126. Prescription of Opioid Medications in VA Outpatient Care
AL Gifford, VA San Diego and VA Center for the Study of Health Care Provider Behavior; C Quach, VA San Diego and VA Center for the Study of Health Care Provider Behavior
Objectives: Pain control in primary care is a high clinical priority, and opioid medications are an important but controversial part of the analgesic pharmacopeia. Yet little is known about how often opioids are prescribed, physician opioid management workload compared with workload for other drug classes, or what proportion of opioid prescribing occurs in primary care settings.
Methods: Prescription data for fiscal 1999 were obtained for all opioids (codeine or hydrocodone+/-acetaminophen [DEA Schedule III]; oxycodone+acetaminophen, hydromorphone, methadone, morphine, fentanyl [Schedule II]) dispensed from all outpatient pharmacies of an urban, academically-affiliated VA healthcare system, with active outpatient specialty practices and a large multi-site Firm Primary Care practice. Data on all antilipid drugs prescribed were obtained for comparison. Drugs were quantified as prescriptions filled, pills, and total drug-days (pills dispensed divided by maximum pills/day). Firm Primary Care patients were classified according to quantity and type of opioid use, and whether or not they were diagnosed with cancer or HIV.
Results: In fiscal 1999, opioids were 3.7% of all VA outpatient prescriptions, and accounted for 16,602 prescriptions, 1,408,431 total pills, 278,806 drug-days provided and 4883 patients treated. In comparison, antilipid drugs accounted for 13,845 prescriptions, 1,500,506 total pills, 1,095,995 drug-days provided, and 4007 patients treated. Of all outpatient opioid users, 1003 patients (21%) were heavy users (>=60 drug-days/year), using 230,461 (83%) drug-days. Of all Firm Primary Care patients, 22% were treated with opioids, 6.6% received a Schedule II drug, 5.5% were heavy users (>=60 drug-days/year), and 2.5% were heavy Schedule II users. Firm patients diagnosed with cancer or HIV had a 1.6-fold greater risk of opioid use, and a 2.6-fold greater risk of heavy Schedule II use, however only 22% of opioid users and 31% of heavy Schedule II users were diagnosed with cancer or HIV. Opioids were prescribed by 545 MDs, of whom 28 were Firm Primary Care MDs: board-certified general internists on staff, responsible for longitudinal patient panels. Firm MDs prescribed nearly half (44%) of all opioid drug-days in the medical center, and wrote or refilled a median of 1.5 opioid prescriptions per day of primary care (interquartile range [IQR], 1.2-3.3), compared with 1.9 antilipid drugs prescribed or refilled per day of primary care (IQR, 1.3-2.5). Firm MDs were 2.9 times more likely than other providers to provide care for the heavy opioid users (95% CI 2.5-3.4). Schedule II drugs were 50% of opioid drug-days prescribed, and were used in similar proportions by Firm MDs (46%) and non-Firm MDs (53%).
Conclusions: In spite of regulatory hurdles to writing and dispensing, and concerns about the appropriateness of opioids, use of these drugs is common in VA outpatient and primary care. Most use is by patients with non-malignant pain. Managing patients on opioids is a substantial task for VA primary care providers.
Impact: If these results generalize to other care settings, they suggest a need to recognize the importance of chronic pain and opioid management, and develop programs accordingly to optimize and rationalize pain care.