Association of Care Practices with Suicide Attempts in US Veterans Prescribed Opioid Medications for Chronic Pain Management.

IMPORTANCE: Patients receiving opioid therapy are at elevated risk of attempting suicide. Guidelines recommend practices to mitigate risk, but it is not known whether these are effective. OBJECTIVE: Our aim was to examine associations between the receipt of guideline-recommended care for opioid therapy and risk of suicide attempt. DESIGN, SETTING, AND PARTICIPANTS: This was a retrospective analysis of administrative data for all Veteran patients prescribed any short-acting opioids on a chronic basis or any long-acting opioids from the Veterans Health Administration during fiscal year 2010. MAIN OUTCOMES AND MEASURES: Multivariate, mixed-effects logistic regression analyses were conducted to define the associations between the risk of suicide attempt and receipt of guideline-recommended care at the individual level and rates of use of recommended care at the facility level, while accounting for patient risk factors. RESULTS: At the individual level, having a mood disorder was highly associated with suicide attempts (odds ratios [ORs] = 3.5, 3.9; 95% confidence intervals [CIs] = 3.3-3.9, 3.3-4.6 for chronic short-acting and long-acting groups, respectively). At the facility level, patients on opioid therapy within the facilities ordering more drug screens were associated with decreased risk of suicide attempt (ORs = 0.2, 0.3; CIs = 0.1-0.3, 0.2-0.6 for chronic short-acting and long-acting groups, respectively). In addition, patients on long-acting opioid therapy within the facilities providing more follow-up after new prescriptions were associated with decreased risk of suicide attempt (OR = 0.2, CI = 0.0-0.7), and patients on long-acting opioid therapy within the facilities having higher sedative co-prescription rates were associated with increased risk of suicide attempt (OR = 20.3, CI = 1.1-382.2). CONCLUSIONS AND RELEVANCE: Encouraging facilities to make more consistent use of drug screening, provide follow-up within 4 weeks for patients initiating new opioid prescriptions, and avoid sedative co-prescription in combination with long-acting opioids may help prevent suicide attempts. Some clinicians may selectively employ guideline-recommended practices with at-risk patients.

Baseline Variation in Use of VA/DOD Clinical Practice Guideline Recommended Opioid Prescribing Practices Across VA Health Care Systems.

OBJECTIVES: The purpose of this study was to determine baseline adherence to key recommendations from the 2010 VA/DOD Clinical Practice Guideline for Opioid Therapy for Chronic Pain at Veterans Health Administration (VA) facilities. We hoped to understand practice patterns at the time of guideline release to guide quality improvement and implementation efforts. METHODS: Overall practice patterns were examined at each of the 140 VA Health Care Systems based on quality metrics developed to assess adherence to the VA/DOD Clinical Practice Guideline. RESULTS: Clinical practice varied widely across facilities on measures of use of urine drug screens, substance use disorder treatment for diagnosed substance use disorder patients, and use of rehabilitative treatments. Less variation was observed in measures of sedative coprescription and use of adjunctive pharmacotherapy. Use of guideline recommended practices was generally more frequent for patients prescribed long-acting opioid formulations and those with chronic use. Relative facility-level implementation was correlated across most measures. Overall implementation of guideline recommended practices was lower at less complex facilities and facilities in the Western United States. DISCUSSION: In 2010, guideline-recommended practices for opioid prescribing were variably used across VA health care systems. Efforts to disseminate practices used at high-performing sites, and increase consistency of use of recommended practices across patients and facilities should be considered to improve pain management and reduce adverse events.

Sex differences in chronic pain management practices for patients receiving opioids from the Veterans Health Administration.

BACKGROUND: Women experience chronic pain and use pain-related health care at higher rates than men. It is not known whether the pain-related health care female veterans receive is consistent with clinical practice guideline recommendations or whether receipt of this care differs between men and women. OBJECTIVE: The aim of this study was to identify whether sex differences in chronic pain management care exist for patients served by the Veterans Health Administration (VHA). DESIGN: Data on patient demographics, diagnostic criteria, and health care utilization were extracted from VHA administrative databases for fiscal year 2010 (FY10). PATIENTS: Patients in this study included all VHA patients (excluding metastatic cancer patients) who received more than 90 days of a short-acting opioid medication or a long-acting opioid medication prescription in FY10 study. MEASURES: Multilevel logistic regressions were conducted to identify sex differences in receipt of guideline-recommended chronic pain management. RESULTS: A total of 480,809 patients met inclusion criteria. Female patients were more likely to receive most measures of guideline-recommended care for chronic pain including mental health assessments, psychotherapy, rehabilitation therapy, and pharmacy reconciliation. However, women were more likely to receive concurrent sedative prescriptions, which is inconsistent with guideline recommendations. Most of the observed sex differences persisted after controlling for key demographic and diagnostic differences. CONCLUSIONS: Findings suggest that female VHA patients are more likely to receive an array of pain management practices than male patients, including both contraindicated and recommended polypharmacy. Quality improvement efforts to address underutilization of mental health and rehabilitative services for pain by male patients and polypharmacy in female patients should be considered.

Measurement of adherence to clinical practice guidelines for opioid therapy for chronic pain.

The safe and effective prescribing of opioid therapy for chronic pain has become a significant health care priority over the last several years. Substantial research has focused on patient-oriented interventions toward preventing problematic use, but provider and system level factors may be more amenable to quality improvement approaches. Here, we outline administrative data-based metrics that are intended to assess adherence to key practices outlined in the 2010 Department of Veterans Affairs/Department of Defense Clinical Practice Guideline for management of opioid therapy for chronic pain. In addition to the metrics, we discuss their development process, which was done in consultation with experts on chronic opioid therapy.