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. Author manuscript; available in PMC: 2015 Nov 1.
Published in final edited form as: Pain. 2014 Aug 29;155(11):2337–2343. doi: 10.1016/j.pain.2014.08.033

Patterns of Opioid Use for Chronic Non-Cancer Pain in the Veterans Health Administration from 2009 to 2011

Mark J Edlund 1,2,*, Mark A Austen 3, Mark D Sullivan 4, Bradley C Martin 3,5, James S Williams 3, John C Fortney 3,6,7, Teresa J Hudson 3,6
PMCID: PMC4252255  NIHMSID: NIHMS635009  PMID: 25180008

Abstract

Although opioids are frequently prescribed for chronic non-cancer pain (CNCP) among Veterans Health Administration (VHA) patients, little has been reported on national opioid prescribing patterns in the VHA. Our objective was to better characterize the dosing and duration of opioid therapy for CNCP in the VHA. We analyzed national VHA administrative and pharmacy data for fiscal years 2009 to 2011. For individuals with CNCP diagnoses and any opioid use in the fiscal year, we calculated the distribution of individual mean daily opioid dose, individual total days covered with opioids in a year, and individual total opioid dose in a year. We also investigated the factors associated with being in the top 5% of individuals for total opioid dose in a year, which we term receipt of high volume opioids. About half of the patients with CNCP received opioids in a given fiscal year. The median daily dose was 21 milligrams morphine equivalents. Approximately 4.5% had a mean daily dose higher than 120 milligram morphine equivalents. The median days covered in a year was 115 to 120 days in these years for those receiving opioids. Fifty-seven percent had at least 90 days covered with opioids per year. Major depression and post-traumatic stress disorder were positively associated with receiving high volume opioids, but non-opioid substance use disorders were not. Among VHA patients with CNCP, chronic opioid therapy occurs frequently, but for the large majority of patients the average daily dose is modest. Doses and duration of therapy were unchanged 2009–2011.

Keywords: chronic noncancer pain, opioids, Veterans

INTRODUCTION

Chronic non-cancer pain (CNCP) is common in Veterans Health Administration (VHA) patients, with over 50% of VA primary care patients reporting chronic pain [25; 26; 35; 38; 42]. Frequently occurring disorders include neck and back pain, arthritis, headache/migraine, and neuropathic pain [19]. Opioids are commonly prescribed for patients with CNCP, in both VHA [15; 47] and non-VHA populations [9; 40]. Although supported by guidelines [1; 12; 21; 22], this use is controversial. In particular there are concerns over opioid misuse and abuse, opioid overdose deaths, and the association of opioids with emergency room visits and fractures [3–8; 10; 13; 16; 23; 29; 30; 32–34; 40]. Negative outcomes are particularly common among patients receiving high dose opioids [8; 10; 16; 34].

Opioid over-prescribing is a concern in the VHA, and the VHA has been in the vanguard of developing opioid prescribing guidelines. An October 28, 2009 VHA pain management directive stresses the risks associated with opioid use and mandates certain clinical changes, including the adoption of a stepped care approach, based on a biopsychosocial model, with quality of life as the primary outcome [14]. In May 2010 guidelines were released for the management of opioid therapy for chronic pain, along with new patient provider tools, including a sample opioid pain care agreement, opioid drug tables, and a table on urine drug screens [43]. However, despite the high prevalence of CNCP and frequent use of opioids among VHA patients with CNCP, there is little in the literature about opioid prescribing patterns in the VHA at a national level, with most studies utilizing either regional data [15; 27; 31; 36; 37] or national subsamples [11].

Our objective was to characterize in greater detail patterns of opioid use for CNCP in the VHA, using national VHA administrative and pharmacy data from fiscal years 2009 to 2011. In particular we investigated the percentage of VHA patients with CNCP who were prescribed any opioids in the past year, and among those who were prescribed opioids: (1) the distribution of individual mean daily opioid dose; (2) the distribution of individual total days covered with opioids in a year; (3) the distribution of individual total opioid dose in a year; and (4) the characteristics of individuals with receipt of high volume opioids. So that we could compare and contrast our results with non-VHA populations we patterned our analytical methods after those from the Trends and Risks of Opioid Use for Pain (TROUP) study [40] [17], a study that investigated opioid prescribing trends among patients with CNCP in Arkansas Medicaid and HealthCore, a consortium of five commercial Blue Cross/Blue Shield health plans representing the West, Mid-West, and South-East regions. The TROUP study utilized data from 2000 to 2005.

METHODS

Data

Data came from the Pharmacy Benefits Management (PBM), the MedSAS service utilization data, the Corporate Data Warehouse, and the Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) roster. All analyses were approved by the Institutional Review Boards of The Central Arkansas Veterans Healthcare System and the University of Arkansas for Medical Sciences. A data use agreement was executed with each data repository.

Study Sample

The study sample consisted of VHA patients in years 2009 to 2011 who met the following criteria. Inclusion Criteria: 1) CNCP diagnosis, as defined by two clinical encounters for the same CNCP condition (neck pain, back pain, arthritis, headache/migraine, or neuropathic pain) at least 30 days apart, but no more than 365 days apart. 2) Age 18 or older. Exclusion Criteria: 1) Cancer diagnosis in the year reported other than non-melanoma skin cancer, 2) resident of VHA nursing home or living in VHA domiciliary, 3) enrolled in VHA hospice benefits, 4) incomplete opioid prescription data, or 5) received a parenteral, suppository, or trans mucosal opioid. These criteria allow us to focus on outpatient enrollees likely receiving opioids for the treatment of CNCP.

Opioid Use

Data included all opioid prescriptions (including date, dose, and type of opioid), other than injectable opioids and opioid suppositories (due to lack of conversion factors). We formed separate analytical files for each fiscal year 2009, 2010, and 2011, and included all individuals with one of the CNCP diagnoses in one of those years. We recorded the total number of opioid prescription fills for each patient within the fiscal year and calculated the number of days covered for each patient in the year accounting for overlapping concurrent opioid therapy, as recorded by the dispensing pharmacist. If any two prescriptions overlapped by greater than 20% or greater than ten days, the overlapping portions of the prescription were assumed to be taken concurrently and the overlapping days were only included once in the opioid days calculation. If the overlap was ≤ 20% and ≤ 10 days the second prescription was shifted and the overlapping days from both the first and second prescription were included in the opioid days calculation. We refer to this variable as the “individual total days covered with opioids in a year.” Total morphine equivalents for each prescription were calculated by multiplying the quantity of each prescription by the strength of the prescription (milligrams of opioid per unit dispensed). The quantity-strength product was then multiplied by conversion factors derived from published sources to estimate the milligrams of morphine equivalent to the opioids dispensed in the prescription [2; 41; 44]. The total opioid dose for a patient in a year was obtained by summing across all prescriptions, which we refer to as the “individual total opioid dose in a year.” The mean dose in morphine equivalents per day covered for each patient was calculated by summing the morphine equivalents for each prescription filled during the year, and dividing by the number of days covered. We call this variable the “individual mean daily opioid dose.”

Other Variables

We used International Classification of Diseases-9th Revision (ICD-9) codes from the MedSAS data to construct variables for mental health diagnoses (major depression, posttraumatic stress disorder, and schizophrenia) and non-opioid substance use disorder. Demographic information such as age, race, gender and marital status were also extracted from the MedSAS files.

To protect against data entry errors and extreme cases, individuals with average daily dose greater than 1000 mg morphine equivalents were excluded from the analysis. This approach conservatively estimates the morphine equivalents. The total excluded was about 0.03% for each year.

Analyses

Results from a consortium of Blue Cross/Blue Shield plans and Arkansas Medicaid suggest that the distribution of individual mean daily opioid dose, individual total days covered with opioids in a year, and individual total opioid dose in a year are all highly right skewed and thus the means are relatively non-informative [17]. Therefore, we investigated the distribution of these variables. To do this, among individuals with a CNCP diagnosis and any opioid use in 2009 we calculated the 10th, 20th, 30th, 40th, 50th, 60th, 70th, 80th, 90th, 95th and 99th percentiles for (i) individual mean daily dose in year 2009, in morphine equivalents, (ii) individual total days covered with opioids in year 2009, (iii) and individual total opioid dose in 2009, in morphine equivalents. That is, for (i), using the distribution of the variable individual mean daily opioid dose, we determined the individual mean daily dosage for an individual in the 10th percentile, the 20th percentile, etc. We performed analogous calculations for fiscal years 2010 and 2011. That is, each year was analyzed as a separate analytical file. Individuals were not followed across years, but may have contributed repeated observations.

We also calculated the percentage of the total opioid morphine equivalents used by the individuals within percentiles in a given year. For example, to determine what fraction of the total opioid morphine equivalents were consumed by all individuals in the 21st to 30th percentile we first summed the total opioid morphine equivalents across all patients in the 21st to 30th percentile, and divided this by the total opioid morphine equivalents in the entire population. Finally, to investigate the characteristics of individuals with high volume opioid receipt we constructed a dichotomous variable indicating whether or not the individual was in the top 5% of individual total annual dose, and utilized logistic regression to assess the association of our sociodemographic and clinical variables with high volume opioid receipt, using data from FY 2011.

RESULTS

The number of VHA patients with CNCP increased slightly from 2009 to 2011, from 1.33 million in 2009 to 1.44 million in 2011 (Table 1), reflecting increases in the number of Veterans receiving care in VHA. In each year about 50% of VHA patients with one of the CNCP diagnoses received at least one opioid prescription. The sociodemographic and clinical profiles of CNCP patients who received any opioids, those who did not receive any opioids, and the total CNCP sample, is shown in Table 2 (FY 2011 data). Among those receiving opioids, back pain (52%) and arthritis pain (65%) were the most common CNCP diagnoses. Depression (32%), PTSD (21%), and substance use disorders (15%) were common.

Table 1.

Number of VHA patients with chronic non-cancer pain who did and did not receive opioids

2009 2010 2011
Patients received opioids 662,090 (49.7%) 700,140 (49.8%) 720,287 (50.1%)
Patients did not receive opioids 670,720 (50.3%) 705,423 (50.2%) 717,105 (49.9%)
Total 1,332,810 1,405,563 1,437,392
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Table 2.

Sociodemographic and Clinical Characteristics of Fiscal Year 2011 Sample (Percentages in first row are row percentages, all other are column percentages)

Opioid Users Non-Opioid Users Total
N % N % N %
Total 720,287 50.1 717,105 49.9 1,437,392 100
Age
 18 to 25 10,178 1.4 12,890 1.8 23,068 1.6
 26 to 35 48,027 6.7 56,305 7.9 104,332 7.3
 36 to 45 72,463 10.1 66,340 9.2 138,803 9.7
 46 to 55 162,515 22.6 114,818 16.0 277,333 19.3
 56 to 65 267,259 37.1 224,520 31.3 491,779 34.2
 66 to 75 92,162 12.8 120,020 16.7 212,182 14.8
 76 + 67,683 9.4 122,212 17.0 189,895 13.2
Race
 White 503,102 69.9 489,743 68.3 992,845 69.1
 Non-White 158,591 22.0 142,542 19.9 301,133 20.9
 Unknown 58,594 8.1 84,820 11.8 143,414 10.0
Gender
 Male 658,653 91.4 653,231 91.1 1,311,884 91.3
 Female 61,634 8.6 63,874 8.9 125,508 8.7
Marital Status
 Married 372,263 51.7 416,050 58.0 788,313 54.8
 Divorced 199,159 27.6 149,891 20.9 349,050 24.3
 Single 112,351 15.6 108,358 15.1 220,709 15.4
 Widowed 32,158 4.5 36,492 5.1 68,650 4.8
 Unknown 3,365 0.5 5,990 0.8 9,355 0.6
OEF/OIF 58,566 8.1 85,363 11.9 143,929 10.0
Type of Pain
 Neck 81,857 11.4 48,562 6.5 128,419 8.9
 Back 374,753 52.0 230,331 32.1 605,084 42.2
 Arthritis 466,462 64.8 468,735 65.4 935,197 65.1
 Headache 56,569 7.9 57,050 8.0 113,619 7.9
 Neuropathic 100,681 14.1 92,267 12.9 193,948 13.5
Psychiatric Disorders
 Anxiety 222,309 30.9 160,369 22.4 382,678 26.6
 PTSD 150,902 20.9 110,552 15.4 261,454 18.2
 Mood 265,877 36.9 174,243 24.3 440,120 30.6
 Major Depression 230,664 32.0 150,547 21.0 381,211 26.5
 Schizophrenia 13,617 1.9 10,256 1.4 23,873 1.7
 Substance 109,330 15.2 69,902 9.8 179,232 12.5
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Because of the extremely large sample sizes, sociodemographic and clinical differences between those who received any opioids and those who did not were generally all statistically significant, so we comment only on those where there were substantive differences. Those who received opioids were more likely to be divorced (27.6% vs 20.9%), less likely to be married (51.7% vs 58.0%), less likely to be Veterans of recent conflicts (OEF/OIF Veterans) (8.1% vs 11.9%), more likely to have neck pain (11.4% vs 6.5%) and back pain (52.0% vs 32.1%), and more likely to have psychiatric disorders than those who did not (Table 2). Among OEF/OIF Veterans with CNCP, 41% received any opioids (58,566 out of 143,929) versus 51% (661,721 out of 1,293,463) of non OEF/OIF Veterans.

The distribution of individual mean daily opioid dose (percentiles) for 2009 to 2011 is shown in Figure 1 and Table A1. (The data from which Figures 1 to 3 were constructed are shown in Appendix Tables A1, A2, A3). The median dose (50th percentile) in years 2009, 2010, and 2011 were 21.4, 21.4, and 21.2 mg morphine equivalents respectively. Only about 4.5% received more than 120 mg morphine equivalents, which is sometimes used as a measure of high dose opioid therapy [46]. The mean daily dose for an individual in the 99th percentile was 284.4, 282.4 and 280.7 mg morphine equivalents in years 2009, 2010, and 2011 respectively.

Figure 1.

Figure 1

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Distribution of individual mean daily opioid dose for patients with CNCP and any opioid use.

Figure 3.

Figure 3

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Distribution of individual total opioid dose in a fiscal year for patients with CNCP and any opioid use

The median of individual days covered with opioids in a year was 115 days, 118 days, and 120 days, in years 2009, 2010, and 2011 respectively (Figure 2 and Table A2). In each year about 57% of those receiving opioids had at least 90 days of opioid use, which is sometimes used as an indicator of chronic opioid therapy (COT) [15; 20; 45]. About 10% of individuals who received opioids had at least 350 days covered with opioids in a year.

Figure 2.

Figure 2

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Distribution of individual total days covered with opioids in a fiscal year for patients with CNCP and any opioid use.

The median of individual total opioid dose in a year was 2190, 2190, and 2220 mg morphine equivalents in 2009 to 2011 (Figure 3 and Table A3). The 4% of the patients in the 95th to 99th percentiles of total opioid dose accounted for 27% of the total opioid dose (Figure 4 and Table A4). Individuals in the top 1% (i.e., 99th percentile) accounted for another 17%.

Figure 4.

Figure 4

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Percentage of total opioids consumed by individuals within a given percentile.

Our multivariate results from the logistic regression indicated that those more likely to have receipt of high volume opioids in terms of total annual dose included those who were middle aged and white (Table 3). OEF/OIF Veterans were significantly less likely to have high volume opioid receipt (OR=0.38, 95% CI=0.36, 0.41). While PTSD was positively associated with receipt of high volume opioids, the magnitude of the effect was modest (OR=1.10, 95% CI =1.07, 1.13), and smaller than that for depression (OR=1.52, 95% CI=1.49, 1.56). Individuals with non-opioid substance use disorders were less likely to have receipt of high volume opioids, although the effect was small (OR=0.95, 95% CI=0.92, 0.98).

Table 3.

Characteristics associated with high volume opioid receipt

Odds Ratio 95% Confidence Interval P value
Age <0.0001
 18 to 25 1.00 –
 26 to 35 1.65 (1.40–1.96)
 36 to 45 2.02 (1.71–2.38)
 46 to 55 2.71 (2.29–3.19)
 56 to 65 2.35 (1.99–2.77)
 66 to 75 1.56 (1.32–1.84)
 76 + 0.76 (0.64–0.91)
Race <0.0001
 White 1.00 –
 Non-White 0.42 (0.40–0.43)
 Unknown 0.67 (0.65–0.71)
Gender <0.0001
 Male 1.00 –
 Female 0.68 (0.65–0.71)
Marital Status <0.0001
 Married 1.00 –
 Divorced 1.01 (0.98–1.03)
 Single 0.92 (0.89–0.96)
 Widowed 1.07 (1.01–1.14)
 Unknown 0.65 (0.52–0.80)
OEF/OIF 0.38 (0.36–0.41) <0.0001
Type of Pain
 Neck 1.40 (1.36–1.45) <0.0001
 Back 2.64 (2.57–2.71) <0.0001
 Arthritis 0.94 (0.92–0.96) <0.0001
 Headache 1.00 (0.96–1.04)   0.9106
 Neuropathic 1.48 (1.44–1.52) <0.0001
Psychiatric Disorders
 PTSD 1.10 (1.07–1.13) <0.0001
 Major Depression 1.53 (1.49–1.56) <0.0001
 Schizophrenia 0.83 (0.77–0.91) <0.0001
 Substance 0.95 (0.92–0.99)   0.0137
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DISCUSSION

To our knowledge, this is the first detailed national report on opioid prescribing for the entire population of VHA patients with CNCP. Our analyses suggest that VHA patients with the identified CNCP diagnoses are frequently prescribed opioids, with about half receiving some opioids during a 12-month period. Among those VHA patients with CNCP who received opioids, COT was common. Using 90 days covered per year as a threshold for COT, 57% of patients who received any opioids had COT. This is generally higher than we found in HealthCore and Arkansas Medicaid.

On the other hand, opioid doses in VHA were generally modest. More than sixty percent had an average daily dose less than 30 mg morphine equivalents. Only 4.5% received an average daily dose of greater than 120 mg morphine equivalents, which is sometimes used as a marker of high dose opioid therapy [46]. While our data do not allow us to assess the appropriateness of the opioid prescribing in VHA, in recent studies high opioid dose has been shown to be associated with adverse drug events, such as opioid drug overdose [10; 16], fractures [34], and opioid misuse [39]. Our results suggest that this type of high dose opioid prescribing occurs much less frequently among VHA patients, compared to the HealthCore and Arkansas Medicaid populations.

Further, in the HealthCore and Arkansas Medicaid populations, individuals with non-opioid substance use disorders and mental health disorders were more likely to have receipt of high volume opioids. This is important, because non-opioid substance use disorders and mental health disorders are the strongest risk factors for opioid abuse and dependence [18; 19; 28]. Thus, in the HealthCore and Arkansas Medicaid populations, individuals most at risk for development of opioid abuse and dependence were also the most likely to be prescribed chronic high doses (i.e., individuals with high volume opioid receipt) [17]. On the other hand, in VHA individuals with substance use disorders were significantly less likely to receive high volume opioids, and the magnitude of the association of high volume opioid receipt with depression and PTSD in our VHA analyses was smaller than those found in HealthCore and Arkansas Medicaid. Thus, it appears that VHA does better than other health care systems previously studied in terms of patient selection for chronic, high dose opioid therapy.

There has been concern about the use of opioids in OEF/OIF Veterans [6; 23; 27; 35]. However, our results give reason for optimism, as OEF/OIF Veterans with CNCP were less likely to receive opioids than non OEF/OIF Veterans with CNCP (41% vs 51%), and much less likely to receive high volume opioids (OR=0.38, 95% CI=0.36, 0.41).

Opioids are unique in the modern pharmacopeia in that there is no absolute limit to dose (due to the development of tolerance). Because of this, a small percentage of patients may account for a large percentage of the opioids prescribed. In this VHA analysis, the top 1% accounted for 18% of total opioid use, and the top 5% accounted for 45% of total opioid use. Unfortunately, we know very little about these individuals with high volume opioid receipt, as studies to date have only utilized administrative data to established a few of the characteristics of these individuals [17]. Given that this relatively small percentage of individuals use such a large percentage of the total opioids prescribed, we believe a key research priority is to better characterize these users, and the treatment they receive, either through interviews, chart reviews or both. For example, to what extent is there evidence for misuse or diversion among individuals with high volume opioid receipt?

Limitations

Although we utilized conversion factors from published sources to derive morphine equivalents [2; 41; 44] there are no canonical conversion tables, and estimates of conversion factors differ, generally by small amounts. Differences among conversion tables were resolved by consensus among the clinicians on this study, in collaboration with other researchers and clinicians. We relied upon administrative data for diagnoses and for pharmacy records. No independent clinical assessment of patients to confirm diagnoses could be done. Pain diagnoses have high specificity, although sensitivity is likely lower [24]. We did not examine all possible CNCP diagnoses, but focused on those which are most common, which account for a large majority of individuals with CNCP [19]. The entire population of individuals with any possible CNCP diagnosis would be higher. Our results may not be applicable to other CNCP conditions, such as fibromyalgia. We focused on national level estimates, but there is substantial geographical variation [7]. Our study does not reflect opioids received outside of the VHA system. As we analyzed each year’s data separately and did not track individual subjects’ status from year to year our results represent population trends and not the trends of individual enrollees. We compared VHA data from 2009 to 2011 with HealthCore and Arkansas Medicaid data from 2005; rates of opioid prescribing in HealthCore and Arkansas Medicaid may have changed during this time, or there could have been improvements in the data sources during this time.

Conclusion

There are three important findings from our study. First, half of all opioid recipients in VHA with CNCP receive chronic opioid therapy (>90 days per year). Second, daily opioid doses are generally modest in VHA with a median of 20 mg morphine equivalents. Since many opioid risks are linked with daily dose, this is important. Third, receipt of high volume opioids is not increased in patients with substance use disorders as it is in non-VHA samples. This suggests appropriate vigilance at VHA, which may be facilitated by a transparent and universal electronic medical record.

Acknowledgments

This work was supported by NIDA R01 DA030300 and the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development VA HSR&D HFP 09–155. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.

Role of funding sources: The sponsors had no role in study design, data collection, analysis, interpretation of data, writing of report, or the decision to submit the article for publication.

Table A1.

Distribution of individual mean daily dose in milligram morphine equivalents for patients with CNCP and any opioid use.

Variable Percentile 2009 2010 2011
Days covered
10th 10.0 10.0 10.0
20th 14.0 13.8 13.7
30th 15.8 15.6 15.4
40th 20.0 19.8 19.6
50th 21.4 21.4 21.2
60th 26.5 26.0 25.6
70th 32.1 31.6 31.2
80th 42.7 41.5 40.2
90th 68.7 65.2 61.7
95th 111.5 109.4 107.1
99th 284.4 282.4 280.7
Max 997.5 1000.0 1000.0
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Table A2.

Distribution of individual total days covered with opioids in a fiscal year for patients with CNCP and any opioid use.

Variable Percentile 2009 2010 2011
Days covered
10th 12.0 11.0 10.0
20th 30.0 30.0 30.0
30th 44.0 44.0 45.0
40th 72.0 74.0 76.0
50th 115.0 118.0 120.0
60th 170.0 174.0 180.0
70th 240.0 247.0 252.0
80th 313.0 318.0 318.0
90th 353.0 354.0 353.0
95th 361.0 362.0 361.0
99th 365.0 365.0 365.0
Max 365.0 365.0 365.0
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Table A3.

Distribution of individual total opioid dose for a fiscal year in morphine equivalents (milligrams) for patients with CNCP and any opioid use.

Variable Percentile 2009 2010 2011
Annual Med
10th 200 200 200
20th 450 450 450
30th 760 750 750
40th 1320 1300 1305
50th 2190 2190 2220
60th 3600 3600 3610
70th 5850 5880 5925
80th 9840 9900 9900
90th 18340 18210 17790
95th 33856 33740 33120
99th 95377 94800 94200
Max 362025 364680 361740
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Table A4.

Percentage of Total Opioids (Milligrams of Morphine Equivalents) Consumed by Individuals Within a Given Percentile

Variable FY 09 FY10 FY11
Total Dose Percentile % % %
0–10th 0.15 0.15 0.15
10–20th 0.39 0.39 0.38
20–30th 0.72 0.71 0.71
30–40th 1.26 1.25 1.26
40–50th 2.11 2.10 2.14
50–60th 3.51 3.53 3.60
60–70th 5.74 5.77 5.88
70–80th 9.4 9.50 9.62
80–90th 16.5 16.5 16.53
90–95th 15.2 15.2 15.01
95–99th 27.17 27.2 27.2
99–100th 17.82 17.71 17.5
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Footnotes

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

There are no conflicts of interest for any authors.

Among Veterans Health Administration patients with chronic non-cancer pain, chronic opioid therapy occurs frequently, but the median daily dose is usually modest.

Contributor Information

Mark J. Edlund, Email: medlund@rti.org.

Mark A. Austen, Email: mark.austen@va.gov.

Mark D. Sullivan, Email: sullimar@uw.edu.

Bradley C. Martin, Email: bmartin@uams.edu.

James S. Williams, Email: James.Williams17745e@va.gov.

John C. Fortney, Email: fortneyjohnc@uams.edu.

Teresa J. Hudson, Email: Teresa.Hudson@va.gov, hudsonteresaj@uams.edu.

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