Publication Briefs

Publication Briefs
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Giving Veterans an Active Voice in Creating a Veteran-Centered Chronic Pain Research Agenda Veterans Action League (VAL) 2.0 was a two-year community engagement project (2019–2021) that sought to develop a national Veteran-centered chronic pain research agenda that includes Veteran-generated recommendations for chronic pain management and chronic pain research priorities. Findings showed that Veterans’ most frequently cited need for chronic pain management and treatment was better access to care, with easier appointment booking and shorter wait times. Veterans also requested improved coordination among providers, and more thorough, holistic assessments for identifying contributors to their chronic pain. Some Veterans perceived that many providers overprescribed opioids as a “quick fix,” while other Veterans warned that the anti-opioid pendulum had swung too far. Veterans across states strongly agreed that they wanted to be offered choices for chronic pain management, with their options clearly outlined and their preferences sought. Veterans’ preferred approaches for managing chronic pain were diverse and included acupuncture, an anti-inflammatory diet, and epidural injections. Many Veterans voiced that they would like to see more studies on the efficacy of non-traditional therapies, including cannabis, chiropractic treatments, and therapeutic massage. Date: March 23, 2023 VA Treatment of Opioid Use Disorder was Maintained During the COVID Pandemic Through Rapid Shift to Telehealth At the beginning of the COVID pandemic, key federal policy changes were implemented to decrease barriers to telehealth-delivery of buprenorphine, a life-saving medication treatment for patients with opioid use disorder (OUD). This study examined the impact of these COVID-19 policies on buprenorphine treatment across different modalities (telephone, video, and in-person visits). Findings showed that buprenorphine treatment for OUD was maintained during the COVID-19 pandemic – across the VA healthcare system – through a rapid shift to telehealth, at a time when other healthcare delivery decreased. The number of Veterans receiving buprenorphine increased from 13,415 in March 2019 to 15,339 in February 2021. By February 2021, phone visits were used by the most patients (50%), followed by video (32%) and in-person (17%). Among Veterans receiving a buprenorphine treatment visit each month, the proportion of telehealth visits (phone and video) increased dramatically from 12% in March 2019 to 83% in February 2021. The proportion of Veterans reaching 90-day retention on buprenorphine treatment decreased significantly from the pre- to post-pandemic periods (50% to 48%), but days on buprenorphine increased significantly from 204 to 209. Policy changes that were rapidly implemented to reduce barriers to telehealth allowed continued delivery of buprenorphine treatment. Future changes to these policies (e.g., reversing support for telehealth prescribing of buprenorphine) could have major implications for patient care. Date: July 28, 2022 Antipsychotic Prescribing Decreased in VA Nursing Homes, but Prescribing Alternative Drugs, such as Opioids, Increased This study sought to evaluate national trends in prescribing antipsychotic and other central nervous system (CNS)-active medications for Veterans with dementia residing in VA nursing homes, as well as how use has changed over time. Findings showed that antipsychotic use steadily decreased between FY2009 and FY2018 (from 34% to 28%), with similar declines in anxiolytic prescribing (from 34% to 27%). Over the same period, prescribing of antiepileptics, antidepressants, and opioids increased significantly: from 27% to 43%, 57% to 63%, and 33% to 41%, respectively. The decline in prescribing antipsychotics was most significant following VA’s Psychotropic Drug Safety Initiative (2013-2018). The overall prescribing of non-antipsychotic psychotropic medications grew from 75% to 81%. Prescribing of memory medications declined throughout the study – from 32% to 22%, representing an 11% absolute decline. Memory medications were the least prescribed medication class for Veterans with dementia throughout the study period. Initiatives focused on improving care for nursing home residents should: 1) monitor the use of all CNS-active medication and other potentially sedating treatments used for sedation in dementia; and 2) consider how to incentivize the use of evidence-based non-pharmacological alternatives. Date: May 26, 2022 Predictive Tool Associated with 22% Lower Odds of All-Cause Mortality among High-Risk Veterans Taking Opioids In 2018, VA mandated a case review intervention that targeted patients who had been prescribed opioid analgesics and who were at high risk of adverse outcomes. The Stratification Tool for Opioid Risk Mitigation (STORM), a provider-facing dashboard that uses predictive analytics to stratify patients prescribed opioids based on their risk for overdose/suicide, was developed to identify these patients and assist providers in determining whether a patient needed a revised treatment plan or augmented care. Investigators then evaluated the impact of the case review mandate on serious adverse events (SAEs) and all-cause mortality among Veterans designated as high-risk between 2018-2020. Findings showed that identifying high-risk patients and mandating they receive an interdisciplinary case review was associated with 22% lower odds of all-cause mortality relative to control patients. This kind of impact is on par with interventions such as common medications for heart disease. Mandated review patients were five times more likely to receive a case review than non-mandated patients with similar risk – and they received more risk mitigation strategies. Date: May 2, 2022 High Virologic Cure Rates for Hepatitis C Virus among Veterans with Opioid Use Disorder Treated with Elbasvir/Grazoprevir Elbasvir (EBR)/grazoprevir (GZR) is a fixed-dose combination treatment for hepatitis C virus (HCV). This study sought to evaluate the real-world effectiveness of EBR/GZR among Veterans with HCV genotype (GT) 1 who also had a diagnosis of opioid use disorder (OUD). Findings showed that high rates of virologic cure were achieved among VA patients with HCV, OUD, and multiple comorbidities, including very high rates of psychiatric medication use, after receiving EBR/GZR for 12 weeks. Overall, 97% of Veterans achieved sustained virologic response (SVR). SVR rates were high regardless of baseline characteristics, comorbidities, or concomitant medications. SVR was achieved by 95% of Veterans receiving medication for OUD (MOUD) – and by 98% of Veterans who were not receiving MOUD. A total of 128 Veterans were reported as homeless during the year prior to initiating treatment; 98% of those Veterans achieved SVR. This first real-world evaluation of EBR/GZR in a population of patients with OUD suggests that treatment for 12 weeks represents an effective option for patients with HCV GT1 infection receiving MOUD, including people who inject drugs. Date: January 25, 2022 Death from Overdose Involving Stimulants Increasing in Veterans This study sought to describe trends in stimulant-alone and stimulant and other substance use overdose deaths among Veterans and to measure patient and treatment use characteristics across stimulant-related overdose death profiles. Findings showed that the rate of deaths among Veterans from stimulant-related overdose, alone and in combination with other substances, tripled from 2012 to 2018 with the greatest increase in cocaine + opioid-related overdoses (4 times higher in 2018 than 2012). During this time, 3,631 Veterans died from stimulant-involved overdoses. Of stimulant-involved overdoses, 67% involved cocaine and 38% involved methamphetamine. Fatal overdoses from methamphetamine compared to cocaine were more frequent among younger Veterans, as were overdoses involving both stimulants and opioids. Of all stimulant-related overdoses, 54% (1,965) also involved an additional substance, including 48% that co-involved opioids. Of stimulant + opioid-involved overdoses, 45% involved heroin and 46% involved synthetic opioids (e.g., fentanyl). Alcohol was the most common co-involved substance other than opioids. Fewer than 30% of Veterans who died from stimulant-involved overdoses received treatment in a substance use disorder clinic in the year before death. This study highlights vulnerable patient characteristics and treatment gaps for Veterans who die from stimulant overdose, suggesting a need for increased focus on polysubstance use treatment as well as distinct treatment needs based on stimulant use type. Date: October 14, 2021 Veterans Do Not Always Receive Appropriate Continuation of OUD Medications During Surgical Hospitalizations This study sought to describe practice patterns of perioperative buprenorphine use within VA – and patient outcomes up to 12 months following surgery. Findings showed that the majority of VA surgical patients in this study who received buprenorphine for opioid use disorder experienced a dose hold at some point during the perioperative period despite a trend in clinical guidelines recommending buprenorphine continuation: 40% of Veterans were instructed to hold buprenorphine prior to surgery, more than 60% did not receive buprenorphine on the day of surgery, and 55% did not receive a buprenorphine dose on the day following surgery. Homelessness/housing insecurity and rural residence were the only two predictors explored in this study that were associated with decreased likelihood of a perioperative buprenorphine dose hold. Discontinuation of buprenorphine following surgery also was relatively common. One month following surgery,13% of Veterans had no active buprenorphine prescription, increasing to 25% and 33% at 6- and 12-months post-surgery, respectively. As holding buprenorphine perioperatively does not align with emerging clinical recommendations – and carries significant risks – educational campaigns or other provider-targeted interventions may be needed to ensure patients with OUD receive recommended care before and after surgery. Date: September 20, 2021 Veterans Receiving Buprenorphine for Opioid Use Disorder Have Lower Risk of Suicide/Overdose Mortality This study sought to determine the association between buprenorphine pharmacotherapy and suicide, overdose, and all-cause mortality among Veterans initiating buprenorphine within VA. Findings showed that Veterans who were not receiving buprenorphine pharmacotherapy on any given day had more than a four-fold increase in suicide/overdose death compared to those who received buprenorphine, even when accounting for time periods on other medication for opioid use disorder. Over the 5-year follow-up from the initial buprenorphine prescription, 3% died from suicide or overdose, and 8% died of any cause. Among suicide/overdose deaths, the majority (90%) were due to overdose and 71% of overdoses involved a prescription or illicit opioid. Date: May 19, 2021 Medication Therapy for Opioid Use Disorder Saves Lives and Can Save Money for Society Investigators in this study developed a mathematical model to assess the cost-effectiveness of opioid use disorder treatments and the association of these treatments with outcomes in the US. Two analyses were done, the first considering only health sector costs, and the second also considering criminal justice costs. Findings showed that medication-assisted treatment (MAT), with or without overdose education and naloxone distribution, contingency management, and psychotherapy, is associated with significant health benefits and is cost-effective compared to usual benchmarks when considering only healthcare costs. When criminal justice costs were included in addition to healthcare costs, all forms of MAT (buprenorphine, methadone, and naltrexone) were cost-saving compared with no treatment, yielding savings of $25,000 to $105,000 in lifetime costs per individual. An analysis using demographics and cost data for VA yielded similar findings, but quality of life gains from treatment were lower due to Veterans being older, on average, than the general population. Date: March 31, 2021 Research Suggests Battlefield Acupuncture is Immediate but Short-Term Pain Management Tool This commentary summarizes work conducted to examine battlefield acupuncture’s (BFA’s) implementation and effectiveness within the VA healthcare system. Findings show that there is some evidence that BFA is a potentially effective, immediate, but short-term pain management tool that can be used in adjunct with other pain therapies. BFA produced a minimal clinically important improvement in pain for over half of Veterans receiving it, including patients who recently filled opioid prescriptions or had significant psychological and physical comorbidities. Both individual and group BFA sessions were effective. BFA providers perceived BFA as having many benefits; they also reported that it was low risk and easy to deliver. Given its effectiveness in providing immediate, short-term pain relief, from the perspective of both providers and patients, BFA is one potentially important tool to address pain. BFA also may provide a “window” to allow some patients to engage in more long-term self-management approaches (i.e., yoga and Tai Chi) to address their chronic pain. Date: March 26, 2021 JGIM Supplement Features VA Research on Improving Opioid Safety among Veterans with Chronic Pain and Addiction In the fall of 2019, HSR&D convened a state-of-the-art (SOTA) conference – “Effective Management of Pain and Addiction: Strategies to Improve Opioid Safety” – to develop research priorities for advancing the science and clinical practice of opioid safety, including both the use of opioid analgesics and managing opioid use disorder (OUD). A group of researchers and VA clinical stakeholders defined three areas of focus for the SOTA: 1) managing OUD, 2) long-term opioid therapy for pain including consideration for opioid tapering, and 3) treatment of co-occurring pain and substance use disorders. SOTA participants included VA and non-VA health services researchers, clinicians, and policymakers. Funded by HSR&D, this JGIM Supplement presents recommendations from the SOTA, as well as original research papers on opioid safety across the VA healthcare system. Date: December 1, 2020 Cannabinoid Use Increased while Opioid Use Decreased among VA Patients Undergoing Total Joint Replacement This single-institution (VA Palo Alto) study sought to determine whether preoperative cannabinoid use and opioid use increased or decreased over a 6-year interval among total hip and knee arthroplasty (THA and TKA) patients – and whether complications were associated with cannabinoid use. Findings showed that use of cannabinoids in Veterans undergoing total joint arthroplasty was far greater than previously reported in the literature, while opioid use decreased. Over the six-year study period, cannabinoid use increased more than 60%, while opioid use decreased about 30%. When compared with patients not using cannabinoids, investigators were unable to find a difference in rates of readmission, infection, reoperation, or other complications captured in the VASQIP database, even after controlling for age, gender, surgery type, and ASA score. Cannabinoid users were more likely to also be taking opioids than non-users, and they were significantly younger than both non-users (62 vs.66 years) and opioid users (63 vs. 65 years). Date: October 1, 2020 Treatment Disparities for Vulnerable VA Patient Populations with Opioid Use Disorder This study examined the association between vulnerable populations, facility characteristics, and receipt of medications for opioid use disorder (OUD). Findings showed that since the last national study of VA patients (using FY2012 data), the prevalence of receipt of medications for OUD increased overall from 33% to 41%; however, vulnerable patient populations – including women, older, Black, rural, homeless, and justice-involved Veterans – had lower odds of receiving medications for OUD than their non-vulnerable counterparts. Veterans had higher odds of receiving medications at facilities with a higher proportion of patients with OUD, and lower odds of receiving medications at facilities in the Southern region of the United States compared to the Northeast. The prevalence of OUD was notably higher among homeless compared to housed Veterans (10% vs 2%), and justice-involved compared to non-justice-involved Veterans (10% vs 2%). Date: August 18, 2020 Opioid Agonist Therapy Infrequent for Veterans with Opioid Use Disorder Admitted to a VA Hospital This retrospective cohort study sought to describe and examine patient- and hospital-level characteristics associated with the receipt of opioid agonist therapy (OAT) during VA hospitalization for various reasons. Findings showed that the delivery of OAT was infrequent, varied across the VA healthcare system, and was associated with specific patient and hospital characteristics. Only 15% of the entire study cohort received any OAT during hospital admission. Of 10,969 Veterans who had an OUD diagnosis at the time of hospitalization but were not already being treated for it, only 2% received OAT along with a link to care after their discharge. Instead, most of these patients (80%) received opioid withdrawal management, representing a missed opportunity to continue OUD treatment beyond hospitalization. Hospital admission interrupted ongoing outpatient OUD treatment, with more than one-third of Veterans having their outpatient OAT discontinued during admission. Veterans on pre-admission OAT, those with an acute opioid use disorder diagnosis, and who were male had increased odds of receiving OAT. Veterans who received non-OAT opioids or surgical procedures had decreased odds of receiving OAT. Veterans admitted to large and medium-sized VA hospitals had increased odds of OAT receipt compared with those admitted to small VA hospitals. Date: April 14, 2020 Among Veterans Who Experience Homelessness, Non-fatal Overdose is a Relatively Common Problem Overdose is one of the most common causes of death for younger homeless individuals, but the prevalence of non-fatal overdose among the homeless is unknown. Investigators in this study administered a survey to Veterans who had experienced homelessness (current or past) and received primary care at one of 26 VA medical centers across the nation asking if they had experienced an overdose within the past three years that required an ED visit or immediate medical care (and the substances involved in the overdose) – and/or if they had witnessed someone else experience an overdose during the same time period. Findings showed that 7% reported an overdose in the previous three years. Those who reported an overdose were nearly three times as likely to have witnessed an overdose. Compared to Veterans without overdose, those reporting an overdose were younger, more likely to be white, more likely to be homeless at the time of the survey, more likely to be taking medication for mental health issues, had greater psychological distress, and were more likely to report an alcohol or drug problem. Alcohol was the most common substance reported with overdose, nearly as common as all drugs combined and more than twice as common as opioids. Improving access to addiction treatment for homeless and recently-housed Veterans, especially for those who have experienced or witnessed overdose, could protect this population. Also, given the prevalence of high emotional distress in persons who experienced overdose, enhanced mental health services could mitigate some risk for individuals residing on the streets, in shelters, or newly in housing. Date: March 17, 2020 Veterans at Higher Risk of Overdose/Suicide Death After Stopping Opioid Treatment; Increasing Risk with Duration on Opioids This study examined the associations between stopping outpatient opioid treatment, length of opioid treatment, and overdose/suicide death among VA patients. Findings showed that Veterans were at a higher risk of overdose/suicide death after stopping opioid treatment, with increasing risk the longer they had been treated before stopping. Even patients treated for up to 30 days had a rise in risk of death after treatment was stopped. Factors independently associated with a higher risk for overdose/suicide death included: receiving prescriptions for long-acting or short-acting opioids compared to tramadol; maximum daily morphine milligram equivalents; number of medical diagnoses; and having a mental health disorder diagnosis or substance use disorder diagnosis. Older age, female gender, and being currently married were independently associated with a lower risk for overdose/suicide death. Risk of death from overdose or suicide was increased for 3 months after starting or stopping treatment with opioids, highlighting these vulnerable risk periods. Date: March 4, 2020 Integrated Pain Team Programs Improve Outcomes for Chronic Pain and May Reduce Reliance on High-Risk Opioid Therapy This study examined changes in self-reported chronic pain-, opioid-, and treatment-related outcomes among Veterans with chronic pain following the implementation of a primary care-based biopsychosocial Integrated Pain Team (IPT) model within the San Francisco VA Health Care System. Findings showed that Veterans with chronic pain who engaged in the IPT program reported improvement in several outcomes related to pain-related distress and disability, and opioid misuse. While patients did not report a significant change in pain severity from baseline to follow-up, they did report significantly reduced pain interference in daily functioning. Pain catastrophizing also showed significant reduction, driven by decreases in pain-related magnification and helplessness. Regarding patients prescribed opioids at both baseline and follow-up, opioid misuse decreased significantly. For example, there was a significant reduction in the frequency of opioid misuse behaviors. At follow-up versus baseline, patients reported increased use of integrative (e.g., acupuncture) and active pain management strategies (e.g., exercise), and were less likely to use only pharmacological pain management strategies. Findings suggest that primary care-based IPT programs may improve patient-centered outcomes for individuals with chronic pain and reduce reliance on potentially high-risk opioid therapy. Date: February 25, 2020 Few Disparities in Medical Treatment for Opioid Use Disorder after Non-Fatal Overdose This study assessed the association between race and ethnicity and patterns of opioid prescribing before and after a non-fatal opioid overdose – and also assessed the receipt of medications for opioid use disorder (MOUD: buprenorphine, methadone, and naltrexone) following such events among VA patients. Findings showed that receipt of an opioid prescription decreased by 16-21 percentage points in the 30 days after overdose, but remained high, with no significant differences across racial and ethnic groups. After overdose, the frequency of receiving opioids was reduced by 18.3, 16.4, and 20.6 percentage points in whites, blacks, and Hispanics, respectively. Overall, MOUD prescribing in VA was very low in all racial groups in the 30 days after overdose, though statistically significantly higher in black and Hispanic patients. After overdose, 3% of patients received MOUDs (3% white, 5% black, and 6% Hispanic). Blacks and Hispanics had significantly larger odds of receiving MOUDs than whites. Findings demonstrate an opportunity to improve the quality of care for all patients with opioid use disorder, particularly in the vulnerable period around a non-fatal overdose event. Date: January 21, 2020 Increases in Opioid Dosing of 20% or Greater were Not Associated with Improvements in Pain among Veterans This study examined the influence of opioid dose escalation on pain scores recorded in the VA electronic medical record among patients on chronic opioid therapy for chronic non-cancer pain. Findings showed that increases in opioid dose of 20% or greater were not associated with improvements in pain scores. In the follow-up period, dose escalators had higher average morphine milligram equivalents (MME) when compared to dose maintainers and were more likely to use long-acting opioids in combination with a short-acting opioid (18% vs. 8%, respectively). Clinicians should carefully evaluate increasing opioid doses, regardless of the current dose. When determining whether to escalate the dose, considerations should focus less on the potential benefit to improve pain intensity and more on the balance of other potential benefits and harms. Date: January 7, 2020 Past Year Opioid Misuse Associated with Past-Year Suicide Attempt among High-Risk Veterans The main objective of this study was to test the relationship between past-year suicide attempt and past-year opioid misuse among Veterans at high risk of suicide who also reported using at least one illicit substance or alcohol in the past year. Findings showed that past-year opioid misuse was associated with past-year, but not lifetime, suicide attempt in high suicide-risk Veterans: 82% of opioid misusers had attempted suicide in the past year versus 56% of those who misused other substances. The relationship between past-year opioid misuse and past-year suicide attempt remained significant when psychosocial factors associated with suicide attempt and opioid misuse were included as covariates. Suicide attempt rates did not differ among those who misused different types of opioids. Among Veterans with past-year suicide attempt, those who misused opioids in the past year were more likely to use overdose as a method to attempt suicide compared to those who misused other substances. Opioid misuse may be a marker of more lethal near-term suicide behavior, supporting current VA opioid therapy guidelines in which suicide risk assessment during opioid therapy is recommended. Lethal means restriction of toxic substances among Veteran opioid misusers also may be important. Date: December 1, 2019 History of Military Sexual Trauma Common among Older Women Veterans This study sought to determine the prevalence of military sexual trauma (MST) among older women Veterans – and investigate associations between MST and medical and mental health diagnoses. Findings showed that a history of MST was common among older women Veterans. Positive MST screens were observed in nearly 1 in 5 women aged 55-64, and 1 in 10 aged 65-74. [This is similar to the 23% prevalence found in previous studies in women younger than age 55. Accounting for demographic risk factors, MST was associated with increased odds of a range of medical and mental health diagnoses. Most notably, MST was associated with 7.25 times the odds of PTSD and over two-fold odds of depression and suicidal ideation, as well as increased odds of anxiety, alcohol use disorder, substance use disorder, opioid use disorder, sleep disorders, and chronic pain. Thus, older women Veterans remain at risk for the effects of potentially remote MST. Findings call attention to the need for additional research in this understudied population, and the importance of trauma-informed care approaches for women across the lifespan. Date: November 11, 2019 VA Opioid Treatment Outcomes Vary Significantly among Homeless and Unstably Housed Veterans To better address the opioid epidemic in Veterans who are unstably housed or homeless, it is necessary to determine where gaps in opioid-related care exist. This study examined a national sample of 59,954 Veterans who accessed VA homeless programs and represented a range of homeless experiences; 6% of this cohort (3,624 Veterans) entered a homeless program with a history of opioid use disorder (OUD). Findings showed that among the subgroup of homeless Veterans with an OUD history, opioid dose prescribing practices and rates of medication for addiction treatment (MAT) and naloxone receipt varied significantly. Less than one-quarter (23%) of Veterans received a prescription for naloxone, with homeless program-level rates of receipt ranging from 19% to 32%. Thirty-eight percent of Veterans received MAT in the year following entry into a VA homeless program, with program-specific rates ranging from 31% to 50%. Rates of high-dose opioid prescribing and concomitant opioid-benzodiazepine prescribing were highest, and rates of MAT and naloxone prescribing were lowest, among those ages 55+. Current treatment gaps indicate the need for universal policy goals to address OUD among Veterans at risk of being homeless – or who are currently or formerly homeless. Implementation strategies are needed to tailor opioid treatment access and dissemination to homeless and similar vulnerable Veteran groups. Date: August 1, 2019 Dual use of VA and Medicare Drug Benefits Associated with Potentially Unsafe Medication Prescribing among Veterans Previous research shows that dual VA-Medicare Part D prescription drug use is a risk factor for potentially unsafe medication (PUM) exposure in Veterans with dementia and opioid users. Thus, this study evaluated the association of dual prescription use through VA and Part D (vs. VA-only use) with the prevalence of PUM exposure in a national cohort of dually-eligible older Veterans. Findings showed that dual use of VA and Part D prescription drug benefits was associated with an almost 2-fold increase in the odds of exposure to any PUM compared with VA-only use and more than 3 times the odds of exposure to severe drug-drug interactions. PUM exposure was lowest among VA-only users, and PUM exposure peaked in Veterans receiving prescriptions in near-equal proportions (50/50) from VA and Part D. To mitigate the potential risks associated with unsafe medication prescribing, policies intended to expand access to non-VA providers must ensure patient information is shared and integrated into routine practice for all patients seeking care across multiple healthcare systems. Date: July 22, 2019 Increase in Opioid Overdose Deaths among Veterans Attributed to Increased Overdoses from Heroin and Synthetic Opioids This study examined trends in VA opioid overdose rates and receipt of prescription opioids among Veterans receiving VA care who died from opioid overdose from 2010 through 2016. Findings showed that the overall rate of fatal opioid overdose among Veterans increased from 14.47 per 100,000 person years in 2010 to 21.08 per 100,000 person years in 2016. There was a decline in methadone overdose and no significant change in natural/semisynthetic opioid overdose, however the synthetic opioid overdose rate and heroin overdose rate increased substantially. Among all opioid overdose decedents, prescription opioid receipt within 3 months before death declined from 54% in 2010 to 26% in 2016. Fatal opioid overdose rates among Veterans receiving VA care increased because of increases in heroin and synthetic opioid overdose rates. Risk of overdose from heroin and synthetic opioids may need to be considered separately from risk from prescription opioids, and prevention efforts must broaden beyond Veterans actively receiving opioids. Date: July 1, 2019 Strategies VA Clinicians Use to Structure Difficult Conversations Regarding Opioid Prescribing This study aimed to identify and describe clinicians’ strategies for managing prescription opioid misuse and aberrant behaviors among patients prescribed long-term opioid therapy (LTOT) for chronic pain. Interview results identified challenges faced by clinicians in navigating conversations about opioid management, stemming from patient dissatisfaction and clinician ambivalence about enacting guideline-recommended changes. To manage difficult conversations, clinicians shared “verbal heuristics” – essentially a pre-packaged response or conversational short-cut – to more quickly and efficiently guide and defuse challenging, emotional conversations. Four varieties of heuristics were identified and include: safety (i.e., “I don’t feel comfortable prescribing for you anymore because you’re using in a way that’s unsafe.”); setting expectations (i.e., “no early refills even for legitimate reasons”); following orders (i.e., “we’re following the rules…and have no choice”), and standardization (i.e., “I do this for all my patients.”). Date: July 1, 2019 Opioid Prescribing Safety Initiative Effective in Decreasing Rates of Opioid Prescribing for Older Veterans with Osteoarthritis Investigators in this study examined national trends in opioid and non-opioid analgesic prescribing before and after implementation of VA’s Opioid Safety Initiative (OSI). Findings showed that before OSI implementation, total analgesic prescriptions showed a steady rise, which abruptly decreased to a flat trajectory after the OSI was implemented. This trend was primarily due to a decrease in opioid prescribing after OSI, as well as a significant modest rise in acetaminophen prescriptions post-OSI. Among Veterans reporting pain, the intensity of pain remained unchanged over the study period. Thus, changes in analgesic prescribing trends were not accompanied by changes in reported pain intensity for older Veterans with osteoarthritis. No changes in non-steroidal anti-inflammatory drug prescribing were observed. Thus, over the period 2012-2016, VA’s successful efforts to reduce opioid prescribing did not result in worsening pain among patients with osteoarthritis. Date: June 1, 2019 Substantial Variation in Opioid Prescribing Rates among ED Providers in the Same VA Healthcare Facility The study team examined the extent to which variation in individual ED physicians’ opioid prescribing was independently associated with long-term opioid use in Veterans. Using VA data, investigators identified Veterans with an index ED visit at any VA facility in 2012 – and who were opioid naïve (without opioid prescriptions in the prior 6 months). Findings showed that there was a three-fold variation in the rates of opioid prescribing by ED physicians within the same VA facility (21% vs. 6%), regardless of patients’ severity of pain or primary diagnosis. The frequency of long-term opioid use was higher among opioid-naïve Veterans treated by high vs. low-quartile ED prescribers, though above the threshold for statistical significance (1.39% vs. 1.26%). Though the increase in long-term opioid use among Veterans treated by the highest-prescribing ED providers was not significant in the overall sample, it was significant among important patient subgroups, including those with back pain, musculoskeletal pain, or depression. High-intensity prescribers were more likely to prescribe opioids across the spectrum of pain intensity, while low-intensity prescribers were less likely to prescribe opioids across the spectrum. Date: May 29, 2019 Rural and Western Region Veterans Prescribed More Opioids Than Urban, Other Regions This study sought to characterize regional variation in opioid prescribing across VA and examine prescribing differences between rural and urban Veterans. Findings showed substantial rural-urban variation in VA opioid prescribing, with rural Veterans receiving over 30% more opioids than their urban counterparts, with most of the difference attributable to long-term use. Utilization was lowest in the Northeast and highest in the West. Mean days’ supply dispensed at initiation was higher for rural veterans (15 vs. 13) and the proportion prescribed an initial 30 days’ supply was 23% for rural vs. 19% for urban Veterans. The prescribing gap between urban and rural Veterans in the South was 33% vs. 13% in the Northeast, and similar in the West and Midwest. Higher rates of opioid prescribing among rural compared to urban Veterans are driven mostly by higher rates of long-term use, indicating a need for interventions to improve access to non-pharmacologic treatment for chronic pain among rural Veterans. Date: May 21, 2019 Receipt of Opioid Prescriptions from Both VA and Medicare Associated with Greater Likelihood of Overdose Death This study assessed the association between dual receipt of opioid prescriptions from VA and Medicare Part D and prescription opioid overdose death among Veterans enrolled in both VA and Part D. Findings showed that receipt of opioid prescriptions from both VA and Part D was associated with 2-3 times greater odds of overdose death than among Veterans receiving opioids from VA or Part D only. Dual users also had a higher cumulative opioid dose over 180 days and average daily opioid dose. Dual enrollees are a vulnerable group of Veterans, emphasizing the importance of care coordination across providers and healthcare systems to increase the safety of opioid prescribing within and outside VA. Date: March 12, 2019 Links Between Opioid Use and Suicide This review describes what is known about the links between suicide and overdoses, with a focus on pathways through opioid use, issues of intent, risk factors, prevention strategies, and unresolved issues. Many factors promote the initiation and persistence of opioid use, but several specific pathways toward vulnerability to overdose and suicide are highlighted. Interventions that address shared causes and risk factors, such as programs to improve the quality of pain care, expanding access to psychotherapy, and increasing access to medication-assisted treatment for opioid use disorders, have the potential to be high-value investments by addressing both problems. Date: January 3, 2019 Link between Length of Prescription for Initial Exposure to Opioids and Long-Term Use This study examined the association between initial opioid exposure and subsequent long-term use in two national VA cohorts from 2011 and 2016. Findings showed a strong relationship between initial opioid exposure and the future likelihood for long-term use. Cumulative days’ supply of prescription opioids emerged as the strongest predictor of long-term opioid use, which occurred in only 2% of Veterans dispensed 7 days’ or less supply, and in 28% of patients dispensed greater than 30 days’ supply. Comparing 2011 and 2016 data, the association between day’s supply and long-term use persisted, even as the overall rate of long-term opioid use decreased. Findings suggest that limiting initial opioid exposure may reduce risk for long-term opioid use. Moreover, examination of early opioid exposure may offer an opportunity to recognize when a patient is in the process of starting long-term opioid use. Date: November 5, 2018 Pharmacotherapy for Opioid Use Disorder Highly Variable across VA Residential Substance Abuse Treatment Programs Pharmacotherapy, including methadone, buprenorphine, and naltrexone, is both efficacious and cost-effective for treating opioid use disorder (OUD), however it is infrequently prescribed in VA. Investigators in this study sought to describe barriers to and facilitators of pharmacotherapy provided to a national cohort of VA patients with OUD in VA residential substance use disorder (SUD) treatment programs in FY2012. Findings showed that implementation of pharmacotherapy for OUD is highly variable across VA residential SUD treatment programs. Across all 97 treatment programs, the average rate of receipt of pharmacotherapy for OUD in FY2012 was 21% and ranged from 0% to 67%. There were 11 programs where 0% of patients received pharmacotherapy for OUD. Barriers included program or provider philosophy against pharmacotherapy and a lack of care coordination with non-residential treatment settings. Facilitators included education for staff and patients and having a prescriber on staff. Intensive educational programs, such as academic detailing, and policy changes such as mandating buprenorphine waiver training for VA providers, may help improve receipt of pharmacotherapy for OUD. Date: November 1, 2018 Veterans Receiving Prescriptions Through Both VA and Medicare Are More Likely to Be Taking Opioids and Benzodiazepines This study sought to assess the association between receiving medications from both VA and Medicare Part D (dual use) and the receipt of overlapping opioid and benzodiazepine prescriptions. Findings showed that receiving prescription medications from both VA and Medicare Part D was associated with a 27% increased risk of overlapping opioids and benzodiazepines – and more than twice the risk of overlapping high-dose opioids with benzodiazepines – compared to receiving prescriptions from VA alone. Receipt of prescriptions from both VA and Medicare also was associated with a greater risk of opioid/benzodiazepine overlap compared to Medicare alone, although the difference was smaller. Receipt of medications from more than one healthcare system is a key risk factor for unsafe prescribing practices, highlighting the need to enhance coordination of care across healthcare systems to optimize the quality and safety of prescribing. Date: October 9, 2018 Pain Intensity Following Discontinuation of Long-Term Opioid Therapy Does Not, on Average, Worsen for Patients This study sought to characterize pain intensity over 12 months following opioid discontinuation. Findings showed that average pain intensity did not significantly worsen in the 12 months after Veterans discontinued opioid therapy; for some patients, pain intensity improved. Mean estimated pain at the time of opioid discontinuation was 4.9 on a scale from 0-10. Changes in pain following discontinuation were characterized by slight but statistically non-significant declines in pain intensity over 12 months post-discontinuation. Veterans in the mild (average pain = 3.9) and moderate (average pain = 6.3) pain categories experienced the greatest pain reductions post-discontinuation. Of this study cohort, 87% of Veterans were diagnosed with chronic musculoskeletal pain, 6% with neuropathic pain, and 11% with headache pain (including migraine). Study findings can aid clinicians during discussions with patients about opioid discontinuation. Date: June 13, 2018 Medical Records Flag for Suicide Risk Increases VA Healthcare Visits among Veterans with Substance Use Disorder VA has identified suicide prevention as a top priority and established policies to include high-risk suicide patient record flags (PRFs) in the electronic medical record to alert providers of patient risk and increase healthcare contacts. This study sought to identify predictors of new PRFs and to describe healthcare use before and after PRF initiation among VA patients who had received a substance use disorder (SUD) diagnosis. Findings showed that consistent with VA policy, 62% of Veterans with new suicide risk flags attended the recommended number of visits in months 1 to 3, with an additional 14% meeting recommended targets in month 1 only. Further, outpatient contacts in mental health and substance use disorder clinics increased 2 and 4 times, respectively, over the three-month follow-up period, with mean contacts in these services exceeding the minimum required one contact per week in month one. ED visits decreased by 45% in the three months following initiation of a PRF. Demographic predictors of PRF initiation included being younger than 35, White, and homeless. Clinical predictors were cocaine, opioid and sedative use disorders, PTSD, psychotic, bipolar, and depressive disorders, and suicide-attempt diagnoses. Suicide risk PRFs in an electronic medical record and subsequent follow-up increased service use for those Veterans with flags initiated. Date: June 8, 2018 Then and Now: Medications for Opioid Use Disorder in VA As the largest provider of substance use disorder treatment in the nation, VA has taken proactive steps to increase access to medications indicated for opioid use disorder (OUD), which is an essential component of evidence-based care. This article examines the history of those medications (methadone, buprenorphine, and injectable naltrexone) within VA, as well as early and ongoing efforts to increase access to and build capacity for the treatment of OUD, which included adding buprenorphine to the VA formulary in 2006, educational and quality improvement initiatives, targeted resources, national policy, and “big data” initiatives. This article also summarizes research on barriers and facilitators to prescribing and medication receipt. Date: March 29, 2018 State-based Prescription Drug Monitoring Programs Might Help Increase Opioid Prescribing Safety among Veterans Using VA and Non-VA Healthcare This study evaluated VA physicians’ perspectives and experiences regarding the use of state-based Prescription Drug Monitoring Programs (PDMPs) to monitor Veterans’ receipt of opioids from non-VA prescribers. Findings showed that VA primary care physicians broadly embraced PDMPs as a tool to monitor Veterans’ receipt of opioids from non-VA sources despite identifying multiple barriers to optimal use. They also identified several key best practices currently used within VA and made suggestions for future improvements that may enhance efforts to ensure safe opioid prescribing. Key barriers included incomplete or unavailable prescribing data, while key facilitators included linking PDMPs with VA’s electronic health record, using templated notes to document PDMP use, and delegating routine PDMP queries to ancillary staff (i.e., nurses or clinical pharmacists). Applying improvements identified in this study may enable VA to serve as a national model for those seeking to enhance PDMP use, thereby improving opioid prescribing safety. Date: March 8, 2018 Opioids Do Not Result in Better Pain-Related Function or Pain Intensity Compared to Non-Opioid Drugs in Veterans with Chronic Pain This randomized trial compared opioid therapy versus non-opioid medication therapy over 12 months for primary care patients with chronic back pain or hip or knee osteoarthritis pain. Findings showed that the use of opioid therapy compared with non-opioid medication therapy did not result in significantly better pain-related function over 12 months. Opioid therapy compared with non-opioid medication therapy resulted in significantly worse pain intensity over 12 months, but the importance of this is unclear because the magnitude was small. Opioids caused significantly more medication-related adverse symptoms than non-opioid medications. Overall, opioids did not demonstrate any advantage over non-opioid medications that could potentially outweigh their greater risk of overdose and other serious harms. Results do not support initiation of opioid therapy for moderate to severe chronic back pain or hip/knee osteoarthritis pain. Date: March 6, 2018 Dual Use of VA and Medicare Associated with Substantial Increase in Risk of Potentially Unsafe Opioid Use among Veterans This study sought to estimate the prevalence and consequences of receiving prescription opioids from both VA and Medicare Part D for all dually-enrolled Veterans who filled a prescription opioid in either system in calendar year 2012. Findings showed that among Veterans dually enrolled in Medicare Part D and VA and receiving prescription opioids in 2012, more than 1 in 8 received opioids from both systems, in many cases concurrently. Compared to VA-only use of opioids, dual use was associated with a 3-fold higher risk of high-dose opioid exposure and more than twice the risk of long-term high-dose opioid exposure. Dual use also was associated with a 60-90% greater risk of these exposures than Part D only use. VA is evolving into a less integrated delivery system with more community care options. As these options increase, the prevalence of poorly coordinated dual-system care (e.g., overlapping opioids and other drug interactions and duplication) also will likely increase. Date: February 1, 2018 Declining Rates in VA Prescriptions for Long-Term Opioids This study sought to characterize the overall prevalence of opioid prescribing in the VA healthcare system from 2010 through 2016 by duration of use. Findings showed that opioid prescribing trends followed similar trajectories in VA and non-VA settings, peaking around 2012 and subsequently declining. The prevalence of VA opioid prescribing was 20.8% in 2010, 21.2% in 2012, and declined annually to 16.1% in 2016. Changes in long-term opioid prescribing accounted for 83% of the decline seen in VA patients. Comparing data from 2010-2011 to data from 2015-2016, declining rates in new long-term use accounted for more than 90% of the decreasing prevalence of long-term opioid use among Veterans, whereas increases in cessation among existing long-term users was less than 10%. Investigators observed a decrease in overall opioid prevalence between 2012 and 2015 of 16% in VA healthcare settings, compared to 13% reported in non-VA settings. Recent VA opioid initiatives may be preventing patients from initiating long-term use. Date: January 29, 2018 Medical Record Alert Associated with Reduced Opioid and Benzodiazepine Co-prescribing This implementation project evaluated the effectiveness of an advanced medication alert designed to reduce opioid and benzodiazepine co-prescribing among Veterans with high-risk conditions (substance use disorder, sleep apnea, suicide risk, and age =65) at one VA healthcare system (VA Puget Sound). Findings showed that the proportions of patients with concurrent prescriptions decreased significantly post-alert launch among Veterans with substance use (25%), sleep apnea (39%), and suicide risk (62%), with greater decreases at the alert site relative to the comparison site in sleep apnea and suicide-risk cohorts. Significant decreases in benzodiazepine prescribing were observed at the alert site only. Date: December 28, 2017 Systematic Review: Patient Outcomes in Dose Reduction or Discontinuation of Long-term Opioid Therapy Suggest Utility of Multimodal Care Investigators examined the evidence on the effectiveness of strategies to reduce or discontinue long-term opioid therapy (LTOT) prescribed for chronic pain – and the effect of dose reduction or discontinuation on important patient outcomes, including pain severity and pain-related function. Findings showed that there are multiple strategies to reduce or discontinue long-term opioid treatment for chronic pain, however the quality of the evidence for effectiveness was very low. In 3 good-quality trials of behavioral interventions and 11 fair-quality studies of interdisciplinary pain programs, patients received multimodal care that emphasized non-pharmacologic and self-management strategies. Sixteen fair-quality studies reported improvement in pain severity (8/8 studies), function (5/5 studies), and quality of life (3/3 studies) following opioid dose reduction. However, few studies examined the potential risks of opioid dose reduction such as adverse events (i.e., opioid overdose), illicit substance abuse, or suicide. Date: July 18, 2017 Higher Risk of Suicidal Ideation and Suicidal Self-Directed Violence following Discontinuation of Long-term Opioid Therapy The primary objective of this study was to identify predictors of suicidal ideation (SI) and non-fatal suicidal self-directed violence (SSV) following clinician-initiated discontinuation of long-term opioid therapy. Findings showed that a substantial proportion of Veterans with substance use disorder diagnoses and similar matched patients experienced suicidal ideation or suicidal self-directed violence following discontinuation of long-term opioid therapy by their opioid-prescribing clinicians, most of whom represent new onset cases. Approximately 12% of patients in this sample had SSV and/or SI documented in the medical record in the 12 months following discontinuation of opioid therapy: 47 patients had SI only, while 12 had SSV. Half of patients with SSV attempted suicide by overdose, most commonly with benzodiazepines. Mental health diagnoses associated with having SI/SSV included PTSD and psychotic disorders. The majority of patients (75%) were discontinued from opioid therapy due to aberrant behaviors. Healthcare providers should pay special attention to safety when patients are discontinued from long-term opioid therapy, particularly patients with PTSD or psychotic disorders. Date: July 1, 2017 Managing Chronic Pain in the Wake of the Opioid Backlash This JAMA Viewpoint commentary discusses several options for managing pain, as well as the overuse of the term “opioid epidemic.” Authors warn that imperfect treatments do not justify therapeutic distrust, and suggest that there is a broad menu of partially effective treatment options that can maximize the chances of achieving at least partial amelioration of patients’ chronic pain. Date: June 20, 2017 Greater Risk of Opioid Prescription Overlap in Veterans Using Medicare Part D–Reimbursed Pharmacies This study sought to identify trends in dispensed prescriptions for opioids and the frequency of overlapping days’ supply of prescriptions for opioid medications in Veterans dually eligible for VA and Medicare Part D benefits. Findings showed that over the study period, there was an increasing reliance on the use of Part D–reimbursed pharmacies for opioid prescriptions among Veterans. Although opioid overlap appears to be declining within the VA healthcare system, overlap is increasing among opioid prescriptions dispensed from Medicare Part D–reimbursed pharmacies. Predictors for overlap included female gender, Part D enrollment, no VA medication copay, sleep disorders, psychiatric diagnoses, and substance or alcohol abuse. Veterans who were Hispanic, older, and had higher incomes had lower odds of overlap. Date: May 1, 2017 Opioid Use among Afghanistan and Iraq War Veterans This study sought to understand current opioid use in OEF/OIF/OND Veterans who are regular users of VA care and did not have a cancer diagnosis at the time of this study. Findings showed that opioid use among OEF/OIF/OND Veterans is characterized by moderate doses that are used over relatively long periods of time by a minority of Veterans. Approximately 23% of all OEF/OIF/OND Veterans received opioids, with 7-8% receiving them chronically. The prevalence of high-dose opioids, concurrent use of multiple opioids, and use of long-acting opioids was fairly low. Diagnoses of PTSD, major depressive disorder, and tobacco use disorder were strongly associated with chronic opioid use. Back pain also was strongly associated with chronic use. Findings suggest that the use of opioids is less common among OEF/OIF/OND Veterans compared with Veterans as a whole, and provide a strong baseline for evaluating the impact of recently implemented opioid-related policies. Date: March 25, 2017 Addressing the Opioid Epidemic: Lessons Learned from VA This article describes VA’s efforts to address the opioid epidemic, and lessons learned that can inform other healthcare systems planning comprehensive action to reduce the risks associated with opioid therapy. Date: March 13, 2017 Discontinuation of Long-Term Opioid Therapy among Veterans is Overwhelmingly Initiated by VA Clinicians The aim of this study was to compare reasons for discontinuation of long-term opioid therapy (LTOT) between Veterans with and without substance use disorder (SUD) receiving care within the VA healthcare system in the years following release of 2009 and 2010 clinical practice guidelines. Findings showed that the majority of Veterans (85%) discontinued opioid use because their clinician stopped prescribing, rather than the patients deciding to stop. For patients whose clinicians initiated discontinuation, 75% were discontinued due to opioid-related aberrant behaviors (i.e., suspected substance abuse, aberrant urine drug test). Veterans with SUD diagnoses were more likely to discontinue LTOT due to aberrant behaviors, particularly abuse of alcohol or other substances, compared to Veterans without SUD. High proportions of patients received diagnoses for mental health disorders in the year prior to discontinuation of LTOT, including PTSD, anxiety disorders other than PTSD, and depressive disorders (25%). Increasing rates of opioid discontinuation are likely to occur due to policies and programs that encourage close monitoring of Veterans on LTOT for opioid misuse behaviors. Integrating non-opioid pain therapies and SUD treatment into multiple settings such as primary care and specialty SUD care is one possible approach to enhance their care. Date: March 1, 2017 VA Pharmacy Use in the First Year of Choice Act This study sought to describe pharmaceutical use during the first year of the Veterans Choice Program (VCP) and to understand barriers and facilitators for VA pharmacists to dispensing medications under the VCP. Findings showed that a majority of VCP pharmacy spending in the first year was for hepatitis C virus (HCV) medications, which accounted for only 5% of prescriptions but 90% of costs. However, in 2015, VA experienced greater than expected demand for HCV medications, which exceeded available funding, thus some patients obtained medications through the VCP. The impact of HCV medications on the VCP should be short-lived given broadened availability in VA in 2016. Topical eye drops and opioids represented the most commonly dispensed prescriptions: 16% and 9% of all prescriptions, respectively. Most prescriptions dispensed (93%) were for formulary agents, but substantial efforts were required from VA pharmacists to work with non-VA providers to use formulary drugs. Challenges related to obtaining medications from VA pharmacies through VCP included requiring controlled substance prescriptions to be hand-delivered, a lack of access to lab data required to safely dispense medications, and substantial time required by pharmacists to communicate with non-VA providers. Safe use of opioids, efficient management of non-formulary medications, and unintended new barriers to access created by the VCP must be addressed, in addition to robust ongoing evaluations to identify new cost, quality, and safety concerns. Date: February 17, 2017 VA Opioid Safety Initiative Decreases Potentially Risky Opioid Prescriptions among Veterans This study examined changes associated with Opioid Safety Initiative (OSI) implementation among all adult VA patients who filled outpatient opioid prescriptions from October 2012 through September 2014 in any of 141 VA facilities. Findings showed that during the two-year study period there was a decrease in the number of VA patients receiving risky opioid regimens, with an overall reduction of 16% among Veterans receiving >100 morphine-equivalent milligrams (mEq) daily dosages and 24% among Veterans receiving >200 mEq. There was a 21% reduction in Veterans receiving benzodiazepines concurrently with opioids. Implementation of the OSI dashboard tool was associated with a significant decrease in all three outcomes (>100 mEq, >200 mEq and concurrent opioid/benzodiazepine prescribing). The implementation of the OSI dashboard tool was associated with a significant decrease in risky opioid prescribing across the VA healthcare system, which highlights the possibility of system-wide approaches to address high-risk opioid prescribing. However, a large number of VA patients remained on these regimens at the end of the study period, which emphasizes the challenges of making significant changes in healthcare systems that treat a large population of complex patients. Date: January 4, 2017 Safety Risk for Veterans Receiving Overlapping Buprenorphine, Opioid, and Benzodiazepine Prescriptions from VA and Medicare Part D Ensuring safe buprenorphine prescribing is especially challenging for VA, which treats a substantial number of Veterans with chronic pain and opioid use disorder, as well as an increasing number of patients who receive concurrent care in the private sector (i.e., Medicare Part D). This study identified Veterans dually enrolled in VA and Medicare Part D who filled a buprenorphine prescription in 2012 from either healthcare system and identified the proportion of Veterans with overlapping prescriptions from either system. Findings showed that more than one in four Veterans who received a VA prescription for buprenorphine – and one in five Veterans who received a Medicare prescription for buprenorphine – also received overlapping prescriptions for opioids from a different healthcare system. Among Veterans receiving buprenorphine from VA, 1% received an overlapping benzodiazepine prescription from Medicare, while among those receiving buprenorphine from Medicare, 16% received an overlapping benzodiazepine prescription from VA. Among VA and Part D buprenorphine recipients who had cross-system opioid overlap, 25% and 35%, respectively, had >90 days of overlap. Findings indicate a previously undocumented safety risk for Veterans dually enrolled in VA and Medicare who are receiving prescriptions for buprenorphine and overlapping prescriptions for opioids and/or benzodiazepines. Date: December 7, 2016 OEF/OIF/OND Veterans that Currently Smoke More Likely to Receive Opioid Prescription than Non-Smokers This study sought to determine if smoking status is associated with the receipt of opioids among OEF/OIF/OND Veterans – and to examine important covariates of smoking (i.e., current pain intensity, gender, and mental health diagnoses) and receipt of opioids. Findings showed that compared to non-smokers, OEF/OIF/OND Veterans who were current smokers were more likely to receive an opioid prescription, even after controlling for covariates including: pain intensity, age, gender, service-connection, substance use disorder, mood disorders, and anxiety disorders. Veterans who reported a higher current pain intensity and those with pain diagnoses also were more likely to receive an opioid prescription. Among this young cohort of Veterans (mean age=30 years), more than one-third (34%) reported moderate to severe current pain intensity within +/-30 days of smoking status, with approximately 8% receiving at least one opioid prescription. Date: September 21, 2016 Prescription Opioids Associated with Lower Likelihood of Sustained Improvement in Pain among Older Veterans This study sought to identify patient factors associated with improvements in pain intensity in a national cohort of Veterans 65 years or older with chronic pain. Findings showed that on average, Veterans prescribed an opioid were less likely to demonstrate sustained improvement in pain intensity scores compared to Veterans who were not prescribed opioids. Overall, average relative improvement in pain intensity scores from baseline ranged from 25% to 29%; almost two-thirds of Veterans met criteria for sustained improvement during follow-up. Findings call for further characterization of heterogeneity in pain outcomes in older adults, as well as further analysis of the relationships between prescription opioids and treatment outcomes. Date: July 1, 2016 Prescription Opioid Use among Patients with Recent History of Depression Increases Risk of Recurrence This study examined whether patients in depression remission who were prescribed opioids for non-cancer pain had an increased risk of depression recurrence. Investigators analyzed two patient populations: Veterans treated in the VA healthcare system, and patients treated by a non-profit integrated healthcare system located in Texas. Findings showed that prescription opioid use among patients with a recent history of depression increased the chance of depression recurrence, and this effect was independent of pain diagnoses and pain intensity scores. Patients with remitted depression who were exposed to opioid analgesics at any point during the follow-up period were 77% to 117% more likely to experience a recurrence of depression than those who remained opioid free, after controlling for other factors. Among VA patients with depression remission, those who received opioids during follow-up were younger, had more psychiatric comorbidities, and had more painful conditions and higher pain scores than those who didn’t receive opioids. Date: April 1, 2016 Prescription Use of Codeine Associated with Greater Risk of New Onset Depression among Veterans This study sought to determine whether the hazard of new depression diagnosis differs among VA patients prescribed only codeine, only hydrocodone, or only oxycodone. Findings showed that Veterans prescribed only codeine for 30 days or longer had a 29% increased risk of a new diagnosis of depression compared to Veterans prescribed only hydrocodone for 30 days or longer. Those prescribed only oxycodone for 30 days or longer were not significantly more likely to develop a new depression diagnosis compared to patients prescribed hydrocodone only. Opioid use of 30-90 days was most common among oxycodone users, and opioid use of more than 90 days was most common among hydrocodone users. The distribution of individual comorbid conditions did not significantly differ across the three types of opioids. Date: March 22, 2016 Increased Dose of Prescription Opioids Raises Risk of Suicide among Veterans with Chronic Non-Cancer Pain This study examined the association between prescribed opioid dose and suicide in a national sample of VA patients with a chronic non-cancer pain condition who received opioid therapy. Findings showed that increased dose of opioids was found to be a marker of increased suicide risk, even when relevant demographic and clinical factors were statistically controlled. Type of opioid dosing schedule (i.e., regularly scheduled, as needed, or both) did not significantly affect suicide risk after accounting for other factors. Similar to the U.S. population and other large studies of VA patients, the vast majority of suicides involved firearms (64%), with overdose accounting for 20% of all suicides. Date: January 5, 2016 Individual and Facility-Level Factors Associated with Higher Risk of Suicide Attempt among Veterans Receiving Opioid Therapy This study examined the associations between the receipt of guideline-recommended care for opioid therapy and risk of suicide-related events, assessing associations between individual-level and facility-level delivery of recommended care, and individual-level suicide-related events. Findings showed that within 180 days following opioid prescription, 1.6% of the study population on chronic short-acting opioids and 2.1% of the study population on long-acting opioids experienced suicide-related events. At the individual level, Veterans who received opioid therapy and had medical frailty, drug, alcohol, or mood disorder, and/or traumatic brain injury had a higher risk of suicide-related events. Patients on opioid therapy within VA facilities that ordered more drug screens were associated with a decreased risk of suicide-related events. Patients on long-acting opioid therapy within facilities that provided more follow-up after new prescriptions also were associated with decreased risk of suicide-related events. Patients on long-acting opioid therapy within facilities having higher sedative co-prescription rates had an increased risk of suicide -related events. Among the sub-population of patients with a substance use disorder and a short-acting opioid prescription, the facility rate use of specialty substance use disorder treatment was associated with lower risk of suicide-related events. Encouraging facilities to make more consistent use of drug screening, providing follow-up within four weeks for patients initiating new opioid prescriptions, avoiding sedative co-prescription in combination with long-acting opioids, and engaging patients with substance use disorders in specialty substance use treatment, may help prevent suicide-related events. Date: July 1, 2015 Receipt of Opioid Analgesics and Benzodiazepines Associated with Increased Risk of Death Due to Drug Overdose This study sought to describe the relationship between the receipt of concurrent benzodiazepines and opioid analgesics and death due to drug overdose in patients receiving prescription opioids for acute, chronic, and non-terminal cancer pain. Findings showed that during the study period, 27% of Veterans who received opioid analgesics also received benzodiazepines. Among those receiving opioid analgesics, receipt of benzodiazepines was associated with an increased risk of death due to drug overdose. About half of the overdose deaths occurred when Veterans were concurrently prescribed benzodiazepines and opioids. Patients who were prescribed concurrent opioids and benzodiazepines –and then stopped receiving benzodiazepines had higher rates of overdose than those patients who had only received opioids. Veterans who received benzodiazepines were more likely to be female, middle-aged, white, and to reside in wealthier areas. Veterans who received benzodiazepines were also more likely to have had a recent mental health or substance use disorder-related hospitalization, a diagnosis of a substance use disorder, or a number of psychiatric disorders (i.e., PTSD, depression, anxiety). These findings provide empirical support for the goal of the VA Opioid Safety Initiative (OSI) to reduce unnecessary co-prescribing of opioids and benzodiazepines, for which there had been limited evidence prior to this study. Date: June 10, 2015 Gender Differences in Chronic Pain among Veterans This study examined a) gender differences in trauma, social support, and family conflict among OEF/OIF/OND Veterans with chronic pain, and b) whether these variables were differentially associated with pain severity, functioning, and depressive symptom severity as a function of gender. Findings showed that 69% of Veterans in the study reported experiencing pain for 3 months or longer (67% of men and 71% of women); 75% stated pain had been present for more than one year. The most problematic sites of pain were: back (37%), joint (33%), headache (12%), and neck (9%). Men and women Veterans did not differ significantly in terms of pain severity, pain interference with function, depressive symptom severity, or use of prescription opioids. Relative to men, women Veterans reporting chronic pain evidenced higher rates of childhood interpersonal trauma (51% vs. 34%) and military sexual trauma (54% vs 3%), as well as lower levels of combat exposure. Being married was associated with greater pain-related functional difficulty for women and lower difficulty for men. Combat exposure was associated with pain-related functional difficulty for women but was unrelated for men. Childhood interpersonal trauma was more strongly associated with pain-related functioning among men. Family conflict was associated with greater pain-related functional difficulty and depressive symptoms for men, but was unrelated for women. Thus, gender may be a salient target of investigation when examining development of and/or adaptation to chronic pain, and is an important consideration in tailoring treatment programs to meet the needs of Veterans with chronic pain. Date: June 1, 2015 Stepped Care Intervention Benefits Veterans with Chronic Pain This randomized controlled trial tested the Evaluation of Stepped Care for Chronic Pain (ESCAPE) intervention in primary care settings that included 12 weeks of analgesic treatment (i.e., acetaminophen, topical analgesics, opioids) coupled with pain self-management strategies (i.e., goal setting, positive self-talk), which was followed by 12 weeks of cognitive behavioral therapy. Findings showed that the stepped-care intervention resulted in statistically significant reductions in pain-related disability, pain interference, and pain severity in Veterans with chronic musculoskeletal pain compared to usual care. Date: March 9, 2015 VA Primary Care Intervention Decreases High-Dose Opioid Prescription for Veterans with Non-Cancer Pain In October 2013, VA initiated a nationwide Opioid Safety Initiative (OSI) that includes goals of decreasing high-risk opioid prescribing practices, including prescribing of high-dose opioids. Prior to this national initiative, the Minneapolis VA Health Care System implemented a primary care population-based OSI aimed primarily at reducing high-dose opioid prescribing. This study evaluated the Minneapolis initiative. Findings showed that the number of Veterans prescribed daily high-dose opioids decreased from 342 to 65. Overall, the number of unique pharmacy patients who received at least one opioid prescription within 90 days decreased 14%. The number of Veterans receiving oxycodone SA decreased from 292 to 3 over the study time period. The number of Veterans receiving other long-acting opioids, as well as hydrocodone-acetaminophen, hydromorphone, and oxycodone/acetaminophen also decreased. The proportion of primary care providers who agreed that it was reasonable for the medical center to set a dosage limit was 76% at baseline and 87% at follow-up. The two most commonly endorsed barriers to lowering doses were patients becoming upset (62% baseline and 64% follow-up) and pressure from patient service representatives or the administration (59% baseline and 22% follow-up). Date: February 3, 2015 JGIM Supplement Highlights VA’s Partnered Research In this JGIM Supplement, 12 articles describe partnered research at various stages – from conceptualizing partnered research to examples of findings borne from bi-directional collaborations with investigators and leaders from clinical operations. These articles cover a wide range of topics highly relevant to VA policy and practice, including performance measure implementation on provider motivation, opioid management, suicide prevention, homelessness, medical home models, and communication of adverse events. Date: November 1, 2014 Increased Prescribing Rates for Concurrent Sedative Medications among Veterans with PTSD This is the first national study that sought to characterize polysedative prescribing in Veterans with PTSD. Findings showed that, over time, there was an increase in the use of polysedatives among Veterans with PTSD: from 34% to 37% for two or more sedative classes, and from 10% to 12% for three or more classes. This represents a concerning clinical trend and a relative increase of nearly 25%. The most common combination of sedatives was an opioid plus a benzodiazapine, which were taken concurrently by 16% of Veterans with PTSD. Two other combinations that were used more frequently than expected were opioids plus skeletal muscle relaxants – and benzodiazepines plus atypical antipsychotics. Polysedative use varied across demographic subgroups, with higher rates among women, Veterans residing in rural settings, younger adults, Native Americans, and Whites. Also, benzodiazepine prescribing was markedly elevated among women (44%) compared to men (34%), and was somewhat lower among older adults (31%) compared to younger adults (36%). Date: December 16, 2013 Chronic Opioid Therapy Common among Hospitalized Veterans, Associated with Increased Risk of Death and Re-Admission This study sought to determine the prevalence of prior chronic opioid therapy (COT) among hospitalized medical patients, in addition to examining characteristics associated with inpatients that had previous opioid therapy compared to those with no opioid therapy prior to hospital admission. Findings showed that COT is common among hospitalized Veterans; moreover, occasional and chronic opioid use was associated with increased risk of hospital readmission and COT was associated with increased risk of death. Nearly 1 in 4 hospitalized Veterans had current or recent COT at the time of hospital admission for non-surgical conditions, and nearly half had been prescribed any opioids. Among the Veterans in this study, 26% had received COT in the prior 6 months, and 20% had occasional opioid therapy. Diagnoses more common in Veterans with COT included COPD, complicated diabetes, PTSD, and other mental health disorders. Date: December 6, 2013 Opioid Prescribing for Veterans with Chronic Non-Cancer Pain This study sought to describe patterns of prescription opioid initiation, identify correlates of opioid initiation, and examine correlates of receipt of chronic opioid therapy (COT) among Veterans with persistent non-cancer pain. Findings showed that the initiation of opioid drug therapy is common among Veterans with persistent pain, but most Veterans are not prescribed opioids long-term. During the study year, 35% of Veterans in the sample received an opioid prescription: 30% were prescribed opioids on a short-term basis (<90 days), and 5% received chronic opioid therapy (>90 days). Clinical factors associated with initiating COT include increased pain intensity, nicotine dependence, substance use disorders, and major depression diagnoses. Nearly one-quarter of Veterans prescribed COT also received prescriptions for benzodiazepine medications, which is a concern given that overdose deaths have been linked to the use of multiple sedating medications. Two-thirds of opioid prescriptions resulting in COT were initiated by primary care clinicians. The authors suggest that this supports the development of guidelines geared toward primary care practice. It also supports the provision of interventions and structures in primary care that facilitate proactive planning around opioid use and its monitoring. Date: February 1, 2013 Equitable Rates of Pain Assessment among African American and White Veterans This study sought to determine whether African American Veterans were less likely to be screened for pain than their White counterparts – and to determine the factors associated with differences in screening rates. Findings showed that VA’s mandate for pain screening has resulted in high and relatively equitable rates of pain assessment among both African American and White Veterans. Although rates of pain screening were lower among African Americans compared to Whites (78% vs.82%), this disparity was reduced by half after controlling for prior healthcare use, in which African American Veterans had a greater number of outpatient visits, which was associated with lower rates of pain screening at the index visit. Overall, Veterans were less likely to be screened for pain if they were African American, female, and married; if they had a diagnosis of deficiency anemia; if they had a greater number of outpatient visits; and if they were an established (vs. new) patient. Veterans were more likely to be screened if they had prior diagnoses of chronic joint, neck, or back pain; opioid abuse, anemia, and pulmonary circulation disorders; and if they had a non-opioid analgesic prescription and/or greater number of inpatient admissions in the previous two years. Date: November 21, 2012 Mental Health Diagnoses Associated with Opioid Prescription, High-Risk Use, and Adverse Outcomes among OEF/OIF Veterans Among OEF/OIF Veterans with pain, mental health diagnoses, especially PTSD, were associated with an increased risk of receiving opioids, high-risk opioid use, and adverse clinical outcomes. Compared to those without mental health diagnoses, Veterans with PTSD who were prescribed opioids were more likely to receive higher-dose opioids (16% vs. 23%), receive two or more opioids concurrently (11% vs. 20%), receive sedative hypnotics concurrently (8% vs. 41%), and to obtain early opioid refills (20% vs. 34%). Receiving prescription opioids (vs. not) increased risk for serious adverse clinical outcomes for Veterans (10% vs. 4%) across all mental health categories and was most pronounced in Veterans with PTSD. Of the 141,029 Veterans with pain diagnoses, 15,676 (11%) received prescription opioids for = 20 consecutive days; 77% of which were prescribed by VA primary care providers. Veterans with PTSD and mental health diagnoses excluding PTSD were significantly more likely to receive opioids for pain (18% and 12%) compared to Veterans without mental health diagnoses (7%). Date: March 7, 2012 Veterans that Use Cigarette Smoking to Cope with Chronic Pain Experience Worse Pain-Related Outcomes Veterans who reported smoking as a coping strategy for chronic pain scored significantly worse compared to Veterans who did not smoke and those who denied using cigarettes to cope with pain on the majority of measures of pain-related outcomes. After controlling for demographics and clinical factors, smoking as a coping strategy for pain was significantly and positively associated with pain intensity, pain interference, and fear of pain. There were no significant differences between the three groups on current symptoms of depression or anxiety, indicating that comorbid psychopathology likely did not contribute to poorer pain-related outcomes in the group who used cigarettes to cope with pain. The two smoking groups did not differ with respect to the frequency or severity of nicotine dependence, use of opioid medications, or on other clinical factors, suggesting that impairment in pain-related variables may be due to reliance on cigarettes as a coping strategy for chronic pain. Date: March 1, 2012 Majority of OEF/OIF Veterans with Chronic Non-Cancer Pain are Prescribed Opioids by VA Outpatient Providers This study sought to describe the prevalence of prescription opioid use, types and doses of opioids received, as well as factors associated with the prescription of opioids among OEF/OIF Veterans. Findings showed that about two-thirds of OEF/OIF Veterans with chronic non-cancer pain were prescribed opioids over a one-year timeframe. Of Veterans prescribed any opioids, 59% were prescribed opioids ‘short-term’ compared to 41% prescribed opioids ‘long-term’ (more than 90 days). The mean duration of opioid prescription was 61 days for Veterans in the short-term group and 285 days for Veterans in the long-term group. Several findings suggest a need for improvement in adherence to pain and opioid treatment guidelines. For example, among long-term opioid users, 51% were prescribed short-acting opioids only (guidelines recommend transitioning to long-acting opioids); only 31% were administered one or more urine drug screens (guidelines suggest more frequent drug screening); and 33% were also prescribed sedative-hypnotic medications (monitoring by prescribing physicians is recommended to prevent possible overdose or death). Diagnoses associated with an increased likelihood of receiving an opioid prescription included: low back pain, migraine headache, PTSD, and nicotine use disorder. Date: September 7, 2011 Veterans Receiving Higher-Dose Opioid Prescriptions for Pain at Increased Risk of Death from Overdose This study examined the association of maximum prescribed daily opioid dose and dosing schedule (“as needed,” regularly scheduled, or both) with risk of opioid overdose death among Veterans with cancer, chronic pain, acute pain, and substance use disorders. Findings showed that among Veterans receiving opioid prescriptions for pain, higher opioid doses were associated with increased risk of death from opioid overdose. The frequency of fatal overdose among Veterans treated with opioids was rare – estimated to be 0.04% - and was directly related to the maximum prescribed daily dose of opioid medication. There was no significant increased risk of opioid overdose among Veterans who were treated with both “as-needed” and regularly scheduled opioids – a strategy for treating pain exacerbations – after adjusting for maximum daily dose and patient characteristics. Veterans who died from opioid overdose were significantly more likely to have chronic or acute pain, substance use disorders, and other psychiatric disorders, but they were less likely to have cancer. This study highlights the importance of implementing strategies for reducing opioid overdose among patients being treated for pain, for example, ascertaining history of substance abuse, using treatment contracts, and scheduling frequent follow-up visits and toxicological screens for patients at special risk. Date: April 6, 2011 Rates of Accidental Poisoning among VA Patients Higher than General Population This study describes the rate of accidental poisoning mortality among Veterans who used VA healthcare services, compares this rate to the general U.S. population, and describes the drugs/medications involved. Findings show that for FY05, VA patients had nearly twice the rate of fatal accidental poisoning compared to adults in the general population. Among VA patients who died from accidental poisoning, opioid medications (including methadone) made up 32% of the reported deaths; cocaine also was common at 23%. In both the VA and U.S. general populations, the rate of accidental poisoning mortality was higher for men than women, and higher for individuals ages 30 to 64 as compared to those ages 18 to 29, or ages 65 and older. Although VA patients have a greater risk of suicide than death by accidental poisoning, their risk for accidental poisoning death relative to the general population is larger than that of suicide. Date: April 1, 2011 Primary Care-Based Collaborative Care for Chronic Pain May Be More Effective than Usual Care A primary care-based collaborative care intervention for chronic pain was significantly more effective than usual care across a variety of outcome measures, including pain disability and intensity. However, these improvements were generally modest. Depression severity and pain disability and intensity improved among Veterans in the intervention group who reported both chronic pain and depression. Greater use of adjunctive pain medications and long-term opioids among the intervention group suggested that the intervention contributed to the delivery of guideline-concordant care. Date: March 25, 2009
What is included in Publication Briefs? HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations. ^ top

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