Does Opioid Therapy Affect Quality of Care for Diabetes Mellitus?
Published Online: April 02, 2009
Adam J. Rose, MD, MSc; John A. Hermos, MD; Susan M. Frayne, MD, MPH; Leonard M. Pogach, MD, MBA; Dan R. Berlowitz, MD, MPH; and Donald R. Miller, ScD
Understanding the role of clinical complexity as a determinant of quality of care is a major research goal.1 In previous studies,2-9 the effect of clinical complexity on quality of care has varied depending on the diagnoses, the clinician and patient, and the clinical environment. Seeking to harmonize these mixed results into a unifying theory, Piette and Kerr10 proposed that symptomatic conditions may have a greater effect on quality of care than asymptomatic conditions and that conditions with dissimilar management goals (“discordant conditions”) may have a greater effect than those with similar goals (“concordant conditions”).
By this reasoning, chronic pain could have a considerable adverse effect on quality of care for unrelated conditions. Pain is highly symptomatic, and pain management is discordant with the management of other conditions.11 While the use of opioids to treat chronic noncancer pain is increasingly accepted,12 opioid therapy may present additional challenges due to the potential for abuse, dependence, and diversion and due to conflicts over appropriate dosages.13-19 However, opioid therapy could also facilitate care for unrelated conditions. Patients receiving opioids may visit the clinic more often, allowing more opportunities for medical management.10 Adequate treatment of pain may improve the patient’s functional status and quality of life,12 allowing greater focus on self-care activities.
Diabetes mellitus, a common, costly, and highly morbid condition,20,21 is a good condition in which to examine this possibility. Adequate management of diabetes requires collaboration among clinicians and the patient within a system of care,22-27 and explicit guidelines and diabetes performance targets exist with which to examine the adequacy of diabetes care.28-30 Krein et al31 showed that among patients with diabetes, chronic pain is a barrier to the completion of self-care activities such as taking medications, exercising, and pursuing a prudent diet. However, the effect of pain on process and outcome measures of diabetes care is unknown. In addition, no study has specifically examined the effect of opioid therapy on the quality of care for unrelated chronic conditions, but there is reason to believe that opioid therapy may impart more complexity and challenge than pain alone.32
To clarify whether the net effect of opioid therapy is to promote or impede care for diabetes, we analyzed a large database of patients with diabetes in the US Department of Veterans Affairs (VA) and identified those receiving chronic opioid therapy. We compared patients receiving chronic opioids versus patients not receiving opioids regarding selected diabetes performance measures. We hypothesized that the distractions and concerns associated with chronic opioid therapy, as well as perhaps other characteristics of patients with chronic pain, would be reflected in worse diabetes performance measures. We also hypothesized that among those receiving opioids there would be a dose-response relationship between higher opioid dosages and decrements in diabetes performance measures.
We identified subjects from the Diabetes Epidemiology Cohort, which comprises all patients with diabetes seen in the VA.21 The Diabetes Epidemiology Cohort links administrative, laboratory, and pharmacy data from the VA with Medicare claims, providing a rich data set for analysis.21,33 We first looked at all veterans treated for diabetes during fiscal year (FY) 2004 whose diabetes had been diagnosed before the start of FY 2002. Based on earlier work,21 we defined patients as having diabetes if they had at least 2 International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for diabetes or any prescriptions for antiglycemic medications within a 2-year period.
We excluded patients who had an ICD-9-CM diagnosis of malignant neoplasm (other than basal or squamous carcinoma of the skin) within 2 years of study inception. The management of cancer-related pain is qualitatively different; moreover, diabetes performance measures may not apply to patients with active malignant neoplasms. We also excluded all patients receiving methadone hydrochloride or buprenorphine hydrochloride–naloxone hydrochloride for treatment of opioid dependence. Finally, we excluded patients who had fewer than 2 VA primary care visits in FY 2004, as a large portion of their diabetes care may not appear in our database.
This study was approved by the Institutional Review Board of Bedford VA Medical Center.
Independent Variable: Chronic Opioid Therapy
Our independent variable was the prescription of chronic opioids. We considered the following “major” opioids: codeine, fentanyl citrate, hydrocodone, hydromorphone hydrochloride, methadone, morphine sulfate, and oxycodone; all are Schedule II or III controlled substances according to the US Drug Enforcement Administration.34 Any formulation suitable for outpatient administration was considered, including tablets, patches, elixirs, and sprinkles. We also included formulations that combine opioids with other drugs such as acetaminophen. Buprenorphine, butorphanol, nalbuphine hydrochloride, pentazocine, and propoxyphene, which are less potent, were considered “minor” opioids.34
Patients who received at least 6 prescriptions for major opioids during FY 2004, with or without additional minor opioids, constituted the chronic opioid group (cases). This cutoff of 6 prescriptions was chosen to distinguish treatment for chronic pain from treatment for acute pain and is consistent with previous definitions of chronic pain.17,18 Patients who received any major or minor opioids during FY 2004 but did not meet criteria for the case group were excluded from the study. We randomly selected controls from among the remaining patients, who had received no opioids during FY 2004, to achieve a control group approximately 4 times as numerous as the case group.
Dependent Variables: Diabetes Performance Measures
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