Impact of the VA opioid safety initiative on pain management for cancer patients.

Abstract

102 Background: Limited research exists on how risk reduction policies in response to the opioid epidemic have impacted pain management among cancer patients. This study investigated the impact of the Veteran’s Health Administration (VHA) Opioid Safety Initiative (OSI) on opioid prescribing patterns and opioid-related toxicity among patients undergoing definitive cancer treatment. Methods: This retrospective cohort study included 42,064 opioid-naïve patients receiving definitive local therapy for prostate, lung, breast, and colorectal cancer at the VHA from 2011-2016. Interrupted time series analysis with segmented regression was used to evaluate the impact of the OSI, which launched October 2013. The primary outcome was the incidence of new opioid prescriptions with diagnosis or treatment. Secondary outcomes included rates of high daily dose opioid (≥ 100 morphine milligram equivalent) and concomitant benzodiazepine prescriptions. Additional long-term outcomes included persistent opioid use, opioid abuse diagnoses, pain-related ED visits, and opioid-related admissions. Results: Prior to OSI implementation, the incidence of opioid prescriptions among new cancer patients increased from 26.7% (95% CI 25.0 – 28.4) in the first quarter (Q1) of 2011 to 50.6% (95% CI 48.3 – 53.0) in Q3 2013. There was a monthly increase in opioid prescription rate pre-OSI followed by a monthly decrease post-OSI (Table). High-dose opioid prescriptions were rare, and the monthly rate was stable before and after the OSI. Monthly incidence of concomitant benzodiazepine prescriptions was stable pre-OSI and decreased post-OSI. Persistent opioid use increased pre-OSI and decreased post-OSI. Pain-related ED visits had an incidence of 0.8% (95% CI 0.4 – 1.0) in Q1 2011, 0.3% (95% CI 0.1 – 0.6) in Q3 2013, and 1.8% (95% CI 0.9 – 2.7) in Q4 2016, with an increasing monthly rate after the OSI. At three years, the cumulative incidence of opioid abuse was 1.2% for both the pre- and post-OSI groups but opioid-related admissions were greater in the pre-OSI cohort than the post-OSI cohort (0.9% vs. 0.5%, p < 0.001). Conclusions: The OSI was associated with a decrease in new, persistent, and certain high-risk opioid prescribing as well as an increase in pain-related ED visits. Further research on patient-centered outcomes is required to optimize opioid prescribing policies for patients with cancer.[Table: see text]