronic opioid therapy (COT) has increased dramatically in recent decades. More than 500,000 Veterans are treated with opioid pain medications in spite of inadequate evidence of long-term benefit and growing evidence of harm. Overdose deaths due to opioid medications are now the leading cause of adult injury death in the United States, surpassing motor vehicle accidents. The risk of overdose increases in a dose-dependent manner. It is therefore possible that opioid dose reduction, or opioid tapering, may prevent opioid-related adverse events without negatively impact pain or quality of life. To this end, the Opioid Safety Initiative promotes opioid dose reduction, or opioid tapering, in several high-risk scenarios and instructs VHA networks to establish ?safe and effective tapering programs?. However, several important evidence gaps must first be addressed. First, Veterans? perspectives on opioid tapering are not adequately understood. In our qualitative work, patients have described both barriers and facilitators of opioid tapering. Second, evidence- based, effective protocols to guide tapering are lacking, especially for the majority of patients who are prescribed COT in primary care settings. Third, patient outcomes in opioid tapering are not well characterized. Opioid tapering may both reduce risk and improve quality of life. As one patient in our qualitative work noted, ?I got my life back.? Alternatively, opioid tapering may adversely impact pain, function and substance use. This proposal addresses these research gaps by adapting a collaborative care intervention to provide Veteran- centered, Veteran-driven opioid tapering support in VA primary care Aim 1: Describe the prevalence and correlates of Veterans? desire to taper COT . We will measure patient- reported desire to taper COT and examine its association with patient engagement and other patient and medication characteristics.
Aim 2 : Adapt a collaborative care intervention to support opioid tapering in VA primary care. Building on an existing model, we will develop a team-based approach to deliver coordinated, longitudinal support of opioid tapering. The collaborative care team will use Motivational Interviewing to guide Veteran-centered goal setting to support behavior change. We will use the Nominal Group Technique to achieve stakeholder consensus.
Aim 3 : Conduct a single arm pilot feasibility study to support opioid tapering in a VA primary care setting. We will measure the intervention?s feasibility and acceptability and collect pilot data on patient-reported outcomes. This work is critically important to Veterans and VA healthcare systems nationally. It is well-aligned with the VA?s National Pain Management Strategy with its emphasis on primary care-based programs to promote Veteran-centered pain care. Four accomplished investigators will mentor the proposed research and the applicant?s development into an independent VA investigator. Dr. Cari Levy is the primary mentor. She is a palliative care expert, the Associate Director of the Denver-Seattle COIN and a productive investigator with a track record of VA funding. Dr. Erin Krebs is a co-mentor, primary care physician, and a leading VA pain researcher. Dr. Lisa Brenner is a co-mentor, Director of the VISN 19 Mental Illness Research, Education and Clinical Center and an expert in behavior change intervention development. Dr. Michael Ho is a co-mentor, Director of the Denver-Seattle COIN and an expert in pragmatic clinical trial design and implementation. Career development activities will build the applicant?s expertise in 1) patient-reported outcome measurement; 2) behavior change intervention development; 3) pragmatic clinical trial design. This will be facilitated by mentorship, coursework, and seminars to leverage resources within the Denver-Seattle COIN, the University of Colorado and the VA?s national pain research community. The mentorship, training, and protected time afforded by this award will ensure the applicant?s development as an independent investigator and leader in the development and implementation of Veteran-centered, Veteran-driven, effective pain care.
More than 500,000 Veterans are prescribed opioid pain medications long-term. There is inadequate evidence supporting long-term use and growing evidence of harm caused by opioid medications, including overdose death. Risk of overdose death is highest on high-dose opioid medications. Decreasing or discontinuing opioid medications may prevent overdose but may also negatively affect pain and quality of life. Our work will evaluate dose reduction or discontinuation of long-term opioid medications. We will interview Veterans taking opioid medications to describe perspectives on stopping these medications. We will work with Veterans and healthcare providers to develop and pilot a primary care-based program to support Veterans who wish to stop taking opioid medications. This work addresses an important and timely topic as opioid discontinuation is a goal of current VA initiatives on opioid safety. Our Veteran-centered, primary care-based approach is consistent with the VA?s National Pain Management Strategy and its Stepped Care Model of pain care.
