Guideline-Concordant Long-Term Opioid Therapy Associated with Lower All-Cause Mortality
Long-term opioid therapy (LtOT, defined as receipt of opioid medication for ≥ 90 days) carries a risk of addiction and overdose. Guidelines have been developed to guide practitioners, but there is scant evidence to support them. Researchers used data from the Veterans Aging Cohort Study (patients with HIV infection and matched [1:2] with controls) to investigate the association between guideline-concordant care and all-cause mortality.
- Of approximately 120,000 patients in the cohort, 26,931 were identified as receiving LtOT; patients receiving palliative care or opioid agonists for opioid use disorder were excluded; 17,044 were included in this analysis. During 1 year of follow-up there were 1048 deaths (6%).
- The table below shows propensity-matched hazard ratios (HR) and 95% confidence intervals (CI) for all-cause mortality associated with 6 specific guidelines; researchers looked for the receipt of any of these within 180 days of LtOT start date.
|
Guideline |
Propensity- matched HR (CI) |
|
Primary care follow-up within 2–4 weeks of LtOT start and every 1–6 months thereafter |
1.12 |
|
Urine drug testing as part of assessment and periodically thereafter |
0.96 |
|
Co-prescription of sedatives |
1.39 |
|
Substance use disorder (SUD) treatment for those with SUD |
0.47 |
|
Physical rehabilitation therapy |
0.81 |
|
Psychotherapeutic co-interventions |
0.62 |
Comments:
This study supports a number of the guidelines, particularly regarding avoiding the co-prescription of sedatives. It also supports the use of physical rehabilitation and psychotherapeutic co-interventions at least among those who choose to engage in them. The fact that urine drug testing was not associated with lower mortality may have more to do with how clinicians used the results. Finally, there are number of guideline recommendations that were not assessed in this study, such as limiting the dosage of opioids, as well as the use of treatment agreements and prescription drug monitoring programs.
Darius A. Rastegar, MD
Reference:
Gaither JR, Goulet JL, Becker WC, et al. The association between receipt of guideline-concordant long-term opioid therapy and all-cause mortality. J Gen Intern Med. 2016;31(5):492–501.