The association of opioid use duration and new depression episode among patients with and without insomnia

2020 ◽  
Vol 16 (5) ◽  
pp. 317-328
Author(s):  
Joanne Salas, MPH ◽  
Mary Beth Miller, PhD ◽  
Jeffrey F. Scherrer, PhD ◽  
Rachel Moore, MS ◽  
Christina S. McCrae, PhD ◽  
...  
Keyword(s):  
Propensity Scores ◽  
Opioid Analgesic ◽  
Opioid Therapy ◽  
Veterans Health ◽  
Health Administration ◽  
Opioid Use ◽  
Specific Effects ◽  
Cox Proportional Hazard Models ◽  
Opioid Users

Objective: Insomnia commonly co-occurs with depression, chronic pain, and opioid use. Both insomnia and chronic opioid analgesic use (OAU) are independent risk factors for a new depression episode (NDE). This study determined if the association between longer OAU duration and NDE was stronger in those with versus without insomnia.Design: Retrospective cohort.Setting: Veterans Health Administration electronic medical records (2000-2012).Participants: New opioid users in follow-up (2002-2012), free of depression for two years prior to follow-up, and aged 18-80 (n = 70,997).Methods: NDE was ≥ 2 ICD-9 codes in a 12-month period. Insomnia before OAU initiation was ≥1 ICD-9 code. Cox proportional hazard models stratified on insomnia assessed the relationship between initiating a 1-30, 31-90, or 90 day period of OAU and NDE while controlling for confounders using inverse probability of treatment-weighted propensity scores (PS).Results: Compared to 1-30 day OAU, 31-90 day was associated with NDE in those without (HR = 1.20; 95 percent CI: 1.12-1.28) but not with insomnia (HR = 1.06; 95 percent CI: 0.86-1.32). Results showed a stronger effect of chronic (90) OAU in those with insomnia (HR = 1.59; 95 percent CI: 1.27-1.98) compared to those without (HR = 1.31; 95 percent CI: 1.21-1.42). However, all stratum-specific effects were not significantly different (p = 0.136).Conclusions: Although stratum-specific risks were statistically similar, there was evidence for a trend that chronic OAU is a stronger risk factor for NDE in those with versus without insomnia. Providers are encouraged to monitor sleep impairment among patients on opioid therapy, as sleep may be associated with greater risk for NDE in patients with chronic OAU. 

Scaphotrapeziotrapezoid Arthrodesis: A 10-Year Follow-up Study of Complications in 58 Wrists

Hand ◽  
2020 ◽  
pp. 155894472096497
Author(s):  
Miranda J. Rogers ◽  
Chao-Chin Lu ◽  
Andrew R. Stephens ◽  
Brittany N. Garcia ◽  
Wei Chen ◽  
...  
Keyword(s):  
Risk Factors ◽  
Smoking History ◽  
Fixation Method ◽  
Veterans Health ◽  
Health Administration ◽  
Opioid Use ◽  
Factors Associated ◽  
Increased Risk ◽  
Stt Arthrodesis

Background: Scaphotrapeziotrapezoid (STT) arthrodesis is a procedure used for specific degenerative arthritis and instability patterns of the wrist. This study evaluates nonunion rate and risk factors for reoperation after STT arthrodesis in the Veterans Affairs Department patient population. The purpose of our study was to assess the long-term nonunion rate following STT arthrodesis and to identify factors associated with reoperation. Methods: The national Veterans Health Administration Corporate Data Warehouse and Current Procedural Terminology codes identified STT arthrodesis procedures from 1995 to 2016. Frequencies of total wrist arthrodesis (TWA) and secondary operations were determined. Univariate analyses provided odds ratios for risk factors associated with complications. Results: Fifty-eight STT arthrodeses were performed in 54 patients with a mean follow-up of 120 months. Kirschner wires (K-wires) were the most common fixation method (69%). Six wrists (10%) required secondary procedures: 5 TWAs and 1 revision STT arthrodesis. Four patients underwent additional procedures for nonunion (7%). Twenty-four patients required K-wire removal, 8 (14%) of these in the operating room, which were not included in regression analysis. Every increase in 1 year of age resulted in a 15% decrease in likelihood of reoperation (95% confidence interval: 0.77-0.93; P < .0001). Opioid use within 90 days before surgery ( P = 1.00), positive smoking history ( P = 1.00), race ( P = .30), comorbidity count ( P = .25), and body mass index ( P = .19) were not associated with increased risk of reoperation. Conclusions: At a mean follow-up of 10 years, patients undergoing STT arthrodesis have a 10% risk of reoperation, and this risk decreases with older patient age. There was a symptomatic nonunion rate of 7%, similar to prior published rates. Patient demographics, comorbidity, smoking history, and opioid use did not appear to increase risk of reoperation.

A Two-Year Prospective Multicenter Study of Opioid Therapy for Chronic Noncancer Pain: Prescription Trends and Predictors

Pain Medicine ◽  
2018 ◽  
Vol 20 (11) ◽  
pp. 2166-2178 ◽  
Author(s):  
Dalila R Veiga ◽  
Liliane Mendonça ◽  
Rute Sampaio ◽  
José M Castro-Lopes ◽  
Luís F Azevedo
Keyword(s):  
Chronic Pain ◽  
Clinical Outcomes ◽  
Opioid Therapy ◽  
Opioid Use ◽  
Opioid Prescription ◽  
Chronic Noncancer Pain ◽  
Noncancer Pain ◽  
Opioid Users

Abstract Objectives Opioid use in chronic pain has increased worldwide in recent years. The aims of this study were to describe the trends and patterns of opioid therapy over two years of follow-up in a cohort of chronic noncancer pain (CNCP) patients and to assess predictors of long-term opioid use and clinical outcomes. Methods A prospective cohort study with two years of follow-up was undertaken in four multidisciplinary chronic pain clinics. Demographic data, pain characteristics, and opioid prescriptions were recorded at baseline, three, six, 12, and 24 months. Results Six hundred seventy-four CNCP patients were recruited. The prevalence of opioid prescriptions at baseline was 59.6% (N = 402), and 13% (N = 86) were strong opioid prescriptions. At 24 months, opioid prescription prevalence was as high as 74.3% (N = 501), and strong opioid prescription was 31% (N = 207). Most opioid users (71%, N = 479) maintained their prescription during the two years of follow-up. Our opioid discontinuation was very low (1%, N = 5). Opioid users reported higher severity and interference pain scores, both at baseline and after two years of follow-up. Opioid use was independently associated with continuous pain, pain location in the lower limbs, and higher pain interference scores. Conclusions This study describes a pattern of increasing opioid prescription in chronic pain patients. Despite the limited improvement of clinical outcomes, most patients keep their long-term opioid prescriptions. Our results underscore the need for changes in clinical practice and further research into the effectiveness and safety of chronic opioid therapy for CNPC.

scholarly journals Fluctuations in barriers to medication treatment for opioid use disorder prescribing over the course of a one-year external facilitation intervention

2021 ◽  
Vol 16 (1) ◽  
Author(s):  
Allison M. Gustavson ◽  
Marie E. Kenny ◽  
Jennifer P. Wisdom ◽  
Hope A. Salameh ◽  
Princess E. Ackland ◽  
...  
Keyword(s):  
Implementation Strategies ◽  
Opioid Use Disorder ◽  
Veterans Health ◽  
Health Administration ◽  
Opioid Use ◽  
Medication Treatment ◽  
Conceptual Clarity ◽  
Parihs Framework ◽  
External Facilitation ◽  
Over Time

Abstract Background The Veterans Health Administration (VHA) is invested in expanding access to medication treatment for opioid use disorder (MOUD) to save lives. Access varies across VHA facilities and, thus, requires implementation strategies to promote system-wide adoption of MOUD. We conducted a 12-month study employing external facilitation that targeted MOUD treatment among low-adopting VHA facilities. In this study, we sought to evaluate the patterns of perceived barriers over 1 year of external implementation facilitation using the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework. Methods We randomly selected eight VHA facilities from the bottom quartile of the proportion of Veterans with an OUD diagnosis receiving MOUD (< 21%). The 1-year external implementation intervention included developmental evaluation to tailor the facilitation, an on-site visit, and monthly facilitation calls. Facilitators recorded detailed notes for each call on a structured template. Qualitative data was analyzed by coding and mapping barriers to the constructs in the i-PARIHS framework (Innovation, Recipients, Context). We identified emerging themes within each construct by month. Results Barriers related to the Innovation, such as provider perception of the need for MOUD in their setting, were minimal throughout the 12-month study. Barriers related to Recipients were predominant and fluctuated over time. Recipient barriers were common during the initial months when providers did not have the training and waivers necessary to prescribe MOUD. Once additional providers (Recipients) were trained and waivered to prescribe MOUD, Recipient barriers dropped and then resurfaced as the facilities worked to expand MOUD prescribing to other clinics. Context barriers, such as restrictions on which clinics could prescribe MOUD and fragmented communication across clinics regarding the management of patients receiving MOUD, emerged more prominently in the middle of the study. Conclusions VHA facilities participating in 12-month external facilitation interventions experienced fluctuations in barriers to MOUD prescribing with contextual barriers emerging after a facilitated reduction in recipient- level barriers. Adoption of MOUD prescribing in low-adopting VHA facilities requires continual reassessment, monitoring, and readjustment of implementation strategies over time to meet challenges. Although i-PARIHS was useful in categorizing most barriers, the lack of conceptual clarity was a concern for some constructs.

Sex Differences in Opioid Use Disorder Prevalence and Multimorbidity Nationally in the Veterans Health Administration

2021 ◽  
pp. 1-11
Author(s):  
MacKenzie R. Peltier ◽  
Mehmet Sofuoglu ◽  
Ismene L. Petrakis ◽  
Elina Stefanovics ◽  
Robert A. Rosenheck
Keyword(s):  
Sex Differences ◽  
Veterans Health Administration ◽  
Opioid Use Disorder ◽  
Veterans Health ◽  
Health Administration ◽  
Opioid Use

scholarly journals Associations between stopping prescriptions for opioids, length of opioid treatment, and overdose or suicide deaths in US veterans: observational evaluation

BMJ ◽  
2020 ◽  
pp. m283 ◽  
Author(s):  
Elizabeth M Oliva ◽  
Thomas Bowe ◽  
Ajay Manhapra ◽  
Stefan Kertesz ◽  
Jennifer M Hah ◽  
...  
Keyword(s):  
Opioid Analgesic ◽  
Veterans Health Administration ◽  
Fiscal Year ◽  
Veterans Health ◽  
Health Administration ◽  
Opioid Treatment ◽  
Risk Of Death ◽  
Length Of Treatment ◽  
Increased Risk ◽  
Stopping Treatment

Abstract Objective To examine the associations between stopping treatment with opioids, length of treatment, and death from overdose or suicide in the Veterans Health Administration. Design Observational evaluation. Setting Veterans Health Administration. Participants 1 394 102 patients in the Veterans Health Administration with an outpatient prescription for an opioid analgesic from fiscal year 2013 to the end of fiscal year 2014 (1 October 2012 to 30 September 2014). Main outcome measures A multivariable Cox non-proportional hazards regression model examined death from overdose or suicide, with the interaction of time varying opioid cessation by length of treatment (≤30, 31-90, 91-400, and >400 days) as the main covariates. Stopping treatment with opioids was measured as the time when a patient was estimated to have no prescription for opioids, up to the end of the next fiscal year (2014) or the patient’s death. Results 2887 deaths from overdose or suicide were found. The incidence of stopping opioid treatment was 57.4% (n = 799 668) overall, and based on length of opioid treatment was 32.0% (≤30 days), 8.7% (31-90 days), 22.7% (91-400 days), and 36.6% (>400 days). The interaction between stopping treatment with opioids and length of treatment was significant (P<0.001); stopping treatment was associated with an increased risk of death from overdose or suicide regardless of the length of treatment, with the risk increasing the longer patients were treated. Hazard ratios for patients who stopped opioid treatment (with reference values for all other covariates) were 1.67 (≤30 days), 2.80 (31-90 days), 3.95 (91-400 days), and 6.77 (>400 days). Descriptive life table data suggested that death rates for overdose or suicide increased immediately after starting or stopping treatment with opioids, with the incidence decreasing over about three to 12 months. Conclusions Patients were at greater risk of death from overdose or suicide after stopping opioid treatment, with an increase in the risk the longer patients had been treated before stopping. Descriptive data suggested that starting treatment with opioids was also a risk period. Strategies to mitigate the risk in these periods are not currently a focus of guidelines for long term use of opioids. The associations observed cannot be assumed to be causal; the context in which opioid prescriptions were started and stopped might contribute to risk and was not investigated. Safer prescribing of opioids should take a broader view on patient safety and mitigate the risk from the patient’s perspective. Factors to address are those that place patients at risk for overdose or suicide after beginning and stopping opioid treatment, especially in the first three months.

Perioperative Opioid Prescribing Patterns and Readmissions After Total Knee Arthroplasty in a National Cohort of Veterans Health Administration Patients

Pain Medicine ◽  
2019 ◽  
Vol 21 (3) ◽  
pp. 595-603 ◽  
Author(s):  
Seshadri C Mudumbai ◽  
Paul Chung ◽  
Nick Nguyen ◽  
Brooke Harris ◽  
J David Clark ◽  
...  
Keyword(s):  
Total Knee Arthroplasty ◽  
Hospital Readmission ◽  
Veterans Health Administration ◽  
Care Utilization ◽  
Veterans Health ◽  
Day Hospital ◽  
Health Administration ◽  
Opioid Use ◽  
Short Acting ◽  
Total Knee

Abstract Objective Among Veterans Health Administration (VHA) patients who undergo total knee arthroplasty (TKA) nationally, what are the underlying readmission rates and associations with perioperative opioid use, and are there associations with other factors such as preoperative health care utilization? Methods We retrospectively examined the records of 5,514 TKA patients (primary N = 4,955, 89.9%; revision N = 559, 10.1%) over one fiscal year (October 1, 2010–September 30, 2011) across VHA hospitals nationwide. Opioid use was classified into no opioids, tramadol only, short-acting only, or any long-acting. We measured readmission within 30 days and the number of days to readmission within 30 days. Extended Cox regression models were developed. Results The overall 30-day hospital readmission rate was 9.6% (N = 531; primary 9.5%, revision 11.1%). Both readmitted patients and the overall sample were similar on types of preoperative opioid use. Relative to patients without opioids, patients in the short-acting opioids only tier had the highest risk for 30-day hospital readmission (hazard ratio = 1.38, 95% confidence interval = 1.14–1.67). Preoperative opioid status was not associated with 30-day readmission. Other risk factors for 30-day readmission included older age (≥66 years), higher comorbidity and diagnosis-related group weights, greater preoperative health care utilization, an urban location, and use of preoperative anticonvulsants. Conclusions Given the current opioid epidemic, the routine prescribing of short-acting opioids after surgery should be carefully considered to avoid increasing risks of 30-day hospital readmissions and other negative outcomes, particularly in the context of other predisposing factors.

scholarly journals Mindfulness-Oriented Recovery Enhancement remediates anhedonia in chronic opioid use by enhancing neurophysiological responses during savoring of natural rewards

2021 ◽  
pp. 1-10
Author(s):  
Eric L. Garland ◽  
Spencer T. Fix ◽  
Justin P. Hudak ◽  
Edward M. Bernat ◽  
Yoshio Nakamura ◽  
...  
Keyword(s):  
Chronic Pain ◽  
Skin Conductance Level ◽  
Opioid Therapy ◽  
Opioid Use Disorder ◽  
Opioid Use ◽  
Natural Reward ◽  
Before And After ◽  
Natural Rewards ◽  
Chronic Opioid Use ◽  
Opioid Users

Abstract Background Neuropsychopharmacologic effects of long-term opioid therapy (LTOT) in the context of chronic pain may result in subjective anhedonia coupled with decreased attention to natural rewards. Yet, there are no known efficacious treatments for anhedonia and reward deficits associated with chronic opioid use. Mindfulness-Oriented Recovery Enhancement (MORE), a novel behavioral intervention combining training in mindfulness with savoring of natural rewards, may hold promise for treating anhedonia in LTOT. Methods Veterans receiving LTOT (N = 63) for chronic pain were randomized to 8 weeks of MORE or a supportive group (SG) psychotherapy control. Before and after the 8-week treatment groups, we assessed the effects of MORE on the late positive potential (LPP) of the electroencephalogram and skin conductance level (SCL) during viewing and up-regulating responses (i.e. savoring) to natural reward cues. We then examined whether these neurophysiological effects were associated with reductions in subjective anhedonia by 4-month follow-up. Results Patients treated with MORE demonstrated significantly increased LPP and SCL to natural reward cues and greater decreases in subjective anhedonia relative to those in the SG. The effect of MORE on reducing anhedonia was statistically mediated by increases in LPP response during savoring. Conclusions MORE enhances motivated attention to natural reward cues among chronic pain patients on LTOT, as evidenced by increased electrocortical and sympathetic nervous system responses. Given neurophysiological evidence of clinical target engagement, MORE may be an efficacious treatment for anhedonia among chronic opioid users, people with chronic pain, and those at risk for opioid use disorder.

Abstract 137: Anticoagulation clinic provider’s perspective on management of patients on target specific oral anticoagulants: insights from the Veterans Affairs Health Care System

2014 ◽  
Vol 7 (suppl_1) ◽  
Author(s):  
Supriya Shore ◽  
P. Michael Ho ◽  
Anne Lambert-Kerzner ◽  
Fran Cunningham ◽  
Madeline McCarren ◽  
...  
Keyword(s):  
Side Effects ◽  
Patient Adherence ◽  
Comparative Method ◽  
Oral Anticoagulants ◽  
Anticoagulation Clinic ◽  
Veterans Health ◽  
Health Administration ◽  
Structured Interviews ◽  
High Performing

Background: Patients on target specific anticoagulants (TSOACs) such as dabigatran do not require routine laboratory testing and dose adjustment. In the Veterans Health Administration (VHA), anticoagulation clinics (ACCs) may elect to follow and manage patients on TSOACs, but whether it is needed or the optimal duration of follow-up is unknown. Our objective was to assess the perspective of anticoagulation clinic providers on follow-up care for dabigatran patients and to identify site-level practices associated with improved adherence to dabigatran. Methods: We ascertained ACC providers’ perspectives through semi-structured interviews by a single, trained internist. Purposive sampling was utilized to recruit senior ACC providers or supervisors at VHA sites with over 20 patients on dabigatran. We stratified sites into high and low performing sites based on whether sites had ≥ 75% of their patients adherent, based on a proportion-of-days-covered calculation. Data from the interviews was analyzed by 2 reviewers in an iterative process to identify recurrent and unifying themes. Constant comparative method of qualitative data analysis was used to identify best practices across various sites. Results: We interviewed ACC providers from 39 sites - including 18 providers at 16 high-performing sites and 25 providers at 23 low-performing sites. Follow-up practices for dabigatran varied across sites, with 6 sites not providing any follow-up, 14 sites following-up patients for less than 3 months, 9 sites following-up patients for 6 months, and 10 sites following-up patients indefinitely. During these follow-up visits, patients were contacted at regular intervals, mostly via telephone, by ACC providers to provide education, assess side-effects and adherence. Key strategies implemented at high-performing sites compared to low-performing sites included (1) examining adherence to other twice daily medications prior to approving dabigatran (2) education of patients by ACC providers prior to dabigatran initiation (3) continued telephone follow up by ACC staff despite no need for INR checks. Over a third of ACC providers expressed concerns regarding patient adherence to dabigatran. Most common reasons for this concern included its special storage requirements and high incidence of gastrointestinal side effects leading to high discontinuation rates. Conclusion: Dedicated follow-up of patients on dabigatran is associated with improved adherence. A multi-disciplinary approach involving anti-coagulation clinic providers to provide education and follow-up may be beneficial in management of TSOACs. Future work should compare the apparent benefit of this strategy with its non-trivial cost.

Assessment of patient satisfaction, financial, and environmental impacts of teleoncology.

2021 ◽  
Vol 39 (28_suppl) ◽  
pp. 278-278
Author(s):  
Cindy Jiang ◽  
Garth William Strohbehn ◽  
Rachel Dedinsky ◽  
Shelby Raupp ◽  
Brittany Pannecouk ◽  
...  
Keyword(s):  
Patient Satisfaction ◽  
Rural Areas ◽  
Financial Burden ◽  
Veterans Health ◽  
Health Administration ◽  
Secondary Effects ◽  
Medical Needs ◽  
Care Access ◽  
Strongly Agree

278 Background: There was rapid adoption of teleoncology at Veterans Health Administration (VHA) during the COVID-19 pandemic. One-third of 9 million VHA-enrolled Veterans live in rural areas. While digital solutions can expand capacity, enhance care access, and reduce financial burden, they may also exacerbate rural-urban health disparities. Careful evaluation of patients’ perceptions and policy tradeoffs are necessary to optimize teleoncology post-pandemic. Methods: Patients with ≥1 teleoncology visit with medical, surgical, or radiation oncology between March 2020 and June 2020 identified retrospectively. Validated, Likert-type survey assessing patient satisfaction developed. Follow-up survey conducted on patients with ≥1 teleoncology visit from August 2020 to January 2021. Travel distance, time, cost, and carbon dioxide (CO2) emissions calculated based on zip codes. Results: 100 surveys completed (response rate, 62%). Table with demographics. Patients overall satisfied with teleoncology (83% ‘Agree’ or ‘Strongly Agree’) but felt less satisfied than in-person visits (47% ‘Agree’ or ‘Strongly Agree’). Audiovisual component improved patient perception of involvement in care (two-sided, p = 0.0254), ability to self-manage health/medical needs (p = 0.0167), and comparability to in person visits (p = 0.0223). Follow-up survey demonstrated similar satisfaction. Total travel-related savings: 86,470 miles, 84,374 minutes, $49,720, and 35.5 metric tons of CO2. Conclusions: Veterans are broadly satisfied with teleoncology. Audiovisual capabilities are critical to satisfaction. This is challenging for rural populations with lack of technology access. Patients experienced financial and time savings, and society benefitted from reduced carbon emissions. Continued optimization needed to enhance patient experience and address secondary effects.[Table: see text]

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