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The United States is in the grip of an unprecedented epidemic of prescription opioid and heroin overdose. Drug overdose is now the leading cause of death due to injury and the leading cause of death overall in adults aged 24 to 44 years. Prescription opioid medications have played a major role in the development of this epidemic; over the past 20 years, annual prescriptions for opioids more than doubled, now with enough prescriptions for every adult in America to have a bottle of pills. The death rate from opioid analgesics more than tripled between 1999 and 2012. 1
VA is not immune to these national trends. The number of Veterans receiving opioids from VA providers nearly doubled between 2001 and 2013, from 651,000 to 1,101,346. In 2013, almost one in four VA pharmacy users received an opioid medication. The number of overdoses due to prescription opioids among Veterans has increased as well.2 While VA has adopted several strategies to mitigate the risks of opioid medications, these efforts focus almost entirely on monitoring prescriptions dispensed within VA. Many patients are receiving opioid medications—and other medications that interact with opioids— outside VA. Without understanding this non-VA use, VA will be unable to develop fully successful interventions to address opioid safety.
While much is known about how Veterans receive healthcare from both VA and non-VA health systems, very little is known about opioid prescribing across multiple systems. The theoretical concerns about ‘dual use,’ namely care fragmentation and duplication, are magnified for opioid medications given the added risks from high dosages and concomitant benzodiazepine use. A large majority of Veterans have some form of non-VA health insurance in addition to their VA benefits, but rates of prescription coverage vary—roughly one out of four VA enrollees have private drug coverage, and one in three VA/Medicare dual enrollees have Part D drug coverage.3 The issue of dual use of opioids is increasingly relevant not only because of the overdose epidemic, but also because of the expansion in insurance options through Medicaid and insurance exchanges under the Affordable Care Act (ACA), and the Veterans Choice Program. Each additional opportunity for Veterans to receive care in multiple health systems—from multiple providers who have limited or no communication with each other—represents an additional opportunity for care fragmentation. Most would agree that fragmented healthcare is not beneficial when it comes to managing pain and opioids.
We are currently investigating these very concerns about dual use of opioids through an HSR&D funded project. We are examining linked VA and non-VA data at a national level and talking to VA primary care doctors about their experiences managing dual health system use of opioids. Our analyses are in the early stages, but already it is quite clear that dual use of opioid medications is a problem. Concurrent dual use of opioids and benzodiazepines is also occurring—non-VA providers prescribing opioids while VA providers prescribe benzodiazepines, each potentially not knowing what the other is doing. This fragmentation presents real challenges for the safe use of opioid medications.
What to do about this dual use of opioids? There are programs in place that try to address such use. For example, state prescription drug monitoring programs (PDMPs) allow VA providers in some states to look for non-VA opioids and other scheduled drugs before prescribing through VA. These programs are generally voluntary, do not interface directly with decision support systems within VA, and are state-based and thus difficult to aggregate at the national level. Systems could certainly be developed to incorporate real time queries of the PDMPs into CPRS decision support, but those systems would take time (i.e., years) to develop. In Pennsylvania, for example, the state with the eighth highest drug overdose rate, PDMPs are not yet available for query by providers, and for those providers in the western part of the state, they would have to search not only the Pennsylvania PDMP, but also Ohio and West Virginia, given the close borders. The Veterans Lifetime Electronic Record (VLER) health exchange has potential for allowing real-time notification to providers when opioids are prescribed in multiple systems, but only if the medication lists on both sides are properly updated and the electronic ordering systems query both systems when searching for interacting medications.
Systemic solutions to the problem of dual use of opioid medications are still years away from materializing. The short term solution is increased vigilance by VA providers about their opioid prescribing, and constant reminders that they are not the only ones providing medications to their patients. As in other aspects of dual health care system use, VA HSR&D investigators have an important role to play in identifying these problems and developing, testing, and implementing solutions.
1. Warner M., Hedegaard H., and Chen L. Trends in Drug-poisoning Deaths Involving Opioid Analgesics and Heroin: United States, 1999–2012. CDC. Available at www.cdc.gov/nchs/data/hestat/drug_poisoning/drug_poisoning_deaths_1999-2012.pdf.
2. Bohnert A.S., et al. “Trends and Regional Variation in Opioid Overdose Mortality Among Veterans Health Administration Patients, Fiscal Year 2001- 2009,” Clinical Journal of Pain 2014; 30(7):605-12.
3. Gasper J., Liu H., Kim S., and May L. 2015 Survey of Veteran Enrollees’ Health and Use of Health Care. Available at http://vaww.va.gov/VHAOPP/ SOE/2015/Survey_of_Veteran_Descriptive_Report. pdf (intranet only).