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VA and Opioid Safety

September 7, 2018

In 2013, VA launched the Opioid Safety Initiative (OSI)—the first of several system-wide initiatives to address opioid overuse. By mid-2016 compared with mid-2012, the number of Veterans dispensed an opioid each quarter had decreased by 172,000, or about 25%. Moreover, there were 57,000 (47%) fewer patients receiving concomitant opioids and benzodiazepines, and 22,000 (36%) fewer patients receiving daily opioid dosages of more than 100 morphine milligram equivalents, both measures of potentially unsafe opioid use.1  

Following are just some of the additional important findings from HSR&D researchers regarding this nation’s opioid epidemic.

  • VA’s Opioid Safety Initiative (OSI) also prioritized reductions in opioid and benzodiazepine co-prescribing and other non-recommended opioid prescribing practices. A QUERI 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 show 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. Also, significant decreases in benzodiazepine prescribing were observed at the alert site only.2
  • An HSR&D study published in 2018 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 (n=539,473). Overall, 135,643 Veterans (25%) received opioids from VA only, 332,630 (62%) from Part D only, and 71,200 (13%) from both VA and Part D (dual use). Findings show 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.3
  • Funded by HSR&D, the Strategies for Prescribing Analgesics Comparative Effectiveness (SPACE) trial was a randomized trial that 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. Investigators identified 240 Veterans with chronic pain (nearly every day for ≥6 months) that was moderate-to-severe despite analgesic use. Veterans were recruited from 62 Minneapolis VA primary care clinicians from June 2013 to December 2015. Patients were randomized to one of two intervention groups: opioid therapy or non-opioid medication therapy. 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. Moreover, 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. In addition, opioids caused significantly more medication-related adverse symptoms than non-opioid medications.4

  1. Gellad W. Addressing the opioid epidemic in the United States: Lessons from the Department of Veterans Affairs. JAMA Internal Medicine. May 2017;177(5):611-612.
  2. Malte C, Berger D, Saxon A, et al. Electronic medical record alert associated with reduced opioid and benzodiazepine co-prescribing in high-risk Veteran patients. Medical Care. February 2018;56(2):171-178.
  3. Gellad W, Thorpe J, Zhao X, et al. Impact of dual use of VA and Medicare Part D drug benefits on potentially unsafe opioid use. American Journal of Public Health. February 2018;108(2):248-255.
  4. Krebs E, Gravely A, Nugent S, et al. Effect of opioid vs. non-opioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain: The SPACE Randomized Clinical Trial. JAMA. March 6, 2018;319(9):872-82.

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