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J Gen Intern Med. 2016 May;31(5):492-501. doi: 10.1007/s11606-015-3571-4.

The Association Between Receipt of Guideline-Concordant Long-Term Opioid Therapy and All-Cause Mortality.

Author information

1
Yale School of Public Health, Yale University, New Haven, CT, USA. julie.gaither@yale.edu.
2
VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA. julie.gaither@yale.edu.
3
Yale Center for Medical Informatics, Yale School of Medicine, Yale University, New Haven, CT, USA. julie.gaither@yale.edu.
4
Center for Interdisciplinary Research on AIDS, Yale School of Public Health, Yale University, New Haven, CT, USA. julie.gaither@yale.edu.
5
VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA.
6
Department of Psychiatry, Yale School of Medicine, Yale University, New Haven, CT, USA.
7
Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA.
8
Institute for Health, Health Care Policy, and Aging Research, Rutgers University, New Brunswick, NJ, USA.
9
Center for Interdisciplinary Research on AIDS, Yale School of Public Health, Yale University, New Haven, CT, USA.
10
Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA.
11
Atlanta VA Medical Center, Decatur, GA, USA.
12
VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.
13
Yale School of Public Health, Yale University, New Haven, CT, USA.
14
Yale Center for Medical Informatics, Yale School of Medicine, Yale University, New Haven, CT, USA.

Abstract

PURPOSE:

For patients receiving long-term opioid therapy (LtOT), the impact of guideline-concordant care on important clinical outcomes--notably mortality--is largely unknown, even among patients with a high comorbidity and mortality burden (e.g., HIV-infected patients). Our objective was to determine the association between receipt of guideline-concordant LtOT and 1-year all-cause mortality.

METHODS:

Among HIV-infected and uninfected patients initiating LtOT between 2000 and 2010 through the Department of Veterans Affairs, we used Cox regression with time-updated covariates and propensity-score matched analyses to examine the association between receipt of guideline-concordant care and 1-year all-cause mortality.

RESULTS:

Of 17,044 patients initiating LtOT between 2000 and 2010, 1048 patients (6%) died during 1 year of follow-up. Patients receiving psychotherapeutic co-interventions (hazard ratio [HR] 0.62; 95% confidence interval [CI] 0.51-0.75; P < 0.001) or physical rehabilitative therapies (HR 0.81; 95% CI 0.67-0.98; P = 0.03) had a decreased risk of all-cause mortality compared to patients not receiving these services, whereas patients prescribed benzodiazepines concurrent with opioids had a higher risk of mortality (HR 1.39; 95% CI 1.12-1.66; P < 0.001). Among patients with a current substance use disorder (SUD), those receiving SUD treatment had a lower risk of mortality than untreated patients (HR 0.47; 95% CI 0.32-0.68; P = < 0.001). No association was found between all-cause mortality and primary care visits (HR 1.12; 95% CI 0.90-1.26; P = 0.32) or urine drug testing (HR 0.96; 95% CI 0.78-1.17; P = 0.67).

CONCLUSIONS:

Providers should use caution in initiating LtOT in conjunction with benzodiazepines and untreated SUDs. Patients receiving LtOT may benefit from multi-modal treatment that addresses chronic pain and its associated comorbidities across multiple disciplines.

KEYWORDS:

Opioid analgesics; mortality; pain; practice guideline; quality of health care

PMID:
26847447
PMCID:
PMC4835362
DOI:
10.1007/s11606-015-3571-4
[Indexed for MEDLINE]
Free PMC Article

Conflict of interest statement

Compliance with ethical standards Disclosure The content of this paper is solely the responsibility of the authors and does not necessarily reflect the official views of the National Institutes of Health or the Department of Veterans Affairs. Conflict of Interest Dr. Fiellin received an honorarium from PinneyAssociates to serve on an external advisory board to monitor the diversion and abuse of buprenorphine. All other authors declare that they do not have a conflict of interest. Funding/Support Research reported in this paper was supported by grants from the National Institute on Drug Abuse (F31DA035567; K12DA033312), National Institute on Alcohol Abuse and Alcoholism (U10AA013566; U01AA020790; U24AA020794), National Institute of Mental Health (P30MH062294), VA Health Services Research and Development Center of Innovation (CIN 13–047), and the Agency for Healthcare Research and Quality (U19HS21112). These organizations had no role in the design, conduct, or reporting of this study.

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