Controlled prescription drug overdose, primarily from opioids, is a leading cause of death in the United States. Veterans who use Veterans Affairs (VA) healthcare have twice the risk of medication overdose deaths than non-Veterans. Reasons for this increased risk are unknown. It is possible that Veterans who receive VA prescriptions simultaneously receive controlled prescriptions (e.g., opioids, benzodiazepines) from non-VA prescribers. State prescription drug monitoring programs (PDMPs) can help reduce prescription drug overdose by providing data on controlled medications across providers and systems. However, little is known about the prevalence of dual VA-community prescriber use among Veterans, their full range of medication-related adverse events (i.e., those treated inside or outside the VA), and mechanisms to increase use of state PDMPs within the VA.
Our mixed-methods project will: (1) Quantify, and characterize patterns of, dual use of VA and community prescribers of opioids and benzodiazepines among OEF/OIF/OND Veterans in Oregon; (2) Describe rates, types, and risk factors for all opioid/benzodiazepine-related adverse events among OEF/OIF/OND Veterans in Oregon; and (3) Identify barriers and facilitators to state PDMP use among VA opioid/benzodiazepine prescribers in Oregon.
To accomplish Aims 1 and 2, we will link VA data to multiple state databases to identify controlled prescriptions (VA and community) that OEF/OIF/OND Veterans are receiving as well as their risk of overdose and other adverse events treated inside or outside the VA. Data from 2011, the year the Oregon PDMP was implemented, through 2016 will be used to identify patterns, rates, and risk factors for dual VA/community prescriber use, as well as fatal and nonfatal medication-related adverse events. Changes over time will also be analyzed. To accomplish Aim 3, we will interview and survey Oregon VA prescribers about barriers and facilitators to using the state PDMP. We will also examine organizational and patient factors associated with VA-documented PDMP queries among Veterans receiving long-term opioid therapy (LTOT) in VISN 20.
Among VISN 20 Veterans receiving LTOT, 64% had a PDMP query documented in their medical record; this proportion varied widely by VA site and by primary care provider (PCP). Veterans were more likely to have a documented PDMP query if prescribed opioids by their PCP than by another clinician, if prescribed higher doses, or if diagnosed with a substance use disorder; there was no association between benzodiazepine co-prescribing and PDMP queries. Among Oregon Veterans who received a VA opioid prescription between 2014 and 2016, 15.1% received a concurrent non-VA opioid prescription. Veterans were more likely to have concurrent VA and non-VA prescription fills if they had a 50% or higher VA service connection, were a participant in the Veterans Choice Program, or had diagnoses for post-traumatic stress disorder, pain, depression, traumatic brain injury, or substance use disorder.
Results of our research will build knowledge for VA prescribers, pharmacists, and operations leaders to better address Veterans' medication safety. This work will support interventions that improve the systematic use of state PDMPs to inform prescribing decisions and, ultimately, reduce opioid-related adverse events among Veterans.
- Carlson KF, Gilbert TA, Morasco BJ, Wright D, Otterloo JV, Herrndorf A, Cook LJ. Linkage of VA and State Prescription Drug Monitoring Program Data to Examine Concurrent Opioid and Sedative-Hypnotic Prescriptions among Veterans. Health services research. 2018 Dec 1; 53 Suppl 3:5285-5308.
- Mohr CD, McCabe CT, Haverly SN, Hammer LB, Carlson KF. Drinking Motives and Alcohol Use: The SERVe Study of U.S. Current and Former Service Members. Journal of studies on alcohol and drugs. 2018 Jan 1; 79(1):79-87.