Prescription opioid tapering practices and outcomes at a rural VA health care system

Abstract: Introduction: Rural Veterans face higher rates of chronic pain, mental health disorders, and opioid use compared to their urban counterparts. Prescription opioids are more frequently prescribed in rural settings, raising concerns about overdose and addiction risks, particularly in the context of opioid tapering and de-prescribing efforts. This study aims to examine the clinical characteristics, tapering practices, and outcomes for rural Veterans undergoing opioid tapering at a rural Veterans Affairs (VA) healthcare system. Methods: This retrospective, cross-sectional study analyzed data from the Salem VA Health Care System, which primarily serves rural Veterans in central Appalachia. Veterans prescribed opioids for chronic, non-cancer pain at doses ≥90 Morphine Equivalent Daily Dose (MEDD) for at least 90 days, and who underwent opioid tapering between fiscal years 2017 and 2020, were included. Data on opioid tapering speeds, withdrawal symptoms, pain intensity, and mortality were extracted from electronic medical records. Outcome variables were calculated as proportions for dichotomous variables and mean with standard deviation for continuous variables. Results: Fifty-eight Veterans met the inclusion criteria, with a median age of 66 years. Most were male (87.9%) and White (75.9%), with 81% having a mental health comorbidity. Among those with a documented tapering plan (n = 31), tapering speeds varied from slow (1 patient) to abrupt cessation (10 patients). Of the 58 Veterans, 36 successfully tapered to discontinuation, while 12 reduced their opioid dose. However, 10 patients experienced abrupt cessation, often without documented reasons. There were no suicide attempts recorded during the tapering period, though 7 patients (12%) died after tapering, including 4 from opioid-related overdoses. Pain assessments were inconsistently documented, with 37.9% reporting increased pain post-taper, and 36.2% having no pain assessments recorded. Conclusion: This study highlights significant risks associated with opioid tapering in rural Veterans, including elevated mortality and suicidal ideation. The findings underscore the need for patient-centered tapering practices, consistent pain assessment, and comprehensive biopsychosocial treatment plans. Larger studies focused on rural Veteran populations are warranted to better understand the impact of opioid tapering and develop effective interventions.