Chronic Pain and Opioid Use in Women Veterans: Is there an Association with Menopause?

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1 Chronic Pain and Opioid Use in Women Veterans: Is there an Association with Menopause? Carolyn Gibson, PhD, MPH San Francisco VA Health Care System and University of California, San Francisco NAMS Annual Meeting, October 12, 2017

2 Chronic pain and opioid use are leading causes of disability and mortality Women are more likely than men to have chronic pain, to be prescribed opioids, and to be coprescribed opioids and sedative-hypnotics. Institute of Medicine, 2011; Oliva et al., Pain Med 2010; Jones et al., JAMA 2013; Darnall et al., Pain Medicine 2012; Campbell et al., Am J Public Health 2010

3 Chronic pain and opioid use are leading causes of disability and mortality Since 2000, prescription opioid overdose mortality has increased 265% among men, and 400% among women. Institute of Medicine, 2011; Oliva et al., Pain Med 2010; Jones et al., JAMA 2013; Darnall et al., Pain Medicine 2012; Campbell et al., Am J Public Health 2010

4 Chronic pain and opioid use are primary concerns for woman Veterans health 75% of women Veterans report pain Women Veterans: greater pain intensity, disability, and distress than men Opioids + benzodiazepines 85% among women Veterans with PTSD Nahon et al., J Pain Med, 2016; Driscoll et al., Pain Med 2015; Mosher et al., JGIM 2014; Hawkins, Pain Med 2015

5 High risk for chronic pain, opioid use among women in midlife Chronic pain prevalence increases with aging, some conditions increase with perimenopause Highest use of opioids + sedative-hypnotics, and greatest increase in opioid prescribing rates, among women aged Since 2000, highest rise in overdose mortality rates is among middle-aged white women Bernardy, 2015; Campbell et al., Am J Public Health, 2010; CDC

6 Does menopause contribute to risk for chronic pain and opioid use? Chronic pain, opioid treatment affected by: Mood and mental health comorbidities Sleep difficulty Effects of reproductive hormones on pain modulation, pain sensitivity Martínez-Jauand et al., Clin Rheumatol 2013; Lee et al., J Pain, 2017

7 Does menopause contribute to risk for chronic pain and opioid use? 1) Examine associations between menopause and chronic pain among women Veterans. 2) Examine associations between menopause and opioid use among women Veterans with documented chronic pain.

8 Study design National Cohort Study: De-identified medical records, all Veterans in Department of Veterans Affairs (VA) health care system Analytic cohort: Women Veterans with 1 VA visit in fiscal years 2014 and 2015 All variables defined from ICD-9 diagnostic and procedure codes, pharmacy data

9 Menopause-related diagnoses, treatments, and procedures 1 of the following: Hysterectomy and/or bilateral oophorectomy Menopause-related diagnoses on 2 encounters Hormone therapy

10 Chronic pain and opioid use 1. Chronic pain: Pain diagnoses from same category on 2 encounters, 90 days apart 2. Long-term opioid use: Prescribed oral opioid medication for 90 days 3. Co-prescribed opioids + sedative-hypnotics: Prescribed oral opioid medication for 90 days and overlapping sedative-hypnotic prescriptions

11 Statistical Analyses 1) menopause chronic pain 2) menopause opioid use Multivariable logistic regression, adjusted for age, race, BMI, any mental health diagnosis, any substance use diagnosis

12 Sample characteristics Full cohort N=422,737 Age (mean, SD) 47.3 (13.5) BMI: overweight/obese 61% Race White 59% Black 29% Other 5% Mental health diagnoses 11-17% Substance/alcohol use 4% Menopause 6% Chronic pain 46%

13 Sample characteristics: Chronic pain Full cohort Chronic pain N=422,737 N=194,989 Age (mean, SD) 47.3 (13.5) 49.2 (12.9) BMI: overweight/obese 61% 71% Race White 59% 59% Black 29% 31% Other xx xx Mental health diagnoses 11-17% 15-24% Substance/alcohol use 4% 5% Menopause 6% 9% Chronic pain 46% Long-term opioid use 40% Opioid + sedative-hypnotics 24%

14 Menopause is associated with chronic pain menopause chronic pain OR 1.85 (95% CI ) Multivariable logistic regression, adjusted for age, race, BMI, any mental health diagnosis, any substance use diagnosis

15 Menopause is associated with chronic pain Chronic pain OR (95% CI) Menopause 1.85 ( ) Age ref ( ) ( ) ( ) ( ) Mental health disorders 2.29 ( ) Full sample, n=422,737 Adjusted for age, race, BMI, any mental health diagnosis, any substance use disorder

16 Menopause is associated with chronic pain Chronic pain OR (95% CI) Menopause 1.85 ( ) Age ref ( ) ( ) ( ) ( ) Mental health disorders 2.29 ( ) Full sample, n=422,737 Adjusted for age, race, BMI, any mental health diagnosis, any substance use disorder

17 Menopause is associated with long-term opioid use menopause long-term opioid use OR 1.15 (95% CI ) Multivariable logistic regression, adjusted for age, race, BMI, any mental health diagnosis, any substance use diagnosis

18 Menopause is associated with co-prescribed opioids + sedative-hypnotics menopause opioid + sedative-hypnotics OR 1.18 (95% CI ) Multivariable logistic regression, adjusted for age, race, BMI, any mental health diagnosis, any substance use diagnosis

19 Menopause is associated with opioid use Co-prescribed opioids + sedative-hypnotics OR, 95% CI Menopause 1.18 ( ) Age ref ( ) ( ) ( ) ( ) Mental health disorders 1.95 ( ) Subsample of women with chronic pain, n=194,989 Adjusted for age, race, BMI, any mental health diagnosis, any substance use disorder

20 Menopause is associated with opioid use Co-prescribed opioids + sedative-hypnotics OR, 95% CI Menopause 1.18 ( ) Age ref ( ) ( ) ( ) ( ) Mental health disorders 1.95 ( ) Subsample of women with chronic pain, n=194,989 Adjusted for age, race, BMI, any mental health diagnosis, any substance use disorder

21 Strengths and Limitations Strengths Real world health care data Clinical diagnoses Large sample Limitations Subject to missing information, miscoding Generalizability may be limited No ability to examine causality or mechanisms linking menopause and outcomes

22 Conclusions Menopause transition may be an underrecognized period of risk for chronic pain, + high-risk opioid use Treatment decisions should be informed by potential risks, in midlife and beyond Research is needed to better identify and understand the role of menopause in chronic pain complaints and treatment

23 Thank you! Yongmei Li, PhD Dan Bertenthal, MPH Alison Huang, MD, MAS Karen Seal, MD, MPH Research supported in part by the OAA Advanced Fellowship Program in Women's Health at the San Francisco VA Health Care System (CJG) and the VA HSR&D QUERI (Evaluation of the Implementation of the Integrated Pain Team Clinic; KHS, YL). No conflicts of interest to report.