title: The Association Between Receipt of Guideline-Concordant Long-Term Opioid Therapy and All-Cause Mortality.
abstract: OBJECTIVE
  For patients receiving long-term opioid therapy (LtOT), the impact of guideline-concordant care on important clinical outcomes--notably mortality--is largely unknown, even among patients with a high comorbidity and mortality burden (e.g., HIV-infected patients). Our objective was to determine the association between receipt of guideline-concordant LtOT and 1-year all-cause mortality.
  
  
  METHODS
  Among HIV-infected and uninfected patients initiating LtOT between 2000 and 2010 through the Department of Veterans Affairs, we used Cox regression with time-updated covariates and propensity-score matched analyses to examine the association between receipt of guideline-concordant care and 1-year all-cause mortality.
  
  
  RESULTS
  Of 17,044 patients initiating LtOT between 2000 and 2010, 1048 patients (6%) died during 1 year of follow-up. Patients receiving psychotherapeutic co-interventions (hazard ratio [HR] 0.62; 95% confidence interval [CI] 0.51-0.75; P < 0.001) or physical rehabilitative therapies (HR 0.81; 95% CI 0.67-0.98; P = 0.03) had a decreased risk of all-cause mortality compared to patients not receiving these services, whereas patients prescribed benzodiazepines concurrent with opioids had a higher risk of mortality (HR 1.39; 95% CI 1.12-1.66; P < 0.001). Among patients with a current substance use disorder (SUD), those receiving SUD treatment had a lower risk of mortality than untreated patients (HR 0.47; 95% CI 0.32-0.68; P = < 0.001). No association was found between all-cause mortality and primary care visits (HR 1.12; 95% CI 0.90-1.26; P = 0.32) or urine drug testing (HR 0.96; 95% CI 0.78-1.17; P = 0.67).
  
  
  CONCLUSIONS
  Providers should use caution in initiating LtOT in conjunction with benzodiazepines and untreated SUDs. Patients receiving LtOT may benefit from multi-modal treatment that addresses chronic pain and its associated comorbidities across multiple disciplines.
authors: Yale School of Public Health, Yale University, New Haven, CT, USA. julie.gaither@yale.edu.|VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA. julie.gaither@yale.edu.|Yale Center for Medical Informatics, Yale School of Medicine, Yale University, New Haven, CT, USA. julie.gaither@yale.edu.|Center for Interdisciplinary Research on AIDS, Yale School of Public Health, Yale University, New Haven, CT, USA. julie.gaither@yale.edu.
authors: Julie R
authors: JR
authors: Gaither
authors: VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA.|Department of Psychiatry, Yale School of Medicine, Yale University, New Haven, CT, USA.
authors: Joseph L
authors: JL
authors: Goulet
authors: VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA.|Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA.
authors: William C
authors: WC
authors: Becker
authors: Institute for Health, Health Care Policy, and Aging Research, Rutgers University, New Brunswick, NJ, USA.
authors: Stephen
authors: S
authors: Crystal
authors: Center for Interdisciplinary Research on AIDS, Yale School of Public Health, Yale University, New Haven, CT, USA.|Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA.
authors: E Jennifer
authors: EJ
authors: Edelman
authors: VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA.
authors: Kirsha
authors: K
authors: Gordon
authors: VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA.|Department of Psychiatry, Yale School of Medicine, Yale University, New Haven, CT, USA.
authors: Robert D
authors: RD
authors: Kerns
authors: Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA.|Atlanta VA Medical Center, Decatur, GA, USA.
authors: David
authors: D
authors: Rimland
authors: VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.
authors: Melissa
authors: M
authors: Skanderson
authors: Yale School of Public Health, Yale University, New Haven, CT, USA.|VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA.|Yale Center for Medical Informatics, Yale School of Medicine, Yale University, New Haven, CT, USA.|Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA.
authors: Amy C
authors: AC
authors: Justice
authors: Yale School of Public Health, Yale University, New Haven, CT, USA.|Center for Interdisciplinary Research on AIDS, Yale School of Public Health, Yale University, New Haven, CT, USA.|Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA.
authors: David A
authors: DA
authors: Fiellin
mesh_terms: D000328:Adult; D000701:Analgesics, Opioid / Q000008:administration & dosage* / Q000009:adverse effects*; D001569:Benzodiazepines / Q000627:therapeutic use; D059350:Chronic Pain / Q000188:drug therapy; D016208:Databases, Factual; D004334:Drug Administration Schedule; D004359:Drug Therapy, Combination; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D015658:HIV Infections / Q000401:mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009026:Mortality; D017410:Practice Guidelines as Topic; D019966:Substance-Related Disorders / Q000401:mortality / Q000628:therapy; D014481:United States / Q000453:epidemiology
chemical_list: D000701:Analgesics, Opioid; D001569:Benzodiazepines
keywords: Opioid analgesics; mortality; pain; practice guideline; quality of health care