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2019 HSR&D/QUERI National Conference Abstract

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1167 — Do Veterans' non-VA opioid prescriptions change after a VA dose reduction? Analyses of linked VA and state prescription drug monitoring program data

Lead/Presenter: Kathleen Carlson,  COIN - Portland
All Authors: Carlson KF (Center to Improve Veteran Involvement in Care, VA Portland Healthcare System; School of Public Health, Oregon Health and Science University), Gilbert TA (Center to Improve Veteran Involvement in Care, VA Portland Healthcare System), Morasco BJ (Center to Improve Veteran Involvement in Care, VA Portland Healthcare System; School of Medicine, Oregon Health and Science University) Lovejoy TI (Center to Improve Veteran Involvement in Care, VA Portland Healthcare System; Schools of Medicine and Public Health, Oregon Health and Science University) Cook LJ (School of Medicine, University of Utah)

Objectives:
In response to the US opioid epidemic, the Veterans Health Administration (VA) has significantly reduced opioid prescribing in recent years. However, Veterans whose VA opioid prescriptions are tapered or discontinued may instead receive prescriptions from non-VA providers. Among Veterans receiving long-term opioid therapy (LTOT) from the VA, the objective of this work was to examine patterns of non-VA opioid receipt in the year after a significant reduction in their VA opioid dose.

Methods:
VA healthcare data for 11,897 post-9/11 Veterans were linked to Oregon prescription drug monitoring program (PDMP) data from 2014-2016. Veterans receiving VA outpatient care during one of the three study years were included in the analyses. We examined the proportion of Veterans who received non-VA opioid prescriptions in the year after their VA doses were reduced by ?20% of baseline. For those who received ?7 days of non-VA opioids, we compared total annual VA and non-VA doses dispensed in morphine milligram equivalents (MMEs).

Results:
Among 1,087 Veterans receiving VA LTOT, 731 (67%) had dose reductions. Of these, 195 (27%) received non-VA opioids in the subsequent year; 91 were new non-VA prescriptions and 104 were ongoing prescriptions. Among Veterans with ongoing non-VA prescriptions, 74 (73.1%) increased their non-VA dose by ?20%. There were 122 Veterans (17%) who received ?7 days of non-VA opioids in the year after their VA dose reduction. Although Veterans' average annual VA MMEs were greatly reduced after dose reduction (4,595 to 1,372 MMEs/year; p < 0.001), those who received subsequent non-VA opioids did not have a statistically significant decline in total combined MMEs (5,475 to 4,623 MMEs/year; p = 0.123).

Implications:
Among Veterans who experienced VA opioid dose reductions, a small proportion received non-VA prescriptions for ?7 days in the subsequent year. Total opioid exposure was not significantly reduced for these Veterans. Thus, there is a need to account for non-VA prescriptions when considering Veterans' overall opioid safety.

Impacts:
These findings highlight the potential for high-risk fragmentation of care among Veterans who use both VA and non-VA healthcare. The routine use of state PDMPs to identify complete prescription histories can help identify dual system (or non-VA-only) opioid receipt and mitigate opioid-related risks.