Alcohol-Related Care Among Veterans With Unhealthy Alcohol Use: The Role of Long-term Opioid Therapy Receipt

OBJECTIVES

Long-term opioid therapy (LTOT) is potentially dangerous among patients with unhealthy alcohol use because of possible adverse interactions. We examined receipt of alcohol-related care among patients with unhealthy alcohol use receiving LTOT and without opioid receipt.

METHODS

We use data collected from 2009 to 2017 in the Women Veterans Cohort Study, a national cohort of Veterans engaged in Veterans Health Administration care. We included patients who screened positive for unhealthy alcohol use (score ≥5) using the Alcohol Use Disorder Identification Consumption questionnaire. Our primary exposure was LTOT (receipt of prescribed opioids for ≥90 days) versus no opioid receipt at the time of the first positive Alcohol Use Disorder Identification Consumption. Our primary outcome was receipt of brief intervention within 14 days of positive alcohol screen. Unadjusted and 4 adjusted modified Poisson regression models assessed prevalence and relative rates (RRs) of outcomes.

RESULTS

Among eligible veterans, 6222 of 113,628 (5.5%) received LTOT at screening. Among patients receiving LTOT, 67.5% (95% confidence interval [CI], 66.3%-68.6%) had a documented brief intervention within 14 days of positive screen, compared with 70.1% (95% CI, 69.8%-70.4%) among patients without opioid receipt (RR, 0.96; 95% CI, 0.95-0.98; P < 0.001). Within adjusted models, the rate of brief intervention among patients receiving LTOT remained lower than patients without opioid receipt.

CONCLUSIONS

Among patients with unhealthy alcohol use, patients receiving LTOT had significantly lower rates of brief intervention receipt compared with those without opioid receipt, and they should be a focus for interventions to improve alcohol-related care and safer opioid prescribing.

Pain and smoking study (PASS): A comparative effectiveness trial of smoking cessation counseling for veterans with chronic pain

Introduction

Smoking is associated with greater pain intensity and pain-related functional interference in people with chronic pain. Interventions that teach smokers with chronic pain how to apply adaptive coping strategies to promote both smoking cessation and pain self-management may be effective.

Methods

The Pain and Smoking Study (PASS) is a randomized clinical trial of a telephone-delivered, cognitive behavioral intervention among Veterans with chronic pain who smoke cigarettes. PASS participants are randomized to a standard telephone counseling intervention that includes five sessions focusing on motivational interviewing, craving and relapse management, rewards, and nicotine replacement therapy versus the same components with the addition of a cognitive behavioral intervention for pain management. Participants are assessed at baseline, 6, and 12 months. The primary outcome is smoking cessation.

Results

The 371 participants are 88% male, a median age of 60 years old (range 24–82), and smoke a median of 15 cigarettes per day. Participants are mainly white (61%), unemployed (70%), 33% had a high school degree or less, and report their overall health as “Fair” (40%) to “Poor” (11%). Overall, pain was moderately high (mean pain intensity in past week = 5.2 (Standard Deviation (SD) = 1.6) and mean pain interference = 5.5 (SD = 2.2)). Pain-related anxiety was high (mean = 47.0 (SD = 22.2)) and self-efficacy was low (mean = 3.8 (SD = 1.6)).

Conclusions

PASS utilizes an innovative smoking and pain intervention to promote smoking cessation among Veterans with chronic pain. Baseline characteristics reflect a socioeconomically vulnerable population with a high burden of mental health comorbidities.

Variation in National Opioid Prescribing Patterns Following Surgery for Kidney Stones

Background

Opioid misuse is a significant public health problem. As initial exposures to opioids are frequently encountered through the management of postoperative pain, we examined patterns of opioid prescribing following surgical treatment for nephrolithiasis.

Methods

We identified patients with nephrolithiasis in the national Women Veterans Cohort Study (WVCS) who were treated surgically by diagnosis and procedure codes. Using standard conversion factors, we calculated the morphine milligram equivalent (MME) dose prescribed. We used descriptive statistics to characterize opioid prescription across management strategy and multivariable regression to examine clinical and demographic characteristics associated with dispensed dose.

Results

We identified 22,609 patients diagnosed with kidney stones during 1999-2014, 1,976 of whom were treated surgically and 1,582 (80.1%) of whom received an opioid prescription. The median age was 39 years, and 1,366 (90%) were male; 1,314 (86.3%) were treated with ureteroscopy, 172 (11.3%) with extracorporeal shockwave lithotripsy, and 36 (2.4%) with percutaneous nephrolithotomy. The median number of days supplied per opioid prescription (interquartile range) was 10 (5-14), and patients were dispensed a median of 180 (140-300) MME. A total of 6.4% of patients received ≥50 MME/d. On multivariable analysis, comorbid diagnosis of post-traumatic stress disorder (PTSD) was associated with higher total dispensed dose, whereas surgery type was not.

Conclusions

We observed substantial variation in opioid prescribing following surgical treatment of nephrolithiasis. Although type of surgical intervention did not impact opioid dosing, patients with a diagnosis of PTSD were more likely to receive higher doses. This work can inform efforts to improve the safety and efficacy of postoperative opioid prescribing.

Dual Use of Department of Veterans Affairs and Medicare Benefits on High-Risk Opioid Prescriptions in Veterans Aged 65 Years and Older: Insights from the VA Musculoskeletal Disorders Cohort

OBJECTIVE

To examine the association of dual use of both Veterans Health Administration (VHA) and Medicare benefits with high-risk opioid prescriptions among Veterans aged 65 years and older with a musculoskeletal disorder diagnosis.

DATA SOURCES/STUDY SETTING

Data were obtained from the VA Musculoskeletal Disorder (MSD) cohort and national Medicare claims data from 2008 to 2010.

STUDY DESIGN

We conducted a retrospective analysis of Veterans enrolled in Medicare to examine the association of dual use with long-term opioid use (>90 days of prescription opioids/year) and overlapping opioid prescriptions. Multivariable logistic regression was performed adjusting for demographic and clinical characteristics.

DATA COLLECTION/EXTRACTION METHODS

We identified 21,111 Veterans enrolled in Medicare who entered the MSD cohort in 2008 and received an opioid prescription in 2010. We linked VHA data with Medicare claims data to identify opioid prescriptions for these Veterans in 2010.

PRINCIPAL FINDINGS

As compared to Veterans who used only VHA or Medicare, Veterans with dual use of VHA and Medicare were significantly more likely to be prescribed long-term opioid therapy (OR = 4.61 (95 percent CI 4.05-5.25) and were also found to have higher median number of opioid prescriptions and higher odds of overlapping opioid prescriptions in 1 year. Patients reporting moderate-to-severe pain, non-white-race/ethnicity, and higher scoring on the Charlson comorbidity index had significantly higher odds of long-term opioid prescriptions.

CONCLUSIONS

Among Veterans aged 65 years or older, dual use of both VHA and Medicare was associated with higher odds of long-term opioid therapy. Our findings suggest there may be benefit to combining VHA and non-VHA electronic health record data to minimize exposure to high-risk opioid prescribing.

Differences in Active and Passive Smoking Exposures and Lung Cancer Incidence Between Veterans and Non-Veterans in the Women's Health Initiative

INTRODUCTION

Women Veterans may have higher rates of both active and passive tobacco exposure than their civilian counterparts, thereby increasing their risk for lung cancer.

PURPOSE OF THE STUDY

To compare differences in active and passive smoking exposure and lung cancer incidence among women Veterans and non-Veterans using prospective data from the Women's Health Initiative (WHI).

DESIGN AND METHODS

We used data from the WHI, which collected longitudinal demographic, clinical, and laboratory data on 161,808 postmenopausal women. We employed linear and multinomial regression and generalized linear models to compare active and passive smoking exposure between Veterans and non-Veterans and Cox proportional hazards models to estimate differences in lung cancer incidence rates.

RESULTS

After adjustment, Veterans had 2.54 additional pack years of smoking compared with non-Veterans (95% confidence interval [CI] 1.68, 3.40). Veterans also had a 1% increase in risk of any passive smoking exposure (95% CI 1.00, 1.02) and a 9% increase in risk of any workplace exposure (95% CI 1.07, 1.11) compared with non-Veterans. After adjustment for age and smoking exposures, Veterans did not have a higher risk of lung cancer compared with non-Veterans (relative risk = 1.06 95% CI 0.86, 1.30).

IMPLICATIONS

Women Veterans had higher rates of tobacco use and exposure to passive smoking, which were associated with a higher risk for lung cancer compared with non-Veterans. Clinicians who care for Veterans need to be aware that older women Veterans have more exposures to risk factors for lung cancer.

Abstract 78: Genetic Associations and Mechanisms in Oncology (GAME-ON): A network approach to post-GWAS research

Genome-wide association studies (GWAS) provide the initial evidence that a genetic region harbors a cancer susceptibility locus. However, further research is needed to identify the causal variant(s) and understand the biology of complex diseases. The National Cancer Institute GAME-ON Network consists of five collaborating groups that pursue promising scientific leads from previously generated cancer GWAS and coordinate and accelerate integrative post-GWAS discovery research. The five site-specific groups are ColoRectal Transdisciplinary Study (CORECT), Discovery, Biology, and Risk of Inherited Variants in Breast Cancer (DRIVE), Elucidating Loci Involved in Prostate Cancer Susceptibility (ELLIPSE), Follow-up of Ovarian Cancer Genetic Association and Interaction Studies (FOCI), and Transdisciplinary Research in Cancer of the Lung (TRICL).

Each GAME-ON group is structured into three components: 1) Discovery and replication, which works to find new associations through pooled analyses, conducting GWAS in minority populations, independent replication of associations, and fine mapping of association signals; 2) Biological studies, which focus on evaluating risk-modifying variants, determining the biological mechanisms of risk-enhancement, and understanding the functional consequences of variants; and 3) Epidemiology, to evaluate gene-gene and gene-environment interactions, assess penetrance and population attributable risk, and develop risk models and evaluate their clinical validity.

Six working groups were formed to facilitate collaborations and share methodological expertise across all groups: 1) Analytic and Risk Modeling, to develop analytic tools, share analytic approaches, develop and validate models to characterize risk factors for cancer, 2) Epidemiology and Clinical, to plan and assist collaborative epidemiologic analysis, such as analyzing pan-cancer genes or pathways common to many cancers and the use of standard control sets across consortia, 3) Functional Assays, to share approaches for the characterization of functional consequences of risk variants, including identification of specific gene targets and their interaction mechanisms, 4) Next-Generation Genomic Technologies, to evaluate current and emerging technologies and platforms for optimal genotyping and sequencing, and assist in the search for less common and rare variants, 5) Epigenetics, to explore modification of genetic expression from epidemiological factors, and 6) the hTERT working group, to evaluate the impact of hTERT variations on risk across multiple cancer sites. Descriptive data for the ongoing projects will be presented.

In the past two years, GAME-ON has developed a network infrastructure for post-GWAS research, which will provide an inventory of epidemiologic and clinical data as well as availability of blood and tissue samples. Each group has identified new GWAS variants, completed meta-analyses, and developed strategies for fine-mapping and functional characterization of novel loci. Utilizing the collaborative environment of the network, researchers are currently developing a GAME-ON Oncochip with SNP selection from breast, colon, prostate, ovarian, and lung cancer variants, which will be used to genotype a large and diverse group of cancer cases and controls. Members of GAME-ON have used data from The Cancer Genome Atlas (TCGA) to implement eQTL analyses, conducted methylation and copy number expression analyses, and developed and applied novel methods for gene-environment interaction and pathway analysis. Major achievements and challenges within the past two years will be discussed.

Citation Format: Brett M. Kaminski, Christopher I. Amos, Eric DeRycke, Elizabeth M. Gillanders, Stephen B. Gruber, Brian E. Henderson, David J. Hunter, Pascale K. Lepage, Thomas A. Sellers, Daniela Seminara. Genetic Associations and Mechanisms in Oncology (GAME-ON): A network approach to post-GWAS research. [abstract]. In: Proceedings of the AACR Special Conference on Post-GWAS Horizons in Molecular Epidemiology: Digging Deeper into the Environment; 2012 Nov 11-14; Hollywood, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2012;21(11 Suppl):Abstract nr 78.