Receipt of Overlapping Opioid and Benzodiazepine Prescriptions Among Veterans Dually Enrolled in Medicare Part D and the Department of Veterans Affairs

Abstract

Background: Overlapping opioid and benzodiazepine use is associated with increased risk of overdose. Veterans receiving medications concurrently from VA and Medicare may be at higher risk of such overlap. Objective: To assess the association between dual use of VA and Medicare drug benefits and receipt of overlapping opioid and benzodiazepine prescriptions. Design: Cross-sectional Setting: VA and Medicare Participants: All Veterans enrolled in VA and Part D filling >2 opioid prescriptions in 2013 (n=368,891). Measurements: Two outcome measures: the proportion of patients with (1) a Pharmacy Quality Alliance (PQA) measure of opioid/benzodiazepine overlap (i.e., ≥2 fills for benzodiazepines with ≥30days overlap with opioids); or (2) high-dose opioid/benzodiazepine overlap (i.e., ≥30days overlap with daily opioid dosage >120 MME). We used augmented inverse probability weighting regression to compare these measures by source of prescription drugs: VA-only, Part D-only, or VA and Part D (Dual use). Results: Of the 368,891 eligible Veterans, 18.3% received all their prescriptions from VA only, 30.3% from Medicare only, and 51.4% from both VA and Medicare. The proportion with PQA opioid/benzodiazepine overlap was larger for the dual use group versus the VA only (23.1% vs. 17.3%, adjusted risk ratio (aRR) = 1.27, 95%CI 1.24–1.30) and Medicare only (23.1% vs. 16.5%, aRR 1.12, 95%CI 1.10–1.14) groups. The proportion with high-dose overlap was also larger for the dual use group versus the VA only (4.7% vs. 2.3%, aRR = 2.23, 95%CI 2.10–2.36) and Medicare only (4.7% vs. 2.9%, aRR=1.06, 95%CI 1.02–1.11) groups. Limitations: Data are from 2013 Conclusions: Among a national cohort of Veterans dually enrolled in VA and Medicare, receiving prescriptions from both sources was associated with a greater risk of receiving potentially unsafe overlapping opioid and benzodiazepine prescriptions.

Dual Receipt of Prescription Opioids From the Department of Veterans Affairs and Medicare Part D and Prescription Opioid Overdose Death Among Veterans

“…Dual use is known to increase the likelihood of uncoordinated and poorly managed care, which can increase risk for accidental death from prescription opioid overdose due to duplicative prescriptions. Like prior research (12, 20), our study found higher-intensity opioid use and greater rates of opioid dosages higher than 120 MME among dual users than VA-only or Part D-only users. However, controlling for opioid dose, alcohol and substance use disorders, and RIOSORD measures minimally attenuated the observed effect.…”

“…Because case and control patients were balanced on all matching variables except age, we also included a categorical age variable as a covariate. We described opioid dose, use of benzodiazepines, and use of other central nervous system depressants but excluded these from the main analysis because prior studies indicate that these variables lie in the causal pathway between exposure and outcome and are thus unsuitable for model adjustment (12, 20, 35).…”

“…During the 180 days before the index date, we measured the number of days with prescription opioid supply, the number of days with more than 120 MME, cumulative MME dose, and average daily MME for the days patients had opioid supply. We used previously described methods (12, 20) to estimate daily opioid doses. In addition, we estimated the extent of dual use by calculating the proportion of opioid days’ supply obtained from VA among dual users.…”

“…Furthermore, use of multiple health systems could undermine the effectiveness of VA’s internal efforts to discourage opioid overuse and reduce opioid-related harms (14, 15). Evidence from prior studies indicates that receipt of care from unconnected health systems is associated with excess use and costs (9, 16–18) and increased risk for potentially unsafe prescribing of opioids and other medications (11, 12, 19, 20). Among veterans dually enrolled in VA and Part D, receiving opioids from both systems (that is, dual use) is associated with significantly increased risk for highdose opioid exposure (12) and overlapping opioid and benzodiazepine prescriptions (20), both of which are strongly associated with increased risk for overdose death (21–23).…”

Limited Utility for Benzodiazepines in Chronic Pain Management: A Narrative Review

“…In the US population, 6-13% receive a BZ prescription in any 1 year [8][9][10][11]. In pain management, BZRAs assume a more prominent role being prescribed to 10-33% of persons who are also receiving opioids [12][13][14][15][16][17][18][19]. Of particular concern, use is even greater among those at high risk: the elderly and those who have multiple prescribers, are on at least 200 morphine milligram equivalent (MME) daily opioid doses, or have greater mental health and substance use problems [14,[18][19][20].…”