4030 — Impact of Policy on Opioid Prescribing Trends: Studying the Relationship Between a VHA National Safety Initiative and Opioid Discontinuation
Lead/Presenter: Yufei Li,
All Authors: Li Y (Partnered Evidence-Based Policy Resource Center, Boston; Boston University School of Public Health)), Barr, K (Partnered Evidence-Based Policy Resource Center, Boston) Trafton, J (Program Evaluation and Resource Center, Office of Mental Health & Suicide Prevention) Oliva, E (Program Evaluation and Resource Center, Office of Mental Health & Suicide Prevention) Garrido MG (Partnered Evidence-Based Policy Resource Center, Boston; Boston University School of Public Health) Frakt A (Partnered Evidence-Based Policy Resource Center, Boston; Boston University School of Public Health) Strombotne KL (Partnered Evidence-Based Policy Resource Center, Boston; Boston University School of Public Health)
National health care efforts have been focused on ensuring patientsâ€™ access to safe and effective chronic pain treatment while reducing the risk of opioid use disorder, overdose, and death. The Stratification Tool for Opioid Risk Management (STORM) is a web-based dashboard and a risk profiling tool implemented by the Veterans Health Administration to help clinicians evaluate and mitigate opioid-related risks among their patients. Under the STORM policy, patients classified as very high risk were mandated to be case reviewed by an interdisciplinary team. Prior work has shown that mandated case review is associated with a significant decrease in mortality among high-risk patients. We analyzed prescription trends to further understand the mechanism through which this mortality benefit occurs. Specifically, we examined the impact of STORM mandated case review on discontinuation among high-risk chronic opioid users, as previous studies suggested that discontinuation is associated with increased risk for opioid withdrawal and other adverse events.
Under the STORM policy, all VHA facilities were initially mandated to case review patients with a risk score in the top 1%. The risk threshold used to identify very high-risk patients was expanded from the top 1% to 5% in a randomized stepped-wedge manner (referred to as risk expansion). We utilize this randomization in the policy roll-out and define treatment as mandated case review for patients with a risk score in the top 1-5%. We assigned individual patients to treatment or control status depending on if they enter the cohort prior to or following STORM risk expansion and tracked prescription trends for a 120-day follow-up period. Logistic regressions controlling for entry month and VA facility were conducted to examine the effect of mandated case review on discontinuation (defined as having no drugs-on-hand for 30 consecutive days following an episode of continuous use). The discontinuation analysis focused on chronic opioid users (defined as those with> = 90 days of opioid supply in the 120-day before entry date), who made up 24.7% (n = 13,248) of all eligible patients (n = 53,607).
Chronic users in the treatment condition were less likely to be discontinued compared to patients in control group (26.68% vs. 29.03%, p = 0.01). The unadjusted odds of discontinuation is 0.89 in the treatment group relative to the control group (CI: 0.81-0.97), and 0.54 in the adjusted model (CI: 0.45-0.66).
This is the first national study providing evidence that a predictive model-targeted prevention program had an impact on reducing risk of discontinuation for high-risk patients under long-term opioid therapy. STORM mandated case review was associated with reduced discontinuation for patients with chronic opioid usage, which may be a mechanism for reducing mortality.
Understanding how policy impacts prescribing trends is crucial for ensuring the effectiveness of opioid safety initiatives.