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During the study period, nearly 21,000 patients had their opioid dose escalated. Dose escalation was defined as a more than 20% increase in average daily dose. These patients were compared with more than 32,000 patients who continued to take the same opioid dose.
Patients rated their pain on the Numerical Rating Scale during routine clinical encounters. On the scale, 0 means no pain and 10 means the worst pain imaginable. This scale is one of the most common self-report pain measures.
Patients in the dose escalation group had consistently higher average pain scores than the maintainer group both before and after dose escalation, although the overall differences were small. However, the results show that their pain scores did not go down to any significant degree after their medication doses were increased. After 180 days after dose escalation, average pain scores only decreased by 0.1 on the pain scale. Changes in pain rating need to be at least 0.5 to 1.0 to be meaningful, according to the researchers. In fact, over the same period of time the average pain score for patients who kept the same dosage decreased by 0.3, a greater change than in the escalation group.
The results led the researchers to conclude that "increasing opioid doses was not associated with improvements in pain."
The findings add to mounting evidence that opioid dose escalation does not lead to significantly improved pain scores. A 2016 study by researchers at the VA Portland Health Care System found that opioid prescriptions may actually be linked with a lower likelihood of improved pain scores. Another study by the same group, involving both veterans and privately insured patients, found that higher opioid doses were associated with worse pain outcomes.
VA has taken steps to reduce opioid prescribing in response to the nationwide opioid epidemic. In 2013, VA launched the Opioid Safety Initiative. As a result, the number of veterans prescribed opioids each year has decreased by 25% from the rate in 2013. As of 2016, only about 16% of VA patients received opioid prescriptions. The decline is mostly due to less long-term opioid prescribing, as opposed to short-term use for acute pain. Veterans are also receiving more non-opioid pain therapies, as well as more substance use disorder treatment. Source:
Veterans Affairs Research Communications Journal references:
Hayes, C.J et al. (2020) Impact of opioid dose escalation on the development of substance use disorders, accidents, self‐inflicted injuries, opioid overdoses and alcohol and non‐opioid drug‐related overdoses: a retrospective cohort study. Addiction . doi.org/10.1111/add.14940 .
Hayes, C.J et al. (2020) Impact of opioid dose escalation on pain intensity: a retrospective cohort study. Pain . doi.org/10.1097/j.pain. 1784 .
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