VA Opioid Safety Initiative Decreases Potentially Risky Opioid Prescriptions among Veterans
Over the past two decades, a dramatic rise in the sale of prescription opioids in the United States has coincided with the rise of opioid overdose deaths and other opioid-related adverse outcomes. Further, prescribing higher total daily dosages of opioids and co-prescribing benzodiazepines have been associated with a greater likelihood of opioid overdose. In response, VA leadership developed and implemented the Opioid Safety Initiative (OSI) in 2013 to promote safer opioid-related prescribing in the VA healthcare system. Key components of the OSI include a dashboard tool that uses VA electronic health record data to generate displays of real-time opioid-related prescribing – and identifies a clinical leader at each facility to implement the tool and promote safer prescribing. This retrospective study examined changes associated with OSI implementation among all adult VA patients who filled outpatient opioid prescriptions from October 2012 through September 2014 in any of 141 VA facilities. Investigators focused on total daily opioid dosages at thresholds of >100 morphine-equivalent milligrams (mEq) and >200 mEq because these have been associated with increased risk of unintentional overdose – and are displayed on the OSI dashboard tool. The numbers of patients receiving a benzodiazepine (i.e., alprazolam, clonazepam, and diazepam) concurrently with an opioid (i.e., codeine, morphine, and oxycodone) were also analyzed.
- During the two-year study period there was a decrease in the number of VA patients receiving risky opioid regimens. In October 2012, 55,722 Veterans received daily dosages of opioids >100 mEq, which decreased to 46,780 Veterans in September 2014, for an overall reduction of 16%. In October 2012, 19,952 Veterans received total daily dosages of opioids >200 mEq, which decreased to 15,121 patients by September 2014, for an overall reduction of 24%.
- In October 2012, 112,907 Veterans received benzodiazepines concurrently with opioids, which decreased to 89,564 Veterans by September 2014, for an overall reduction of 21%.
- Implementation of the OSI dashboard tool was associated with a significant decrease in all three outcomes (>100 mEq, >200 mEq and concurrent opioid/benzodiazepine prescribing).
- Although facilities on average exhibited reductions in risky opioid prescribing, there was wide variation in changes across facilities.
- The implementation of the OSI dashboard tool was associated with a significant decrease in risky opioid prescribing across the VA healthcare system, which highlights the possibility of system-wide approaches to address high-risk opioid prescribing. However, a large number of VA patients remained on these regimens at the end of the study period, which emphasizes the challenges of making significant changes in healthcare systems that treat a large population of complex patients.
- The OSI did not have a concurrent control group of facilities.
- A portion of VA patients also may have had access to non-VA healthcare, and it is possible that the OSI was associated with some patients pursuing opioid treatment outside VA.
Lin L, Bohnert A, Kerns R, Clay M, Ganoczy D, and Ilgen M. Impact of the Opioid Safety Initiative on Opioid-Related Prescribing in Veterans. Pain. January 4, 2017;e-pub ahead of print.