(ASPOT46) Comparative Effectiveness of Short Acting Opioid Escalation and Initiation of a Long-Acting Opioid in Nursing Home Residents

Background: Modifications to opioid regimen for persistent pain are typically made after an initial period of short acting opioid use. Regimen changes may include an escalation of the short acting opioid (SAO) dosage or an initiation of a long-acting opioid (LAO) as a switch or add-on therapy. Little is known about the comparative effectiveness between these alternative regimens/options in long stay nursing home residents.

Objectives: To evaluate the comparative effectiveness of SAO dose escalation and LAO initiation in long stay nursing home residents

Methods: A retrospective cohort analysis of US long-stay nursing home residents was conducted using the 2011-2016 national Minimum Dataset (MDS) version 3.0 and linked Medicare data. Opioid regimen changes were identified using Part D dispensing claims to identify dosage escalation of SAOs, initiation of a LAO, or a switch to LAO. Outcomes included indices of pain occurrence, frequency, and severity reported on the earliest MDS assessment within 3-months following the opioid regimen change. Prevalence ratios of pain and depression indices were quantified using doubly robust inverse probability of treatment (IPT) weighted log-binomial regression.

Results: The study cohorts included 2,072 SAO dose escalations, 575 LAO add-on initiations, and 247 LAO switch initiations. After IPT weighting, all observed covariates were balanced across the opioid regimen cohorts. With our doubly robust models analyzing the weighted population with further multivariable adjustment for the baseline indicator of the pain and mood indicators, we observed comparable improvements in pain across the opioid regimen cohorts (all observed prevalence ratios and 95% confidence intervals were consistent with null associations). A substantial number of residents continued to report frequent/constant pain (36% in SAO Escalation Cohort, 42% in LAO Add-on Cohort, 42% in the LAO Switch Cohort). The distribution of depressive symptoms was similar regardless of the opioid regimen change.

Conclusions: Initiation of an LAO as an add-on to SAO or a switch from SAO had comparable effects on pain and mood to SAO dose escalation without initiation of an LAO. Though fewer residents reported any pain after the regimen change, persistent pain was reported by the majority of residents. None of the opioid regimen changes substantially impacted the resident depressive symptoms.