Opioid Prescribing and Opioid Risk Mitigation Strategies in the Veterans Health Administration

Abstract

INTRODUCTION:The Veterans Health Administration (VHA) has taken a multifaceted approach to addressing opioid safety and promoting system-wide opioid stewardship. AIM: To provide a comprehensive evaluation of current opioid prescribing practices and implementation of risk mitigation strategies in VHA. SETTING: VHA is the largest integrated health care system in the United States. PROGRAM DESCRIPTION: VHA prescribing data in conjunction with implementation of opioid risk mitigation strategies are routinely tracked and reviewed by VHA's Pharmacy Benefits Management Services (including Academic Detailing Service) and the Pain Management Program Office. Additional data are derived from the Partnered Evidence-Based Policy Resource Center (PEPReC) and from a 2019 survey of interdisciplinary pain management teams at VHA facilities. Prescribing data are reported quarterly until first quarter fiscal year 2020 (Q1FY2020), ending December 31, 2019. PROGRAM EVALUATION: VHA opioid dispensing peaked in 2012 with 679,376 Veterans receiving an opioid prescription, and when including tramadol, in 2013 with 869,956 Veterans. Since 2012, the number of Veterans dispensed an opioid decreased 56% and co-prescribed opioid/benzodiazepine decreased 83%. Veterans with high-dose opioids (≥ 100 mg morphine equivalent daily dose) decreased 77%. In Q1FY2020, among Veterans on long-term opioid therapy (LTOT), 91.1% had written informed consent, 90.8% had a urine drug screen, and 89.0% had a prescription drug monitoring program query. Naloxone was issued to 217,469 Veterans and resulted in > 1,000 documented overdose reversals. In 2019, interdisciplinary pain management teams were fully designated at 68%, partially designated at 28%, and not available at 4% of 140 VA parent facilities. Fifty percent of Veterans on opioids at very high risk for overdose/suicide received interdisciplinary team reviews. IMPLICATIONS: VHA clinicians have greatly reduced their volume of opioid prescribing for pain management and expanded implementation of opioid risk mitigation strategies. IMPACTS: VHA's integrated health care system provides a model for opioid stewardship and interdisciplinary pain care.

Evaluating implementation of a consult to reduce new combination opioid and benzodiazepine prescriptions at the San Francisco Veterans Affairs Health Care System

“…The total number of consults placed per year initially increased from 2016 to 2017, then steadily reduced afterwards. This correlates with national Veterans Health Administration data, which demonstrated an 83% reduction in concurrent opioid and benzodiazepine prescribing from 2012 to 2019 25 . During this time period, a significant amount of new information was disseminated to patients and clinicians about the risks of combination therapy and available safer alternatives via evidence‐based guidelines, publications, consultations with specialty services at the facility, local OSI Committee educational programming, media, and other information sources.…”

Trends in healthcare expenditures and resource utilization among a nationally representative population with opioids in the United States: a serial cross-sectional study, 2008 to 2017

“…Moreover, removal of formulary restriction resulted in a reduction in substance use-related inpatient admissions (2.0 admissions per plan per year) and emergency department visits (1.4 visits per plan per year) [ 34 ]. The U.S. Department of Veterans Affairs, the largest integrated healthcare system in the United States implemented the Opioid Safety Initiative in 2013 to reduce opioid prescribing and reported a 56% reduction in opioid prescribing, an 83% reduction in opioid and benzodiazepine co-prescribing, and a 77% reduction in high-dose opioid prescribing from 2012 to 2019 [ 35 ]. These policy decisions by healthcare payers have a meaningful impact on the opioid crisis, which not only improve the quality of life for their patients, but they may potentially impact the increased expenditures associated with opioid use in their system.…”

Immersive Virtual Reality: A Safe, Scalable, Non-opioid Analgesic for Military and Veteran Patients

“…Compared to civilians, in Veterans, chronic pain is often more severe and is frequently a function of polytrauma and is accompanied by complex medical and psychiatric issues (Nahin, 2017;O'Malley et al, 2020;Sandbrink et al, 2020). Chronic pain often begins with musculoskeletal and spinal cord injuries, military combat, blasts, and explosions, burns, amputations, vehicle accidents, and/or traumatic brain injury.…”