The Association Between Guideline-Concordant Long-Term Opioid Therapy and All-Cause Mortality in HIV+ and HIV- Veterans

Over the past twenty years, clinicians have increasingly relied on prescription opioids to treat chronic non-cancer pain---opioids are now the most widely prescribed medications in the United States. During this time, a stark picture has emerged of the personal and public health risks associated with these medications. Increasing trends in opioid prescribing have coincided with an unprecedented rise in opioid addiction and drug poisonings---in 2010 alone, approximately 17,000 deaths were attributed to opioids. Mitigating opioid-related adverse events has become one of the leading public health challenges of our time.;Our overall objective with this thesis is to better understand how quality of care contributes to mortality among patients prescribed long-term opioid therapy (LtOT) for chronic pain. To this end, we conducted a secondary analysis of data obtained from the Veterans Aging Cohort Study: A prospective cohort of HIV+ veterans demographically matched to HIV- controls. Our analytic sample consisted of patients initiating LtOT through the Department of Veterans Affairs between 1998 and 2010.;In Chapter One, we examine the extent to which these patients received care in accordance with opioid clinical practice guidelines. After operationalizing the leading guidelines from the American Pain Society and the Department of Veterans Affairs, we found that the overwhelming majority of patients failed to receive recommended care for a range of quality indicators related to risk assessment, patient monitoring, sedative co-prescribing, side effects management, psychotherapeutic co-interventions, and care of high-risk groups. We also found little evidence to suggest that HIV+ patients-a group with a high prevalence of chronic pain and psychiatric comorbidities, conditions that confer higher risk---received a higher standard of care. Moreover, our findings suggest that the promulgation of clinical practice guidelines has not resulted in substantive changes over time in receipt of guideline-concordant care.;In Chapter Two, we examine the association between receipt of guideline-concordant LtOT and all-cause mortality using time-updated Cox regression in propensity-matched samples. We found that patients receiving psychotherapeutic co-interventions and rehabilitative therapies had lower 1-year all-cause mortality rates than those not receiving these services. Conversely, patients receiving LtOT concurrent with benzodiazepines were more likely to die within one year. Among patients meeting the criteria for a current substance use disorder, those engaged in treatment for this serious comorbidity had a mortality rate less than one-half that of those not receiving treatment.;In Chapter Three, we explore whether the presence of a current substance use disorder modified the association between guideline-concordant care and all-cause mortality for those patient-care practices previously found to have the strongest impact on mortality. In stratified analyses, we found evidence of effect measure modification by substance use disorder status for psychotherapeutic co-interventions; these services were found to be more protective of mortality in patients with a substance use disorder compared to those without the disorder. For benzodiazepine co-prescribing, however, we found no significant difference in either receipt of guideline-concordant care or mortality according to substance use disorder status.;From the outset, our goal in completing these three observational studies has been to improve quality of care for vulnerable patients receiving LtOT. Therefore, we conclude this thesis with a discussion of our plans to build on the current findings through a series of quantitative and qualitative studies conducted in clinical settings, involving both patients and providers.