e23347 Background: Evaluating trends in opioid prescribing for veterans with cancer is essential for understanding the impact of national opioid stewardship policies designed to reduce opioid misuse. Methods: We used national Veterans Health Administration (VHA) electronic health record data from January 1, 2000, through December 31, 2021 for individuals with at least one year of continuous VHA care. Cancer patients were veterans who had a diagnosis of a primary malignancy at any point during the study period. Demographic characteristics including race and ethnicity categories were recorded at the time of first VHA encounter. We identified all outpatient pharmacy records for prescriptions of Schedule II opioid analgesics. Among patients diagnosed with cancer, we further determined the timing of the first opioid prescription relative to the cancer diagnosis date. For individuals who received at least one outpatient opioid prescription, we calculated the annual opioid exposure in morphine milligram equivalents (MMEs), as well as total days of opioid prescriptions and the number of prescriptions they received for each of the years they were on opioids. Results: Participants included 2,293,690 veterans diagnosed with cancer and 7,934,886 veterans without cancer. Veterans with cancer were more likely to be prescribed opioids compared to veterans without cancer (59.3% vs. 35.5%), received higher annual MMEs (1,842 vs. 785) and averaged 39 vs. 24 days of annual opioid prescription. Among cancer patients, there was a marked difference between those who started opioids before cancer diagnosis (3,652±8,151 MME) versus opioid-naïve cancer patients (915±3,732 MME; p<0.001). Opioid prescribing increased from 2000- 2012, when it started declining to 15.1% in cancer patients and 8.2% in non-cancer patients in 2021. The decline was particularly pronounced among cancer patients who had started opioids before cancer diagnosis. Similar patterns were observed for median MME, median days on opioids per year, and average number of opioid prescriptions per patient. Cancer patients who received opioids were significantly more likely to be diagnosed with substance use disorder or opioid use disorder compared with those who did not receive opioids. Veterans of Asian ancestry were least likely to receive opioids (40.4%) and had the lowest MME and number of days on opioids compared with all race and ethnicities. Conclusions: Opioid prescribing patterns changed substantially in the VHA during the era of national stewardship initiatives, especially among veterans with cancer. These changes highlight critical shifts in clinical practice but also emphasize the importance of evaluating how these changes have affected pain management and outcomes in veteran populations. Differences in opioid prescription across racial and ethnic groups demand attention to ensure equitable pain management.
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