Dataset Information

Opioid Agonist Therapy During Hospitalization Within the Veterans Health Administration: a Pragmatic Retrospective Cohort Analysis.

ABSTRACT:

Background

Hospitalization of patients with opioid use disorder (OUD) is increasing, yet little is known about opioid agonist therapy (OAT: methadone and buprenorphine) administration during admission.

Objective

Describe and examine patient- and hospital-level characteristics associated with OAT receipt during hospitalization in the Veterans Health Administration (VHA).

Participants

A total of 12,407 unique patients, ≥ 18 years old, with an OUD-related ICD-10 diagnosis within 12 months prior to or during index hospitalization in fiscal year 2017 from 109 VHA hospitals in the continental U.S.

Main measure

OAT received during hospitalization.

Key results

Few admissions received OAT (n = 1914; 15%) and when provided it was most often for withdrawal management (n = 834; 7%). Among patients not on OAT prior to admission who survived hospitalization (n = 10,969), 2.0% (n = 203) were newly initiated on OAT with linkage to care after hospital discharge. Hospitals varied in the frequency of OAT delivery (range, 0 to 43% of qualified admissions). Patients with pre-admission OAT (adjusted odds ratio [AOR] = 15.30; 95% CI [13.2, 17.7]), acute OUD diagnosis (AOR = 2.3; 95% CI [1.99, 2.66]), and male gender (AOR 1.52; 95% CI [1.16, 2.01]) had increased odds of OAT receipt. Patients who received non-OAT opioids (AOR 0.53; 95% CI [0.46, 0.61]) or surgical procedures (AOR 0.75; 95% CI [0.57, 0.99]) had decreased odds of OAT receipt. Large-sized (AOR = 2.0; 95% CI [1.39, 3.00]) and medium-sized (AOR = 1.9; 95% CI [1.33, 2.70]) hospitals were more likely to provide OAT.

Conclusions

In a sample of VHA inpatient medical admissions, OAT delivery was infrequent, varied across the health system, and was associated with specific patient and hospital characteristics. Policy and educational interventions should promote hospital-based OAT delivery.

SUBMITTER: Priest KC

PROVIDER: S-EPMC7403377 | biostudies-literature |

REPOSITORIES: biostudies-literature

ACCESS DATA

Similar Datasets

Project description:BackgroundPrior opioid discontinuation studies have focused on one of two characteristics of opioid prescribing, its duration (long term vs not) or dosage (high vs low). Questions remain about the experience of patients with high-dose, long-term opioid therapy (HLOT) prescriptions who are likely to be at the highest risk for adverse events.ObjectiveWe address the following questions among the Veterans Health Administration (VHA) patients receiving HLOT: 1), How has the prevalence of discontinuation of opioids changed over time? 2), How do patient characteristics vary between those who do and do not discontinue? And 3), how does the prevalence of discontinuation vary geographically?DesignA retrospective observational study of VHA patients with HLOT between fiscal year (FY) 2014 and FY2018.ParticipantsWe identified 1,281,330 patients from VHA outpatient opioid prescription data with at least a 1-day opioid supply between FY2014 and FY2018. We identified and excluded those receiving palliative care or diagnosed with metastatic cancer.Main measuresFor a given patient and month, a patient having a 3-month moving average of ≥ 90 daily morphine milligram equivalent (MME) was defined as having HLOT. Similarly, we used a three-month average MME of zero as discontinuation.Key resultsThe prevalence of discontinuation among patients with HLOT increased from 6.3% in FY2014 to 7.8% in FY2018. Across the years, patients who discontinued were younger, less likely to be married, and more likely to have comorbidities related to substance use disorders compared with patients who continued to receive HLOT. Incidence of discontinuation among those with HLOT increased in more than half (64%) of the 129 VHA medical centers.ConclusionPrevalence of patients receiving HLOT in the VHA decreased as the incidence of discontinuation increased. Further research is needed to understand the process by which patients are discontinued and to assess the relationship between discontinuation and health outcomes.

Project description:IntroductionThe Veterans Health Administration (VHA) has taken a multifaceted approach to addressing opioid safety and promoting system-wide opioid stewardship.AimTo provide a comprehensive evaluation of current opioid prescribing practices and implementation of risk mitigation strategies in VHA.SettingVHA is the largest integrated health care system in the United States.Program descriptionVHA prescribing data in conjunction with implementation of opioid risk mitigation strategies are routinely tracked and reviewed by VHA's Pharmacy Benefits Management Services (including Academic Detailing Service) and the Pain Management Program Office. Additional data are derived from the Partnered Evidence-Based Policy Resource Center (PEPReC) and from a 2019 survey of interdisciplinary pain management teams at VHA facilities. Prescribing data are reported quarterly until first quarter fiscal year 2020 (Q1FY2020), ending December 31, 2019.Program evaluationVHA opioid dispensing peaked in 2012 with 679,376 Veterans receiving an opioid prescription, and when including tramadol, in 2013 with 869,956 Veterans. Since 2012, the number of Veterans dispensed an opioid decreased 56% and co-prescribed opioid/benzodiazepine decreased 83%. Veterans with high-dose opioids (≥ 100 mg morphine equivalent daily dose) decreased 77%. In Q1FY2020, among Veterans on long-term opioid therapy (LTOT), 91.1% had written informed consent, 90.8% had a urine drug screen, and 89.0% had a prescription drug monitoring program query. Naloxone was issued to 217,469 Veterans and resulted in > 1,000 documented overdose reversals. In 2019, interdisciplinary pain management teams were fully designated at 68%, partially designated at 28%, and not available at 4% of 140 VA parent facilities. Fifty percent of Veterans on opioids at very high risk for overdose/suicide received interdisciplinary team reviews.ImplicationsVHA clinicians have greatly reduced their volume of opioid prescribing for pain management and expanded implementation of opioid risk mitigation strategies.ImpactsVHA's integrated health care system provides a model for opioid stewardship and interdisciplinary pain care.

Project description:ObjectivePatients with rheumatoid arthritis (RA) often receive opioid analgesics for pain management. We examined the association between mental health conditions and the risk of chronic opioid therapy.MethodsA retrospective cohort of veterans with RA initiating opioid use was assembled using Veterans Health Administration databases (2001-2012). Mental health conditions included anxiety (N = 1108, 12.9%), depression (N = 1912, 22.2%), bipolar disease (N = 131, 1.5%), and post-traumatic stress disorder (N = 768, 8.9%) and were identified by ICD coded diagnoses and use of specific medications. Cohort members were followed from opioid initiation through chronic opioid therapy, defined as the continuous availability of opioids for at least 90 days. Multivariable Cox proportional hazard regression models assessed the association between mental health conditions and chronic opioid therapy accounting for relevant covariates. Subgroup analyses examined whether the strength of the observed association varied by the duration of the initial opioid prescription.ResultsWe identified 14,767 patients with RA with 22,452 episodes of opioid use initiation. Mental health conditions were identified in 8607 (38.3%) patients. Compared with patients without mental health conditions, patients with mental health conditions have a higher risk of developing chronic opioid therapy (469.3 vs 378.1 per 1000 person-years, adjusted hazard ratio [aHR] 1.18, 95% CI 1.09, 1.29). The increased risk was highest for those with a history of opioid use disorder (aHR 1.94, 95% CI 1.09, 3.46) and also elevated for those with other substance use disorders (aHR 1.35, 95% CI 1.05, 1.73). Duration of the initial opioid prescription was independently associated with chronic opioid therapy, regardless of the estimated opioid daily dose.ConclusionsHistory of mental health conditions and duration of the initial opioid prescription were associated with an increased risk of chronic opioid therapy among patients with RA.Key Points• Approximately a third of patients with RA are exposed to opioid analgesics.• Patients with RA and history of mental health disease, especially substance use disorders, who initiate opioid use have an increased risk of chronic opioid therapy.• This study provides insight in an underrepresented population of mainly male patients with RA.

Project description:BackgroundEmergency departments increasingly use nonopioid analgesics to manage acute pain and minimize opioid-related harms. Urgent care centers are expanding to lower costs and provide efficient access to healthcare. General internists increasingly work in these acute care settings. Much is known about opioid prescribing in the primary care, inpatient, and emergency department setting. Little is known about opioid prescribing in the urgent care setting and associated outcomes.ObjectivesTo assess the association between in-clinic opioid administration and opioid receipt at clinic discharge and on progression to chronic opioid use among urgent care patients.DesignRetrospective cohort study.ParticipantsPatients, 20 years or older and not on opioid medications, who presented for care to an urgent care clinic within a safety-net healthcare system from June 1, 2016, to April 30, 2019.Main measuresWe examined the association between the in-clinic administration of oral or intravenous opioids and opioid receipt at clinic discharge. We also examined the association between in-clinic opioid administration and progression to chronic opioid use after six months.Key resultsThe study sample included 34,978 patients, of which 13.8% (n = 4842) received in-clinic opioids and 86.2% (n = 30,136) did not receive in-clinic opioids. After adjusting for age, gender, race/ethnicity, insurance, and pain diagnosis, patients who received in-clinic opioids were more likely to receive opioids at discharge compared to patients who did not receive in-clinic opioids (aOR = 12.30, 95% CI 11.44-13.23). Among a selected cohort of patients, in-clinic opioid administration was associated with progression to chronic opioid use (aOR = 2.12, 95% CI 1.66-2.71).ConclusionsIn-clinic opioid administration was strongly associated with opioid receipt at discharge and progression to chronic opioid use. Increased use of nonopioid analgesics in urgent care could likely reduce this association and limit opioids available for diversion, overdose, and death.

Project description:OBJECTIVE:To compare the risk of mortality among people with opioid use disorder on and off opioid agonist treatment (OAT) in a setting with a high prevalence of illicitly manufactured fentanyl and other potent synthetic opioids in the illicit drug supply. DESIGN:Population based retrospective cohort study. SETTING:Individual level linkage of five health administrative datasets capturing drug dispensations, hospital admissions, physician billing records, ambulatory care reports, and deaths in British Columbia, Canada. PARTICIPANTS:55?347 people with opioid use disorder who received OAT between 1 January 1996 and 30 September 2018. MAIN OUTCOME MEASURES:All cause and cause specific crude mortality rates (per 1000 person years) to determine absolute risk of mortality and all cause age and sex standardised mortality ratios to determine relative risk of mortality compared with the general population. Mortality risk was calculated according to treatment status (on OAT, off OAT), time since starting and stopping treatment (1, 2, 3-4, 5-12, >12 weeks), and medication type (methadone, buprenorphine/naloxone). Adjusted risk ratios compared the relative risk of mortality on and off OAT over time as fentanyl became more prevalent in the illicit drug supply. RESULTS:7030 (12.7%) of 55?347 OAT recipients died during follow-up. The all cause standardised mortality ratio was substantially lower on OAT (4.6, 95% confidence interval 4.4 to 4.8) than off OAT (9.7, 9.5 to 10.0). In a period of increasing prevalence of fentanyl, the relative risk of mortality off OAT was 2.1 (95% confidence interval 1.8 to 2.4) times higher than on OAT before the introduction of fentanyl, increasing to 3.4 (2.8 to 4.3) at the end of the study period (65% increase in relative risk). CONCLUSIONS:Retention on OAT is associated with substantial reductions in the risk of mortality for people with opioid use disorder. The protective effect of OAT on mortality increased as fentanyl and other synthetic opioids became common in the illicit drug supply, whereas the risk of mortality remained high off OAT. As fentanyl becomes more widespread globally, these findings highlight the importance of interventions that improve retention on opioid agonist treatment and prevent recipients from stopping treatment.

Project description:ObjectivesTo examine the rates and predictors of long-term opioid therapy in older cancer survivors.DesignRetrospective cohort study.SettingTexas, United States.ParticipantsCancer survivors (5 years or more postcancer diagnosis) diagnosed from 1995 to 2008 and who were also Medicare Parts A, B, and D beneficiaries.MeasurementsWe used Medicare Part D event data to calculate the proportion of cancer survivors with a prolonged opioid prescription (90-day or more supply of opioids/year). Adjusted odds ratios were calculated to identify predictors of prolonged opioid prescribing. All analyses were repeated with a subcohort of opioid-naïve cancer survivors.ResultsThe rate of prolonged opioid therapy for cancer patients diagnosed in 2008 was 7.1% prior to cancer diagnosis; it rose to 9.8% within a year of cancer treatments, and to 13.3% at 5 years postdiagnosis. The rate at the sixth year varied by cancer sites: 19.4% in lung cancer and 9.6% in prostate cancer. Among opioid-naïve survivors, the rate increased from 1.4% to 7.1%, from 5 to 18 years postcancer diagnosis. Cancer survivors diagnosed in 2004 to 2008 had higher rates of opioid prescribing compared to those diagnosed in 1995 to 1998 and 1999 to 2003. Years since diagnosis, a later year of diagnosis, female sex, urban location, lung cancer diagnosis, disability as reason for Medicare entitlement, Medicaid eligibility, one or more comorbidity, and history of depression or drug abuse were predictors of prolonged opioid therapy. Among opioid-naïve cancer survivors, diagnosis in 2004 to 2008 was the strongest predictor, while a history of drug abuse was the strongest predictor for all the survivors.ConclusionThe rates of prolonged opioid prescribing for older cancer survivors remained high at 5 or more years after cancer diagnosis. Our findings have potential to inform the development of clinical guidelines and public policy to ensure safer and more effective pain treatment in older cancer survivors. J Am Geriatr Soc 67:945-952, 2019.