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.

Keywords: VHA; academic detailing; opioid epidemic; opioids; pain management.

Figure 1

Quarterly opioid prescribing data. Top left panel: total number of VHA patients dispensed an opioid. PBM OSI dashboard data: opioids dispensed includes buprenorphine products, excludes tramadol (when OSI began, VHA’s Drug File classified buprenorphine products in the opioid class; for consistency in the metric across time, it has continued to be included and internal examination of inclusion of buprenorphine in this metric found that it did not significantly impact results). Top right panel: total number of VHA patients dispensed opioids and benzodiazepines. PBM OSI dashboard data: opioids include buprenorphine products (see above) and tramadol; benzodiazepines exclude clonazepam (when OSI began VHA’s Drug File originally classified it as a seizure medication only and later additionally classified it as a benzodiazepine; for consistency in the metric across time it was excluded, however, internal examination of inclusion of clonazepam in this metric found that it did not significantly impact results). Bottom left panel: total number of VHA patients dispensed high-dose (≥ 100 mg morphine equivalent daily dose [MEDD]) opioids. PBM OSI dashboard data: high-dose opioids include buprenorphine (see above) and tramadol. Bottom right panel: total number of VHA patients dispensed opioids from a VHA pharmacy that were prescribed by a non-VHA prescriber. PBM OSI dashboard data: opioids dispensed excludes buprenorphine/naloxone and tramadol. Data were available beginning in Q1FY2015 when tracking began (early low rates may be due to learning curves involved with uptake of new processes, including how to record the prescriptions). The Veterans Choice program transitioned to the VA Community Care Network in 2018 with a significant reduction in VHA patients dispensed opioids from a VHA pharmacy that were prescribed by a non-VHA prescriber during this transition period. Further evaluation of this reduction may be warranted, with a focus on the factors.

Figure 2

Quarterly opioid risk mitigation data. % LTOT patients with annual UDS: percentage of VHA patients receiving long-term opioid therapy with a urine drug screen (UDS) in the past year. PBM OSI dashboard data: defines LTOT as ≥ 90 days supply of opioids for the selected quarter and the prior quarter (opioids exclude buprenorphine/naloxone and tramadol). % LTOT patients with informed consent: percentage of VHA patients receiving long-term opioid therapy with informed consent (from Q3FY2014). ADS measure: LTOT defined per VHA Directive 1005 (≥ 90 days supply of schedule II or III opioids for the selected quarter and the prior quarter; opioids exclude schedule III and IV opioids such as tramadol and codeine as well as medications for opioid use disorder such as methadone solution and sublingual buprenorphine). % Opioid-prescribed patients with annual PDMP: percentage of VHA patients dispensed opioids with an annual Prescription Drug Monitoring Program check. ADS measure: opioids include tramadol. Per the PDMP policy issued in October 2016, excluded patients with a 5-day supply or less of opioids without refills and hospice patients. Data available since Q1FY2017.

Figure 3

VHA Academic Detailing Service naloxone-related measures data (since Q3FY2014). Top left panel: total number of VHA patients dispensed outpatient naloxone. Top right panel: total number of VHA outpatient naloxone prescribers. Bottom left panel: percentage of VHA patients with ≥ 50 mg morphine equivalent daily dose (MEDD) of opioids with a naloxone prescription in the past year and with overlapping opioid and benzodiazepine prescriptions with naloxone in the past year.

Figure 4

Stratification Tool for Opioid Risk Mitigation (STORM)–identified very high-risk patients prescribed opioids with a data-based opioid risk review data (since FY18Q3).

Figure 5

VHA Academic Detailing Service Opioid-Related Educational Outreach by Academic Detailers data (since Q1FY2015). Total number of VHA clinicians with a pain/Opioid Safety Initiative (OSI)–related Academic Detailing visit. Total number of VHA clinicians with an Opioid Overdose Education and Naloxone Distribution (OEND)–related Academic Detailing visit.