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VA Opioid Treatment Outcomes Vary Significantly among Homeless and Unstably Housed Veterans


BACKGROUND:
In response to the opioid epidemic, VA expanded the Opioid Safety Initiative: expanding access to naloxone for overdose prevention, reducing high-dose opioid users, increasing access to medication for addiction treatment (MAT) for opioid use disorder (OUD), and increasing the availability of safe and effective pain management. However, to better address the opioid epidemic in Veterans who are unstably housed or homeless, it is necessary to determine where gaps in opioid-related care exist. This retrospective study examined a national sample of 59,954 Veterans who accessed VA homeless programs and represented a range of homeless experiences; 6% of this cohort (3,624 Veterans) entered a homeless program with a history of OUD. In this subgroup with a history of OUD, investigators examined several opioid-related measures: opioid dose, concomitant opioid-benzodiazepine prescribing, and receipt of MAT and naloxone. Variations in these outcomes also were assessed by sex, age, and type of homeless program (e.g., Supportive Services for Veteran Families (SSVF) Program).

FINDINGS:

  • Among the subgroup of homeless Veterans with an OUD history, opioid dose prescribing practices and rates of MAT and naloxone receipt varied significantly by type of homeless program and age, and concomitant opioid-benzodiazepine prescribing varied significantly by age.
  • In particular, less than one-quarter (23%) of Veterans received a prescription for naloxone, with homeless program-level rates of receipt ranging from 19% to 32%.
  • Thirty-eight percent of Veterans received MAT in the year following entry into a VA homeless program, with program-specific rates ranging from 31% to 50%.
  • Rates of high-dose opioid prescribing and concomitant opioid-benzodiazepine prescribing were highest, and rates of MAT and naloxone prescribing were lowest, among those ages 55+.

IMPLICATIONS:

  • Current treatment gaps indicate the need for universal policy goals to address OUD among Veterans at risk of being homeless – or who are currently or formerly homeless
  • Implementation strategies are needed to tailor opioid treatment access and dissemination to homeless and similar vulnerable Veteran groups.

LIMITATIONS:

  • This study included only users of VA homeless programs who entered in 2016 – and prescriptions and treatment received within VA only.
  • Investigators did not include a comparison group of non-homeless Veterans engaged in VA care. Thus, it is unclear how homeless Veterans compared to other Veterans on the studied outcomes.

AUTHOR/FUNDING INFORMATION:
This study was funded by VA’s Quality Enhancement Research Initiative (QUERI). Dr. Midboe is co-PI for the Improving Pain-Related Outcomes for Veterans (IMPROVE) and Bridging the Care Continuum QUERI Programs and is part of HSR&D’s Center for Innovation to Implementation (Ci2i), and Drs. Byrne and Smelson are with HSR&D’s Center for Healthcare Organization and Implementation Research (CHOIR).


PubMed Logo Midboe A, Byrne T, Smelson D, et al. The Opioid Epidemic in Veterans Who were Homeless or Unstably Housed. Health Affairs. August 2019;38(8):1289-1297.

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What are HSR&D Publication Briefs?

HSR&D requires notification by HSR&D-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR&D and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR&D based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR&D published articles. Visit the HSR&D citations database for a complete listing of HSR&D articles and presentations.