Head and neck cancer survivors (HNCS) suffer from high rates of chronic pain, substance use, and mental health comorbidities. HNCS have one of the highest rates of suicide among patients with cancer and are almost twice as likely to die by suicide compared to other cancer survivors. Among a national cohort of Veteran HNCS, we examined the associations between chronic pain, mental health and substance use disorder (SUD) diagnoses, and engagement in mental health services with risk of suicidal self-directed violence (SSDV), which included both suicide attempts and death by suicide.

Long-term opioid therapy for chronic pain is common, yet data on long-term outcomes, especially after dose escalation, are sparse. We conducted a two-year cohort study to examine potential benefits and harms associated with prescription opioid dose escalation. All participants (n=517) were receiving a stable dose of long-term opioid therapy (LTOT) at baseline. They completed self-report measures of pain, function, depression, and potential adverse effects at baseline and every six months for two years. We reviewed electronic health record data weekly to identify episodes of prescription opioid dose escalation; participants who increased their dose were seen for an additional research visit within one month of dose escalation. Over the two-year period, 19.5% of participants had an increase in prescription opioid dose of 15% or more of baseline dose (average dose increase was 104%, SD=105). After controlling for covariates, there were no significant changes in pain intensity or pain interference over time, and no differences based on dose escalation status. There were also no significant changes over time in average depression severity or sleep functioning. Statistically significant improvements were found on measures of medication-related side effects and risk for prescription opioid misuse; sexual functioning significantly worsened over time. Across all outcome measures, the only variable that significantly differed based on dose escalation status was risk for prescription opioid misuse; the average score in the dose escalation group was 2.4 points lower at the end of the two-year observation window compared with the non-escalation group (p=0.018). In sum, patients who are prescribed a stable dose of LTOT demonstrate few changes in key pain-related outcomes over time, and prescription opioid dose escalation status is unrelated to most clinical outcomes. Long-term opioid therapy for chronic pain is common, yet data on long-term outcomes, especially after dose escalation, are sparse. We conducted a two-year cohort study to examine potential benefits and harms associated with prescription opioid dose escalation. All participants (n=517) were receiving a stable dose of long-term opioid therapy (LTOT) at baseline. They completed self-report measures of pain, function, depression, and potential adverse effects at baseline and every six months for two years. We reviewed electronic health record data weekly to identify episodes of prescription opioid dose escalation; participants who increased their dose were seen for an additional research visit within one month of dose escalation. Over the two-year period, 19.5% of participants had an increase in prescription opioid dose of 15% or more of baseline dose (average dose increase was 104%, SD=105). After controlling for covariates, there were no significant changes in pain intensity or pain interference over time, and no differences based on dose escalation status. There were also no significant changes over time in average depression severity or sleep functioning. Statistically significant improvements were found on measures of medication-related side effects and risk for prescription opioid misuse; sexual functioning significantly worsened over time. Across all outcome measures, the only variable that significantly differed based on dose escalation status was risk for prescription opioid misuse; the average score in the dose escalation group was 2.4 points lower at the end of the two-year observation window compared with the non-escalation group (p=0.018). In sum, patients who are prescribed a stable dose of LTOT demonstrate few changes in key pain-related outcomes over time, and prescription opioid dose escalation status is unrelated to most clinical outcomes.

Substance use disorders (SUDs) are common in patients with chronic non-cancer pain and associated with poor pain treatment engagement and clinical outcomes. Unfortunately, patients with active SUDs are often difficult to engage in care. Specialty SUD treatment programs may be optimally positioned to concomitantly treat active SUDs and help patients engage in needed pharmacologic and non-pharmacologic pain care. We utilized retrospective VA administrative data to identify a cohort of all U.S. Department of Veterans Affairs (VA) patients with chronic non-cancer pain and a SUD between 2010 and 2013. A total of 126,390 patients met study inclusion criteria. 18,964 of these patients subsequently received a full episode of SUD treatment, while an additional 63,939 received some specialty SUD treatment without completing a full treatment episode. Generalized estimating equations controlled for key demographic and clinical variables and compared 12-month pain care utilization between patients with specialty SUD treatment engagement to those with no specialty SUD treatment. Relative to patients who received no specialty SUD treatment, those who received incomplete episodes of SUD treatment were more likely to be prescribed Non-opioid Pharmacotherapy (OR = 1.05 [95% CI = 1.02–1.08]), and engage in Occupational Therapy (OR = 1.47 [1.40–1.53]), while less likely to be prescribed Opioid Pharmacotherapy (OR = .92[.88–.96]) or Primary Care encounters (OR = .98[.97–.99]). Patients who completed full episodes of SUD treatment, compared to patients who received no SUD treatment, were more likely to be prescribed Non-opioid Pharmacotherapy (OR = 1.72[1.66–1.79]) and receive Rehabilitation Medicine (OR = 1 .75[1.63–1.89]), Occupational Therapy (OR = 5.60[528-5.94]), Specialty Pain Clinic (OR = 1.20[1.11–1.30]), and Primary Care treatment (OR = 1.57[1.53–1.60]), while less likely to be prescribed Opioid Pharmacotherapy (OR = .82[.79–.85]). For patients with comorbid chronic non-cancer pain and active SUDs, episodes of specialty SUD treatment may present an optimal time for delivering needed pain care to this hard-to-reach population. Supported by grant IK2HX001516 from VA Health Services Research & Development.

Screening for pain as the fifth vital sign with the 0–10 numeric rating scale (NRS) is common in clinical practice. Researchers have begun to explore using data generated from NRS scores, which are stored in the electronic medical record, to evaluate pain care and treatment outcomes. However, limited data are available about the utility of NRS scores collected in the context of usual care. We report findings from a prospective cohort study of 186 patients with musculoskeletal pain who were prescribed long-term opioid therapy. All patients received care at a VA medical center and had been screened with the 0–10 NRS during routine outpatient visits. They also completed research visits every six months for two years. We examined bivariate correlations of NRS data obtained from the medical record with scores on standardized measures of pain intensity, pain disability, depression, anxiety, and quality of life. Inferential analyses accounted for non-independence of observations due to repeated measures data. Study results indicate that NRS scores obtained in routine clinical practice are only moderately correlated with pain intensity scores obtained using the standardized Chronic Pain Grade from a research study, that were measured within two weeks of the NRS rating (r = .40). The strength of the correlation decreases as NRS scores are averaged over 4−, 8−, 16−, and 24-week intervals around the research assessment. NRS scores are also moderately correlated with pain disability scores (r = .27). Correlations between pain NRS scores and other standardized measures of depression (Patient Health Questionnaire), anxiety (Generalized Anxiety Disorder-7), and quality of life (Medical Outcomes Study Short-Form, Version 12) were low and often non-significant. Findings from the study suggest that standardized assessments of pain in usual care would benefit greatly from the inclusion of more robust measures of pain-related function and quality of life.

Rates of clinician-initiated discontinuation of long-term opioid therapy (LTOT) for chronic pain are increasing, particularly for patients who may be considered “complex” given significant medical, mental health, and substance use disorder comorbidities. Although it is unclear if opioid therapy discontinuation leads to exacerbation of pain, higher pain intensity is associated with suicidal ideation and self-directed violent behaviors. The objectives of this study were to (1) estimate the prevalence of suicidal ideation (SI) and suicidal self-directed violence (SSV) and (2) identify predictors of SI/SSV following clinician-initiated discontinuation of LTOT. This retrospective study utilized VA electronic medical record data to assemble a cohort of all VA patients prescribed continuous opioid therapy in 2011 who subsequently discontinued opioid therapy in 2012. A random sample of 600 patients was selected and medical charts reviewed to ascertain reasons for LTOT discontinuation and the presence of SI or SSV in the year following discontinuation of LTOT. Logistic regression examined correlates of SI/SSV post-discontinuation among the 509 patients whose clinicians initiated LTOT discontinuation rather than discontinuation that was initiated by patients. Twelve percent of patients (n=59) had SI and/or SSV documented in the medical record in the year following discontinuation of LTOT. Forty-seven had SI only, while 12 had SSV. In unadjusted models, patients with SI/SSV following discontinuation of LTOT were more likely to have diagnoses of PTSD (OR=1.94[1.12-3.37]), psychotic disorder (OR=2.35[1.06-5.21]), and sedative use disorder (including abuse of benzodiazepines; OR=3.56[1.06-11.96]), and have been discontinued by clinicians due to concerns about patient safety (OR=2.28[1.00-5.25]). Covariate-adjusted models that controlled for demographic characteristics, medical comorbidity, and treatment utilization were consistent with unadjusted models. Results point to the importance of monitoring mental health symptoms, particularly suicidal ideation and behaviors, following discontinuation of LTOT.

Although older adults are at high risk for pain, little is known about the factors associated with pain-related outcomes in this age group. The purpose of this study was to identify patient factors associated with improvements in pain intensity scores over time in a national cohort of older veterans with chronic pain. Using Department of Veterans Affairs (VA) administrative data, we identified 12,924 veterans with persistently elevated numeric rating scale (NRS) scores in 2010 who had not been prescribed opioids in the prior 12 months. We used two analytic approaches to examine 1) percentage decrease over 12 months in average pain scores relative to average baseline pain score; and 2) time to sustained improvement in average pain scores, defined as a 30% reduction in 3-month scores compared to baseline. Average relative improvement in pain scores from baseline ranged from 23% to 28%, and almost two-thirds of the sample met criteria for sustained improvement at some point during 12 months of follow-up. In multivariable models, older age and higher baseline pain intensity were associated with greater likelihood of improvement in pain intensity, while VA service connected disability status, mental health, and certain pain-related diagnoses were associated with lower likelihood of improvement. Opioid prescription initiation during follow-up was associated with lower likelihood of sustained improvement within subjects. Although the observational nature of the study precludes determinations regarding causality, the study supports that, on average, older adults who initiate opioids are not likely to demonstrate improvements in pain intensity over time. The findings call for 1) further analyses that adjust for opioid treatment selection bias and receipt of other pain treatments, and that identify patient groups more or less likely to show improvements over time, and 2) development of interventions that identify and target older individuals at risk for treatment refractory chronic pain.

Several factors may accelerate opioid discontinuation rates, including lack of information about the long-term effectiveness of opioids for chronic pain, heightened awareness about opioid-related adverse events, closer monitoring of patients for opioid-related aberrant behaviors, and greater restrictions around opioid prescribing. Rates of discontinuation may be most pronounced in patients deemed to be at "high risk." The purpose of this study was to compare reasons for discontinuation of long-term opioid therapy (LTOT) between patients with and without substance use disorder (SUD) diagnoses receiving care within a major U. S. health care system. This retrospective cohort study assembled a cohort of Veterans Health Administration patients prescribed opioid therapy for at least 12 consecutive months who subsequently discontinued opioid therapy for at least 12 months. From this cohort, we randomly selected 300 patients with SUD diagnoses and propensity score-matched 300 patients without SUD diagnoses. A comprehensive manual review of patients' medical records ascertained reasons for LTOT discontinuation. Most patients (85%) were discontinued as a result of clinician, rather than patient, decisions. For patients whose clinicians initiated discontinuation, 75% were discontinued because of opioid-related aberrant behaviors. Relative to patients without SUD diagnoses, those with SUD diagnoses were more likely to discontinue LTOT because of aberrant behaviors (81% vs 68%), most notably abuse of alcohol or other substances. This is the first study to document reasons for discontinuation of LTOT in a sample of patients with and without SUD diagnoses. Treatments that concurrently address SUD and chronic pain are needed for this high-risk population.

OBJECTIVE Individuals with the hepatitis C virus (HCV) have high rates of both chronic pain and substance use disorder (SUD). Despite high comorbidity, there are limited data available on effective methods of treatment for co-occurring chronic pain and SUD. In this study, we sought to develop and conduct preliminary testing of an integrated cognitive-behavior therapy (CBT) for chronic pain and SUD in patients with HCV. DESIGN Descriptive, including pretreatment, posttreatment, and follow-up testing. SETTING AND PATIENTS Outpatient clinic as part of one VA Medical Center. PARTICIPANTS Veterans with chronic pain, SUD, and HCV. INTERVENTION Eight-session integrated group CBT for chronic pain and SUD in patients with HCV. METHODS Participants completed standardized measures of pain, function, depression severity, and alcohol and substance use at baseline, post-treatment, and 3-month follow-up. RESULTS Generalized estimating equations identified improvements in pain interference, reducing cravings for alcohol and other substances, and decreasing past-month alcohol and substance use. The proportion of participants who met diagnostic criteria for current SUD demonstrated a four-fold decrease over the course of the study from 24% at baseline to 15% at post-treatment and 6% at 3-month follow-up. On response to a global impression of change, 94% of participants noted improvement from baseline. CONCLUSIONS Results from this pilot study suggest that a customized CBT for patients with both chronic pain and SUD (CBT-cp.sud) may be beneficial in improving important pain and addiction-related outcomes in patients with HCV. Larger scale investigations of this intervention appear warranted.

Patients with a history of substance use disorder (SUD) are frequently prescribed opioid medications for chronic pain, yet it is not clear what factors affect prescribing practices for this population. This study examined correlates of receipt of prescription opioid therapy in 214 patients with a SUD history receiving care at one Veterans Health Administration (VHA) medical center. Participants had one or more recent chronic non-cancer pain diagnoses documented in their VHA electronic medical records. Participants completed psychosocial questionnaires assessing pain impact, emotional distress, pain self-efficacy, pain catastrophizing, and pain severity. In addition, historical medical diagnoses and opioid pharmacy data were abstracted from their VHA electronic medical records. Participants were divided into three groups based on opioid prescriptions in the past 90 days: (1) no opioid therapy (n=134), (2) short-term opioid therapy (<90 days; n=31), or (3) chronic opioid therapy (90 days; n=49). Relative to participants with no or short-term opioid therapy, participants prescribed chronic opioid therapy had a greater number of pain diagnoses (p<0.01); higher levels of pain severity (p<0.01), interference (p<0.01), and catastrophizing (p<0.01); and lower chronic pain self-efficacy (p<0.01). Depression, post-traumatic stress disorder, and active SUD were unrelated to opioid therapy in bivariate analyses. In a multivariate logistic regression model, only self-reported pain interference remained a significant predictor of any opioid therapy (p<0.05, OR=1.38), after controlling for demographic and clinical characteristics. Findings highlight the occurrence of poor pain-related functioning in patients with SUD histories who are prescribed opioid therapy. Prescribing clinicians may consider adjuvant analgesic therapies and psychosocial interventions for these patients to further improve pain-related functioning and quality of life. This study was funded in part by grants from the National Institute on Drug Abuse (to B.J.M.) and VA Health Services Research & Development (to T.I.L.).

Urine drug testing (UDT) is a recommended method to screen for prescription drug abuse among patients prescribed chronic opioid therapy (COT). Prior reports examining UDT have been limited by evaluation of activities from single settings. The purpose of this study was to assess the prevalence and predictors of UDT among a national cohort of patients in the Department of Veterans Affairs (VA) healthcare system. This is a retrospective observational cohort drawn from VA databases. We identified 25,036 patients who received opioid medications for pain daily for 90+ days between 10/1/2010 and 9/30/2011, and were opioid-naïve in the prior year. Binomial regression methods with log-link were used to estimate risk for UDT during the first three months of COT as a function of demographic and clinical predictors. Twenty percent (n=4,982) of patients received at least one UDT during the first three months of COT. In multivariable modeling, the adjusted risk of UDT was higher for those without a VA service-connection (Risk Ratio [RR]=1.06, 95% CI=1.01-1.12), living in urban environment compared to rural (RR=1.11, 95% CI=1.06-1.17) or highly rural (RR=1.52, 95% CI=1.06-2.19), with current substance use disorder (RR=1.20, 95% CI=1.12-1.28), higher baseline pain severity (RR=1.04 for a 1-unit increase in baseline pain, 95% CI=1.03-1.05), and prior UDT within 3 months of initiating COT (RR=3.31, 95% CI=3.14-13.50). Age and medical comorbidity score were also associated with likelihood of UDT, but these relationships were more complex (p<0.0001 and p=0.007 for age and comorbidity score quadratic terms, respectively). Neither sex, race, nor opioid dose was predictive of UDT administration. UDT was underutilized in this national cohort of VA patients with new COT initiations. Additional data are needed to determine whether UDT administration differs by clinician-related variables. System support interventions are needed to enhance the frequency and effectiveness of UDT to reduce prescription opioid abuse.

Factors associated with high-dose opioid therapy for noncancer pain are poorly understood. We documented the prevalence of high-dose opioid use as well as associated demographic, clinical, and health service utilization correlates among low back pain patients. Patients prescribed higher doses of opioids (>= 100 mg/day morphine equivalent at last dispensing; n = 453) and receiving opioids for 90+ consecutive days were compared to 2 groups: lower-dose opioid group (1-99 mg/day; n = 4,815) or no-opioid group (n = 10,184). Higher-dose opioid use occurred in 2.9% of patients who received any opioids and in 8.6% of patients who received opioids long-term. The median dose in the higher-dose group was 180.0 mg/day. Compared to the no-opioid group, higher-dose users reported poorer health. Compared to either comparison group, patients in the higher-dose group had higher rates of mental health and substance use disorders, concurrent sedative-hypnotic use (60.5%; n = 274), and health service utilization. After adjusting for select covariates, male gender (odds ratio [OR] = 1.68, 95% confidence interval [CI] = 1.37-2.06), higher comorbidity, Medicare coverage (OR = 1.65, 95% CI = 1.22-2.23), any mental health or substance use diagnosis (OR = 1.58, 95% CI = 1.28-1.95), co-prescriptions of sedative-hypnotics (OR = 1.75, 95% CI = 1.42-2.16), and more emergency department and specialty pain clinic visits were associated with higher likelihood of high-dose prescriptions.Perspective: Higher-dose opioid therapy is being prescribed to 8.6% of back pain patients who receive long-term opioids. These patients had higher mental health and medical comorbidities and co-prescriptions of sedative-hypnotics, raising potential safety concerns. (C) 2012 by the American Pain Society. Published by Elsevier Inc. All rights reserved

Despite increased opioid use, little is known about patients receiving high doses of opioids. In this study we describe the prevalence of high dose opioid use, as well as demographic and clinical characteristics, in VA patients with chronic non-cancer pain. Veterans with chronic pain prescribed high doses of opioids (>=180 mg/day morphine equivalent) for 90+ consecutive days were identified (n=478) from electronic medical records and compared to two chronic pain groups: Traditional Dose group (5-179 mg/day; n=500) or No Opioid group (n=500). The average participant was male (90.7%), 55.1 years (SD=12.6), Caucasian (70.8%), and married (49.3%). The only significant demographic difference among groups was race/ethnicity, as African-Americans were less likely to be in the High Dose group. The most common diagnoses were joint pain (75.0%), low back pain (67.9%), or rheumatism/arthritis (60.9%). High dose opioid use occurred in 2.4% of chronic pain patients and 3.4% of pain patients taking opioids. The average dose in the High Dose group was 324.9 (SD=285.1) mg/day. The Traditional Dose group averaged 32.4 (SD=20.1) mg/day. In a logistic regression analysis, factors associated with an increased likelihood of being prescribed high doses of opioids included diagnoses of neuropathy (OR=1.73, 95% CI=1.14-2.61), low back pain (OR=1.69, 95% CI=1.18-2.42), or rheumatism/arthritis (OR=1.49, 95% CI=1.09-2.04), pain specialty clinic visits (OR=1.88, 95% CI=1.08-3.29), and higher frequency of primary care appointments (OR=1.52, 1.01-2.30). Conversely, African-American race/ethnicity (OR=0.35, 95% CI=0.18-0.68) and diagnosis of hypertension (OR=0.67, 95% CI=0.48-0.93) were associated with decreased likelihood of being in the High Dose group. High dose opioid use occurs in 2-3% of VA chronic non-cancer pain patients and is associated with several pain diagnoses and higher medical utilization. Further study is needed to identify better predictors of high dose usage, as well as the efficacy and safety of such dosing.

The purpose of this pilot study was to examine the effectiveness of a brief integrated intervention for chronic pain in veterans with comorbid substance use disorder (SUD). Patients were referred by their primary care providers if they were diagnosed with chronic pain and active comorbid SUD. The intervention consisted of an assessment and development of treatment recommendations by a team including an addiction psychiatrist and an anesthesia pain specialist. Recommendations often included assistance with detoxification or change to long-acting opioids with ongoing monitoring. Retrospective chart review was used to evaluate changes in indicators of misuse of opioid medications and utilization of medications and healthcare services 12 months pre-intervention and 12 months post-intervention. Complete data are available for 47 veterans. The average age was 50.8 years (SD = 7.7), 92.7% were male, and 53.7% were married. The most common pain diagnoses were back pain (90.2%), neck or joint pain (87.8%), or rheumatoid arthritis or osteoporosis (85.4%). SUDs included alcohol (61.0%), opioid (39.0%), cannabis (29.3%), amphetamine (14.6%), or other SUD (41.5%). In the 12 months post-intervention, there were reductions in the proportions of several indicators of opioid misuse compared to the 12 months pre-intervention, including reports of lost/stolen medications (14.9% pre- versus 10.6% post-treatment), using opioids for purposes other than pain control or over-use of pain medications (38.3% versus 21.3%), and concurrent use of alcohol or illicit substances while taking an opioid (59.6% versus 31.9%). There were no statistically significant differences in pre- versus post-intervention rates of appointment utilization, emergency room visits, mental health visits, substance abuse treatment visits, participation in physical therapy, or use of pain medications. In summary, participation in an integrated pain and SUD consultation clinic is associated with significant reductions in indicators of misuse of opioid medications. The one-time session was not associated with changes in medical utilization.

Patients infected with the hepatitis C virus (HCV) frequently have comorbid chronic pain diagnoses. Little research has examined factors associated with the development and exacerbation of chronic pain in this population. The goal of this pilot study was to examine biopsychosocial factors associated with self-report of chronic pain in HCV patients. Forty-nine HCV patients recruited from a VA medical center completed a battery of psychological measures as part of a larger parent study. Chronic pain diagnoses and HCV-related disease factors (i.e., current viral load, severity of liver disease) were obtained from electronic medical records. The average participant age was 53.7 years (SD = 5.0), 86% were male, 92% were Caucasian, 67% had a current pain diagnosis, and 31% had been prescribed an opioid medication. Two regression analyses examined variables putatively associated with pain intensity and disability. Variables included in the first regression analysis were: Step 1 – age, body mass index (BMI), years of education; Step 2 – liver disease severity, current viral load; and Step 3 – current depression severity and past substance dependence severity. In the pain intensity analysis, only Step 3 was significant (p < 0.001) and the entire model accounted for 33.7% of the variance in self-report of current pain. Significant variables included depression severity (p < 0.001) and liver disease severity (p = 0.035). In the second regression model, only Step 3 was significant (p < 0.001), with the entire model accounting for 48.6% of the variance in disability. Significant predictors were BMI (p = 0.012) and depression severity (p < 0.001). The results from this pilot study confirm that chronic pain diagnoses are common in HCV patients. Factors associated with self-report of pain intensity and disability include current depression, severity of liver disease, and BMI. Research should replicate findings and explore intervention options with a larger sample of HCV patients seeking treatment for chronic pain.