Substance use outcomes of opioid dose reduction and discontinuation

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Project Abstract To address Priority #2 of RFA-CE-16-003, we propose Heroin and Other Illicit Opioid Use and Overdose Among Pain Patients (HOPP), a longitudinal retrospective study of patients who have received opioid pain relievers (OPRs) for chronic non-cancer pain (CNCP) in the setting of shifting opioid prescribing policies. Many health systems, including the safety net primary care clinics of the San Francisco Health Network (SFHN), are implementing substantial changes in opioid prescribing policy. These changes include dose limits, restrictions on prescribing to persons with substance use disorders (SUDs), and required urine testing, pain agreements, and checks of the prescription drug monitoring program (PDMP). Many of these changes are designed to reduce OPR diversion and are expected to lead to termination of OPR therapy for many patients. The impact of these changes on those already reliant upon opioids is unknown, although anecdotal evidence suggests that some patients initiate or resume heroin or other illicit opioid use as prescribed opioids are terminated. In addition, there is concern that these prescribing changes could increase mortality related to heroin and other illicit opioid overdose. To address these major gaps in knowledge, we will recruit 600 patients prescribed OPRs long-term for CNCP from the SFHN registry of patients on chronic opioids for pain, including 150 each whose OPRs have been discontinued, reduced, maintained, and increased. HOPP participants will undergo a detailed interview involving historical reconstruction of their substance use patterns since 2012 and an independent electronic medical record chart extraction to identify OPR and other controlled substance prescription patterns, exposure to opioid stewardship interventions, and medical co-morbidities to characterize the association between changes in OPR prescribing and initiation and use of heroin and other illicit opioids (Aim 1) and overdose involving heroin and other illicit opioids (Aim 2). To capture overall effects in the presence of feedback from earlier outcomes to exposure, we will use a nested cohorts approach to estimate the direct and indirect effects of change in OPR dose. Exploratory analyses will include assessing the association between changes in OPR dose and medical care adherence as well as opioid-related emergency department visits, the association of clinic-level opioid stewardship policy and heroin and other illicit opioid use, and the association between change in OPR dose as subsequent opioid overdose mortality among the full cohort of pain management patients.