The Prevalence of Mental Health Diagnoses and Biopsychosocial Treatment Plans During Opioid Tapering at a Rural Appalachian VA

 The Prevalence of Mental Health Diagnoses and Biopsychosocial Treatment Plans During Opioid Tapering at a Rural Appalachian VA

Background: The use of long-term opioids to treat chronic pain continues to dominate the treatment regimens in rural communities of America. It is widely appreciated that long-term use of opioid medications is not a safe and effective method for treating chronic pain. Thus, many providers and their patients have chosen to taper or discontinue the use of these medications, which involves an increased risk of suicide. The Veteran population is at an even higher risk for suicide during a tapering period. The use of a biopsychosocial chronic pain treatment plan while initiating an opioid taper has proven to help mitigate this risk.

Purpose/Objectives: This research aimed to determine if rural Appalachian Veterans had a documented biopsychosocial treatment plan to address their chronic pain during an opioid tapering period, including engagement in mental health care for those with mental health comorbidities.

Method:

A retrospective chart review was conducted to identify Veterans with active opioid prescriptions > 50 morphine equivalent daily dose prior to dose reduction, >90 days duration, and for chronic, non-cancer pain between 2017-2020. Of those, 150 patients were randomly sampled and included if they had MEDD >90 before taper/intent to taper, discontinue evident within the chart 12 months before or after the taper, opioids were not stopped due to “lost to follow up”,  Veteran was not in palliative/hospice/long-term care or active cancer treatment, opioids were not prescribed by non-VA prescribers, Veteran had not moved to a VA facility with unavailable documentation, and was not unintentionally tapered/discontinued. Researchers extracted data from the medical record, which included the presence of a biopsychosocial treatment plan for chronic pain, mental health diagnoses, and follow-up with a mental health provider during or one year proceeding the taper. Descriptive statistics were utilized.

Results: There were 58 Veterans included in this study. No participants had a documented biopsychosocial treatment plan to address their pain. The Veterans with a mental health comorbidity comprised 81% of the sample including those diagnosed with personality disorders (15%), sleep disorders (36.2%), anxiety disorders (24%), depressive disorders (51.7%), Posttraumatic Stress Disorder (34.5%), bipolar disorders (5.2%), those on the schizophrenia spectrum (5%), and  those with other mental health disorders (3.5%). Over a quarter of the total sample Veterans (27.7%) did not have a follow-up appointment with a mental health provider during or within a year before the tapering period.

Conclusions: Despite the vast majority of Veterans being diagnosed with a mental health comorbidity, none had a documented biopsychosocial treatment plan to address their chronic pain. This is particularly alarming given that mental health comorbidities are a known exacerbating factor for chronic pain and the tapering period is a known high-risk period for suicide. Rural Appalachian Veterans are already at an increased risk for both suicide and mental health comorbidities compared to their urban counterparts. Taken together, these findings suggest that providers offering opioid prescriptions must conduct a biopsychosocial assessment for chronic pain. Interdisciplinary teams have shown promise in addressing each component of the biopsychosocial model and are considered the gold standard treatment for chronic pain. Providers who wish to taper opioids may benefit from consultation with an interdisciplinary team that can follow these Veterans closely during the tapering process, assessing and treating mental health comorbidities, and emphasizing the role of active self-management strategies which have demonstrated effectiveness

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