Temporal Trends in Opioid-Related Care and Pain Among Veterans at the End of Life

In response to the opioid crisis, federal guidelines were implemented, including the Veterans Health Administration's (VA) Opioid Safety Initiative in 2013. The impact of policies on patients near the end of life is unknown.

Examine temporal trends in opioid prescribing, pain, and opioid overdoses among Veterans near the end of life.

Retrospective, time series analysis of VA decedents between October 2009 and September 2018 whose next-of-kin participated in VA's Bereaved Family Survey (BFS). Using multivariate regression to adjust for sociodemographic and clinical covariates, we examined temporal trends in outpatient opioid prescribing, uncontrolled pain based on BFS report, and opioid overdose-related hospitalizations, in the last month of life, overall and by clinical diagnosis (cancer versus non-cancer).

Among 79,409 decedents, mean daily outpatient opioid dose in morphine milligram equivalents in the last month of life decreased from 4.6 mg in 2010 to 2.1 mg in 2018 (adjusted change -0.20 mg/year; P < .001). Opioid overdose-related hospitalization decreased from 0.8% in 2010 to 0.1% in 2018 (adjusted percentage point [PP] change -0.06 PP/year; P < .001). Among the 63,965 Veterans with pain data, the percentage with frequent uncontrolled pain increased from 48.8% in 2010 to 52.2% in 2018 (adjusted PP change +1.37 PP/y; P < .001). Patterns were similar among patients with cancer versus non-cancer conditions.

Over a time period during which opioid safety initiatives were implemented, opioid prescribing near the end of life decreased, accompanied by decreases in opioid-related hospitalizations but increases in pain. These findings suggest that important tradeoffs may exist between reducing opioid-related serious adverse events and undertreating patient pain in the last month of life. Opioid prescribing guidelines could consider incorporating prognosis into recommendations.