Sex differences in the medical care of VA patients with chronic non-cancer pain.

OBJECTIVE: Despite a growing number of women seeking medical care in the veterans affairs (VA) system, little is known about the characteristics of their chronic pain or the pain care they receive. This study sought to determine if sex differences are present in the medical care veterans received for chronic pain. DESIGN: Retrospective cohort study using VA administrative data. SUBJECTS: The subjects were 17,583 veteran patients with moderate to severe chronic non-cancer pain treated in the Pacific Northwest during 2008. METHODS: Multivariate logistic regression assessed for sex differences in primary care utilization, prescription of chronic opioid therapy, visits to emergency departments for a pain-related diagnosis, and physical therapy referral. RESULTS: Compared with male veterans, female veterans were more often diagnosed with two or more pain conditions, and had more of the following pain-related diagnoses: fibromyalgia, low back pain, inflammatory bowel disease, migraine headache, neck or joint pain, and arthritis. After adjustment for demographic characteristics, pain diagnoses, mental health diagnoses, substance use disorders, and medical comorbidity, women had lower odds of being prescribed chronic opioid therapy (adjusted OR [AOR] 0.67, 95% CI 0.58-0.78), greater odds of visiting an emergency department for a pain-related complaint (AOR 1.40, 95% CI 1.18-1.65), and greater odds of receiving physical therapy (AOR 1.19, 95% CI 1.05-1.33). Primary care utilization was not significantly different between sexes. CONCLUSIONS: Sex differences are present in the care female veterans receive for chronic pain. Further research is necessary to understand the etiology of the observed differences and their associations with clinical outcomes.

Adherence to clinical guidelines for opioid therapy for chronic pain in patients with substance use disorder.

BACKGROUND: Patients with chronic non-cancer pain (CNCP) have high rates of substance use disorders (SUD). SUD complicates pain treatment and may lead to worse outcomes. However, little information is available describing adherence to opioid treatment guidelines for CNCP generally, or guideline adherence for patients with comorbid SUD. OBJECTIVE: Examine adherence to clinical guidelines for opioid therapy over 12 months, comparing patients with SUD diagnoses made during the prior year to patients without SUD. DESIGN: Cohort study. PARTICIPANTS: Administrative data were collected from veterans with CNCP receiving treatment within a Veterans Affairs regional healthcare network who were prescribed chronic opioid therapy in 2008 (n = 5814). KEY RESULTS: Twenty percent of CNCP patients prescribed chronic opioid therapy had a prior-year diagnosis of SUD. Patients with SUD were more likely to have pain diagnoses and psychiatric comorbidities. In adjusted analyses, patients with SUD were more likely than those without SUD to have had a mental health appointment (29.7% versus 17.2%, OR = 1.49, 95% CI = 1.26-1.77) and a urine drug screen (UDS) (47.0% versus 18.2%, OR = 3.53, 95% CI = 3.06-4.06) over 12 months. There were no significant differences between groups on receiving more intensive treatment in primary care (63.4% versus 61.0%), long-acting opioids (26.9% versus 26.0%), prescriptions for antidepressants (88.2% versus 85.8%, among patients with depression), or participating in physical therapy (30.6% versus 28.6%). Only 35% of patients with SUD received substance abuse treatment. CONCLUSIONS: CNCP patients with SUD were more likely to have mental health appointments and receive UDS monitoring, but not more likely to participate in other aspects of pain care compared to those without SUD. Given data suggesting patients with comorbid SUD may need more intensive treatment to achieve improvements in pain-related function, SUD patients may be at high risk for poor outcomes.

Patterns and correlates of prescription opioid use in OEF/OIF veterans with chronic noncancer pain.

OBJECTIVES: Little is known about the treatment Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans receive for chronic noncancer pain (CNCP). We sought to describe the prevalence of prescription opioid use, types, and doses of opioids received and to identify correlates of receiving prescription opioids for CNCP among OEF/OIF veterans. DESIGN: Retrospective review of Veterans Affairs (VA) administrative data. SETTING: Ambulatory clinics within a VA regional health care network. PATIENTS: OEF/OIF veterans who had at least three elevated pain screening scores within a 12-month period in 2008. Within this group, those prescribed opioids (N = 485) over the next 12 months were compared with those not prescribed opioids (N = 277). In addition, patients receiving opioids short term (<90 days, N = 284) were compared with patients receiving them long term (≥90 consecutive days, N = 201). RESULTS: Of 762 OEF/OIF veterans with CNCP, 64% were prescribed at least one opioid medication over the 12 months following their index dates. Of those prescribed an opioid, 59% were prescribed opioids short term and 41% were prescribed opioids long term. The average morphine-equivalent opioid dose for short-term users was 23.7 mg (standard deviation [SD] = 20.5) compared with 40.8 mg (SD = 36.1) for long-term users (P < 0.001). Fifty-one percent of long-term opioid users were prescribed short-acting opioids only, and one-third were also prescribed sedative hypnotics. In adjusted analyses, diagnoses of low back pain, migraine headache, posttraumatic stress disorder, and nicotine use disorder were associated with an increased likelihood of receiving an opioid prescription. CONCLUSION: Prescription opioid use is common among OEF/OIF veterans with CNCP and is associated with several pain diagnoses and medical conditions.

VA healthcare costs of a collaborative intervention for chronic pain in primary care.

BACKGROUND: Chronic pain is costly to individuals and the healthcare system, and is often undertreated. Collaborative care models show promise for improving treatment of patients with chronic pain. The objectives of this article are to report the incremental benefit and incremental health services costs of a collaborative intervention for chronic pain from a veterans affairs (VA) healthcare perspective. METHODS: Data on VA treatment costs incurred by participants were obtained from the VA's Decision Support System for all utilization except certain intervention activities which were tracked in a separate database. Outcome data were from a cluster-randomized trial of a collaborative intervention for chronic pain among 401 primary care patients at a VA medical center. Intervention group participants received assessments and care management; stepped-care components were offered to patients requiring more specialized care. The main outcome measure was pain disability-free days (PDFDs), calculated from Roland-Morris Disability Questionnaire scores. RESULTS: Participants in the intervention group experienced an average of 16 additional PDFDs over the 12-month follow-up window as compared with usual care participants; this came at an adjusted incremental cost of $364 per PDFD for a typical participant. Important predictors of costs were baseline medical comorbidities, depression severity, and prior year's treatment costs. CONCLUSIONS: This collaborative intervention resulted in more pain disability-free days and was more expensive than usual care. Further research is necessary to identify if the intervention is more cost-effective for some patient subgroups and to learn whether pain improvements and higher costs persist after the intervention has ended.

Comparison of health service use among veterans with methamphetamine versus alcohol use disorders.

OBJECTIVES: Methamphetamine use disorders (MUD) are associated with severe health effects and psychiatric comorbidities, but little is known about the health care utilization of patients with MUD. The goal of this study was to describe health service use among veterans with MUD relative to a group of veterans with an alcohol use disorder (AUD). METHODS: Using Veterans Affairs (VA) administrative data, we identified 718 patients who were diagnosed with MUD and had confirmatory drug testing. Data were compared with those of 744 patients who had diagnoses of an AUD also with confirmatory testing. We examined diagnoses and medical utilization for 5 years after their index date. RESULTS: Patients with MUD and laboratory-confirmed recent use were younger and more likely to be diagnosed with a mood disorder, posttraumatic stress disorder, and a psychotic-spectrum disorder (all P values < 0.05). After statistical controls, patients with MUD were more likely to have an inpatient hospitalization (80% vs 70%, odds ratio [OR] = 1.8; 95% confidence interval [CI] = 1.4-2.3), discharge from an inpatient admission against medical advice (23.4% vs 8.3%, OR = 2.6, 95% CI = 1.9-3.7), receive care at 3 or more VA medical centers (13.1% vs 5.4%, OR = 2.3, 95% CI = 1.5-3.5), have a behavioral flag in the medical record (5.6% vs 1.1%, OR = 4.6, 95% CI = 2.1-10.6), and have more total missed appointments in the 5-year study period (M = 33.1 vs M = 23.5, P < 0.001). CONCLUSIONS: Among veterans with substance use disorders, those with MUD and laboratory-confirmed recent use have additional behavioral, health care utilization, and psychiatric characteristics that need to be considered in developing programs of care.

Complications after surgery for lumbar stenosis in a veteran population.

STUDY DESIGN: Secondary analysis of the prospectively collected Veterans Affairs National Surgical Quality Improvement Program database. OBJECTIVE: Determine rates of major medical complications, wound complications, and mortality among patients undergoing surgery for lumbar stenosis and examine risk factors for these complications. SUMMARY OF BACKGROUND DATA: Surgery for spinal stenosis is concentrated among older adults, in whom complications are more frequent than among middle-aged patients. Many studies have focused on infections or device complications, but fewer studies have focused on major cardiopulmonary complications, using prospectively collected data. METHODS: We identified patients who underwent surgery for a primary diagnosis of lumbar stenosis between 1998 and 2009 from the Veterans Affairs National Surgical Quality Improvement Program database. We created a composite of major medical complications, including acute myocardial infarction, stroke, pulmonary embolism, pneumonia, systemic sepsis, coma, and cardiac arrest. RESULTS: Among 12,154 eligible patients, major medical complications occurred in 2.1%, wound complications in 3.2%, and 90-day mortality in 0.6%. Major medical complications, but not wound complications, were strongly associated with age. American Society of Anesthesiologists (ASA) class was a strong predictor of complications. Insulin use, long-term corticosteroid use, and preoperative functional status were also significant predictors. Fusion procedures were associated with higher complication rates than with decompression alone. In logistic regressions, ASA class and age were the strongest predictors of major medical complications (odds ratio for ASA class 4 vs. class 1 or 2: 2.97; 95% confidence interval, 1.68-5.25; P = 0.0002). After adjustment for comorbidity, age, and functional status, fusion procedures remained associated with higher medical complication rates than were decompressions alone (odds ratio = 2.85; 95% confidence interval, 2.14-3.78; P < 0.0001). CONCLUSION: ASA class, age, type of surgery, insulin or corticosteroid use, and functional status were independent risk factors for major medical complications. These factors may help in selecting patients and planning procedures, improving patient safety.

Correlates of prescription opioid initiation and long-term opioid use in veterans with persistent pain.

OBJECTIVES: Little is known about how opioid prescriptions for chronic pain are initiated. We sought to describe patterns of prescription opioid initiation, identify correlates of opioid initiation, and examine correlates of receipt of chronic opioid therapy (COT) among veterans with persistent noncancer pain. METHODS: Using Veterans Affairs administrative data, we identified 5961 veterans from the Pacific Northwest with persistent elevated pain intensity scores who had not been prescribed opioids in the prior 12 months. We compared veterans not prescribed opioids over the subsequent 12 months with those prescribed any opioid and to those prescribed COT (>90 consecutive days). RESULTS: During the study year, 35% of the sample received an opioid prescription and 5% received COT. Most first opioid prescriptions were written by primary care clinicians. Veterans prescribed COT were younger, had greater pain intensity, and high rates of psychiatric and substance use disorders compared with veterans in the other 2 groups. Among patients receiving COT, 29% were prescribed long-acting opioids, 37% received 1 or more urine drug screens, and 24% were prescribed benzodiazepines. Adjusting for age, sex, and baseline pain intensity, major depression [odds ratio 1.24 (1.10-1.39); 1.48 (1.14-1.93)], and nicotine dependence [1.34 (1.17-1.53); 2.02 (1.53-2.67)] were associated with receiving any opioid prescription and with COT, respectively. DISCUSSION: Opioid initiations are common among veterans with persistent pain, but most veterans are not prescribed opioids long-term. Psychiatric disorders and substance use disorders are associated with receiving COT. Many Veterans receiving COT are concurrently prescribed benzodiazepines and many do not receive urine drug screening; additional study regarding practices that optimize safety of COT in this population is indicated.

The effects of age on initiation of mental health treatment after positive PTSD screens among Veterans Affairs primary care patients.

OBJECTIVE: The objective was to examine differences by age in mental health treatment initiation in Veterans Health Administration (VA) primary care patients after positive posttraumatic stress disorder (PTSD) screens. METHODS: This was a retrospective cohort study of 71,039 veterans who were administered PTSD screens during primary care encounters in 2007 at four Pacific Northwest VA medical center sites and who had no specialty mental health clinic visits or PTSD diagnoses recorded in the year before screening. Main outcome measures were attendance of any specialty mental health clinic visits or receipt of any antidepressant medication in the year after a positive PTSD screen. RESULTS: Older veterans, compared with veterans less than 30 years old, were less likely to attend any specialty mental health visits after positive PTSD screens [adjusted odds ratios (ORs) ranged from .57 to .12, all P<.001], and veterans 75 years and older were less likely to receive any antidepressant medication (adjusted OR=.56, P<.001). CONCLUSIONS: Initiation of mental health treatment among veterans who screen positive for PTSD varies significantly by age. Further research should examine whether this is due to differences in base rates of PTSD, treatment preferences, provider responses to screens or other age-related barriers to mental health treatment.

Intensive care unit outcomes among patients with lung cancer in the surveillance, epidemiology, and end results-medicare registry.

PURPOSE: Lung cancer is the leading cause of cancer-related mortality. Intensive care unit (ICU) use among patients with cancer is increasing, but data regarding ICU outcomes for patients with lung cancer are limited. PATIENTS AND METHODS: We used the Surveillance, Epidemiology, and End Results (SEER) -Medicare registry (1992 to 2007) to conduct a retrospective cohort study of patients with lung cancer who were admitted to an ICU for reasons other than surgical resection of their tumor. We used logistic and Cox regression to evaluate associations of patient characteristics and hospital mortality and 6-month mortality, respectively. We calculated adjusted associations for mechanical ventilation receipt with hospital and 6-month mortality. RESULTS: Of the 49,373 patients with lung cancer admitted to an ICU for reasons other than surgical resection, 76% of patients survived the hospitalization, and 35% of patients were alive 6 months after discharge. Receipt of mechanical ventilation was associated with increased hospital mortality (adjusted odds ratio, 6.95; 95% CI, 6.89 to 7.01; P < .001), and only 15% of these patients were alive 6 months after discharge. Of all ICU patients with lung cancer, the percentage of patients who survived 6 months from discharge was 36% for patients diagnosed in 1992 and 32% for patients diagnosed in 2005, whereas it was 16% and 11% for patients who received mechanical ventilation, respectively. CONCLUSION: Most patients with lung cancer enrolled in Medicare who are admitted to an ICU die within 6 months of admission. To improve patient-centered care, these results should guide shared decision making between patients with lung cancer and their clinicians before an ICU admission.

Correlates of utilization of PTSD specialty treatment among recently diagnosed veterans at the VA.

OBJECTIVES: This study described utilization of specialty treatment for posttraumatic stress disorder (PTSD) at U.S. Department of Veterans Affairs (VA) facilities among veterans of Operation Enduring Freedom (OEF), in Afghanistan, or of Operation Iraqi Freedom (OIF), in Iraq, and non-OEF-OIF veterans recently diagnosed as having PTSD. It also identified predictors of receiving minimally adequate specialty treatment, defined as attending at least nine clinic visits within 365 days of screening positive for PTSD. METHODS: VA administrative data were obtained for 869 veterans who screened positive for PTSD between November 7, 2006, and September 30, 2008, received a diagnosis of PTSD, and visited a PTSD specialty clinic operated by the VA in the Pacific Northwest at least once within a year of screening positive. RESULTS: A total of 286 (33%) of the 852 veterans for whom complete data were available received minimally adequate specialty treatment; OEF-OIF veterans were less likely than non-OEF-OIF veterans to receive minimally adequate specialty treatment (29% versus 36%, p=.021) and attended fewer mean±SD visits to a PTSD clinic (8.2±11.4 versus 9.9±13.5, p=.045). Predictors of receiving minimally adequate specialty treatment included attending a PTSD clinic visit within 30 days of a positive screen, living in an urban location, and having psychiatric comorbidities. CONCLUSIONS: Most veterans with new PTSD diagnoses who initiated VA PTSD specialty care did not receive minimally adequate specialty treatment. Future studies should examine factors that lead to premature discontinuation of PTSD treatment and to what extent specialty treatment for PTSD is necessary.

Clinical characteristics of veterans prescribed high doses of opioid medications for chronic non-cancer pain.

Little is known about patients prescribed high doses of opioids to treat chronic non-cancer pain, though these patients may be at higher risk for medication-related complications. We describe the prevalence of high-dose opioid use and associated demographic and clinical characteristics among veterans treated in a VA regional healthcare network. Veterans with chronic non-cancer pain prescribed high doses of opioids (≥ 180 mg/day morphine equivalent; n=478) for 90+ consecutive days were compared to two groups with chronic pain: Traditional-dose (5-179 mg/day; n=500) or no opioid (n=500). High-dose opioid use occurred in 2.4% of all chronic pain patients and in 8.2% of all chronic pain patients prescribed opioids long-term. The average dose in the high-dose group was 324.9 (SD=285.1)mg/day. The only significant demographic difference among groups was race (p=0.03) with black veterans less likely to receive high doses. High-dose patients were more likely to have four or more pain diagnoses and the highest rates of medical, psychiatric, and substance use disorders. After controlling for demographic factors and VA facility, neuropathy, low back pain, and nicotine dependence diagnoses were associated with increased likelihood of high-dose prescriptions. High-dose patients frequently did not receive care consistent with treatment guidelines: there was frequent use of short-acting opioids, urine drug screens were administered to only 25.7% of patients in the prior year, and 32.0% received concurrent benzodiazepine prescriptions, which may increase risk for overdose and death. Further study is needed to identify better predictors of high-dose usage, as well as the efficacy and safety of such dosing.