Temporal trends in opioid-related care and pain among Veterans at the end of life

Abstract: Context: 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. Objective: Examine temporal trends in opioid prescribing, pain, and opioid overdoses among Veterans near the end of life. Methods: 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). Results: 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/year; P<.001). Patterns were similar among patients with cancer versus non-cancer conditions. Conclusions: 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.

Read the full article
Report a problem with this article

Related articles

  • More for Policy & Practice

    U.S. Veterans’ reintegration challenges: Policies, impacts, and reforms

    Abstract: This paper provides a comprehensive examination of U.S. veterans’ reintegration challenges in the post-2009 era, emphasizing comparative policy initiatives, long-term social impacts, and key legislative reforms. Drawing on federal reports, policy analyses, and statistical data, it offers an overview of the evolving landscape for veterans in domains such as employment, housing, mental health, and justice involvement. The analysis highlights substantial progress in reducing veteran unemployment—reaching historically low rates below the national average—and cutting homelessness by more than half over the past decade through expanded housing vouchers and support services. Despite these gains, persistently high suicide rates underscore the need for enhanced mental health outreach, early intervention, and strengthened community-based prevention. The review of major legislative acts—including the Post-9/11 GI Bill, the VOW to Hire Heroes Act, and the Veterans Treatment Court Coordination Act—reveals an ongoing commitment to supporting veterans’ transition. However, significant gaps persist, particularly for veterans with other-than-honorable discharges, those in rural areas with limited program access, and subgroups at elevated risk for economic or mental health struggles. By comparing best practices domestically and internationally, this paper identifies policy areas ripe for further development: family-inclusive services, expanded justice diversion pathways, broader eligibility for VA benefits, and improved data collection on incarcerated veterans. Ultimately, the findings suggest that sustained, evidence-based investments in veterans’ well-being can help ensure that no service member is left behind, while charting a path toward an inclusive national strategy that maximizes veterans’ long-term potential in civilian life.

    Well-Being Peer reviewed