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Absence of Brief Intervention Following Positive Alcohol Screen Associated with Increased Opioid-Related Risks within a Year
This study used electronic health record data to examine the association between primary care-delivered alcohol-related brief intervention (BI) and new opioid prescriptions, new opioid use disorder (OUD) diagnosis, or new opioid-related hospitalization in Veterans one year after a positive screen for alcohol use. Findings showed that 13% of Veterans in the sample screened positive for unhealthy alcohol use. Of those, Veterans who did not receive alcohol-related BI had 10% higher odds of obtaining a new opioid prescription within a year, and 19% higher odds of receiving an OUD diagnosis within a year. New opioid-related hospitalizations were also 19% higher, though not statistically significant. Of the Veterans in the sample who had a positive screen, 72% had documented alcohol-related BI, and within one year, 9% had a new opioid prescription, 1% had a new OUD diagnosis, and <1% had a new opioid-related hospitalization. Use of VA’s standard alcohol-related BI suggests a reduction in a cascade of new opioid-related outcomes from prescription through hospitalization.
Date: May 1, 2024
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VA Treatment of Opioid Use Disorder was Maintained During the COVID Pandemic Through Rapid Shift to Telehealth
At the beginning of the COVID pandemic, key federal policy changes were implemented to decrease barriers to telehealth-delivery of buprenorphine, a life-saving medication treatment for patients with opioid use disorder (OUD). This study examined the impact of these COVID-19 policies on buprenorphine treatment across different modalities (telephone, video, and in-person visits). Findings showed that buprenorphine treatment for OUD was maintained during the COVID-19 pandemic – across the VA healthcare system – through a rapid shift to telehealth, at a time when other healthcare delivery decreased. The number of Veterans receiving buprenorphine increased from 13,415 in March 2019 to 15,339 in February 2021. By February 2021, phone visits were used by the most patients (50%), followed by video (32%) and in-person (17%). Among Veterans receiving a buprenorphine treatment visit each month, the proportion of telehealth visits (phone and video) increased dramatically from 12% in March 2019 to 83% in February 2021. The proportion of Veterans reaching 90-day retention on buprenorphine treatment decreased significantly from the pre- to post-pandemic periods (50% to 48%), but days on buprenorphine increased significantly from 204 to 209. Policy changes that were rapidly implemented to reduce barriers to telehealth allowed continued delivery of buprenorphine treatment. Future changes to these policies (e.g., reversing support for telehealth prescribing of buprenorphine) could have major implications for patient care.
Date: July 28, 2022
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High Virologic Cure Rates for Hepatitis C Virus among Veterans with Opioid Use Disorder Treated with Elbasvir/Grazoprevir
Elbasvir (EBR)/grazoprevir (GZR) is a fixed-dose combination treatment for hepatitis C virus (HCV). This study sought to evaluate the real-world effectiveness of EBR/GZR among Veterans with HCV genotype (GT) 1 who also had a diagnosis of opioid use disorder (OUD). Findings showed that high rates of virologic cure were achieved among VA patients with HCV, OUD, and multiple comorbidities, including very high rates of psychiatric medication use, after receiving EBR/GZR for 12 weeks. Overall, 97% of Veterans achieved sustained virologic response (SVR). SVR rates were high regardless of baseline characteristics, comorbidities, or concomitant medications. SVR was achieved by 95% of Veterans receiving medication for OUD (MOUD) – and by 98% of Veterans who were not receiving MOUD. A total of 128 Veterans were reported as homeless during the year prior to initiating treatment; 98% of those Veterans achieved SVR. This first real-world evaluation of EBR/GZR in a population of patients with OUD suggests that treatment for 12 weeks represents an effective option for patients with HCV GT1 infection receiving MOUD, including people who inject drugs.
Date: January 25, 2022
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Veterans Do Not Always Receive Appropriate Continuation of OUD Medications During Surgical Hospitalizations
This study sought to describe practice patterns of perioperative buprenorphine use within VA – and patient outcomes up to 12 months following surgery. Findings showed that the majority of VA surgical patients in this study who received buprenorphine for opioid use disorder experienced a dose hold at some point during the perioperative period despite a trend in clinical guidelines recommending buprenorphine continuation: 40% of Veterans were instructed to hold buprenorphine prior to surgery, more than 60% did not receive buprenorphine on the day of surgery, and 55% did not receive a buprenorphine dose on the day following surgery. Homelessness/housing insecurity and rural residence were the only two predictors explored in this study that were associated with decreased likelihood of a perioperative buprenorphine dose hold. Discontinuation of buprenorphine following surgery also was relatively common. One month following surgery,13% of Veterans had no active buprenorphine prescription, increasing to 25% and 33% at 6- and 12-months post-surgery, respectively. As holding buprenorphine perioperatively does not align with emerging clinical recommendations – and carries significant risks – educational campaigns or other provider-targeted interventions may be needed to ensure patients with OUD receive recommended care before and after surgery.
Date: September 20, 2021
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Veterans Receiving Buprenorphine for Opioid Use Disorder Have Lower Risk of Suicide/Overdose Mortality
This study sought to determine the association between buprenorphine pharmacotherapy and suicide, overdose, and all-cause mortality among Veterans initiating buprenorphine within VA. Findings showed that Veterans who were not receiving buprenorphine pharmacotherapy on any given day had more than a four-fold increase in suicide/overdose death compared to those who received buprenorphine, even when accounting for time periods on other medication for opioid use disorder. Over the 5-year follow-up from the initial buprenorphine prescription, 3% died from suicide or overdose, and 8% died of any cause. Among suicide/overdose deaths, the majority (90%) were due to overdose and 71% of overdoses involved a prescription or illicit opioid.
Date: May 19, 2021
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Medication Therapy for Opioid Use Disorder Saves Lives and Can Save Money for Society
Investigators in this study developed a mathematical model to assess the cost-effectiveness of opioid use disorder treatments and the association of these treatments with outcomes in the US. Two analyses were done, the first considering only health sector costs, and the second also considering criminal justice costs. Findings showed that medication-assisted treatment (MAT), with or without overdose education and naloxone distribution, contingency management, and psychotherapy, is associated with significant health benefits and is cost-effective compared to usual benchmarks when considering only healthcare costs. When criminal justice costs were included in addition to healthcare costs, all forms of MAT (buprenorphine, methadone, and naltrexone) were cost-saving compared with no treatment, yielding savings of $25,000 to $105,000 in lifetime costs per individual. An analysis using demographics and cost data for VA yielded similar findings, but quality of life gains from treatment were lower due to Veterans being older, on average, than the general population.
Date: March 31, 2021
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JGIM Supplement Features VA Research on Improving Opioid Safety among Veterans with Chronic Pain and Addiction
In the fall of 2019, HSR&D convened a state-of-the-art (SOTA) conference – “Effective Management of Pain and Addiction: Strategies to Improve Opioid Safety” – to develop research priorities for advancing the science and clinical practice of opioid safety, including both the use of opioid analgesics and managing opioid use disorder (OUD). A group of researchers and VA clinical stakeholders defined three areas of focus for the SOTA: 1) managing OUD, 2) long-term opioid therapy for pain including consideration for opioid tapering, and 3) treatment of co-occurring pain and substance use disorders. SOTA participants included VA and non-VA health services researchers, clinicians, and policymakers. Funded by HSR&D, this JGIM Supplement presents recommendations from the SOTA, as well as original research papers on opioid safety across the VA healthcare system.
Date: December 1, 2020
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Cannabinoid Use Increased while Opioid Use Decreased among VA Patients Undergoing Total Joint Replacement
This single-institution (VA Palo Alto) study sought to determine whether preoperative cannabinoid use and opioid use increased or decreased over a 6-year interval among total hip and knee arthroplasty (THA and TKA) patients – and whether complications were associated with cannabinoid use. Findings showed that use of cannabinoids in Veterans undergoing total joint arthroplasty was far greater than previously reported in the literature, while opioid use decreased. Over the six-year study period, cannabinoid use increased more than 60%, while opioid use decreased about 30%. When compared with patients not using cannabinoids, investigators were unable to find a difference in rates of readmission, infection, reoperation, or other complications captured in the VASQIP database, even after controlling for age, gender, surgery type, and ASA score. Cannabinoid users were more likely to also be taking opioids than non-users, and they were significantly younger than both non-users (62 vs.66 years) and opioid users (63 vs. 65 years).
Date: October 1, 2020
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Treatment Disparities for Vulnerable VA Patient Populations with Opioid Use Disorder
This study examined the association between vulnerable populations, facility characteristics, and receipt of medications for opioid use disorder (OUD). Findings showed that since the last national study of VA patients (using FY2012 data), the prevalence of receipt of medications for OUD increased overall from 33% to 41%; however, vulnerable patient populations – including women, older, Black, rural, homeless, and justice-involved Veterans – had lower odds of receiving medications for OUD than their non-vulnerable counterparts. Veterans had higher odds of receiving medications at facilities with a higher proportion of patients with OUD, and lower odds of receiving medications at facilities in the Southern region of the United States compared to the Northeast. The prevalence of OUD was notably higher among homeless compared to housed Veterans (10% vs 2%), and justice-involved compared to non-justice-involved Veterans (10% vs 2%).
Date: August 18, 2020
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Opioid Agonist Therapy Infrequent for Veterans with Opioid Use Disorder Admitted to a VA Hospital
This retrospective cohort study sought to describe and examine patient- and hospital-level characteristics associated with the receipt of opioid agonist therapy (OAT) during VA hospitalization for various reasons. Findings showed that the delivery of OAT was infrequent, varied across the VA healthcare system, and was associated with specific patient and hospital characteristics. Only 15% of the entire study cohort received any OAT during hospital admission. Of 10,969 Veterans who had an OUD diagnosis at the time of hospitalization but were not already being treated for it, only 2% received OAT along with a link to care after their discharge. Instead, most of these patients (80%) received opioid withdrawal management, representing a missed opportunity to continue OUD treatment beyond hospitalization. Hospital admission interrupted ongoing outpatient OUD treatment, with more than one-third of Veterans having their outpatient OAT discontinued during admission. Veterans on pre-admission OAT, those with an acute opioid use disorder diagnosis, and who were male had increased odds of receiving OAT. Veterans who received non-OAT opioids or surgical procedures had decreased odds of receiving OAT. Veterans admitted to large and medium-sized VA hospitals had increased odds of OAT receipt compared with those admitted to small VA hospitals.
Date: April 14, 2020
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Few Disparities in Medical Treatment for Opioid Use Disorder after Non-Fatal Overdose
This study assessed the association between race and ethnicity and patterns of opioid prescribing before and after a non-fatal opioid overdose – and also assessed the receipt of medications for opioid use disorder (MOUD: buprenorphine, methadone, and naltrexone) following such events among VA patients. Findings showed that receipt of an opioid prescription decreased by 16-21 percentage points in the 30 days after overdose, but remained high, with no significant differences across racial and ethnic groups. After overdose, the frequency of receiving opioids was reduced by 18.3, 16.4, and 20.6 percentage points in whites, blacks, and Hispanics, respectively. Overall, MOUD prescribing in VA was very low in all racial groups in the 30 days after overdose, though statistically significantly higher in black and Hispanic patients. After overdose, 3% of patients received MOUDs (3% white, 5% black, and 6% Hispanic). Blacks and Hispanics had significantly larger odds of receiving MOUDs than whites. Findings demonstrate an opportunity to improve the quality of care for all patients with opioid use disorder, particularly in the vulnerable period around a non-fatal overdose event.
Date: January 21, 2020
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History of Military Sexual Trauma Common among Older Women Veterans
This study sought to determine the prevalence of military sexual trauma (MST) among older women Veterans – and investigate associations between MST and medical and mental health diagnoses. Findings showed that a history of MST was common among older women Veterans. Positive MST screens were observed in nearly 1 in 5 women aged 55-64, and 1 in 10 aged 65-74. [This is similar to the 23% prevalence found in previous studies in women younger than age 55. Accounting for demographic risk factors, MST was associated with increased odds of a range of medical and mental health diagnoses. Most notably, MST was associated with 7.25 times the odds of PTSD and over two-fold odds of depression and suicidal ideation, as well as increased odds of anxiety, alcohol use disorder, substance use disorder, opioid use disorder, sleep disorders, and chronic pain. Thus, older women Veterans remain at risk for the effects of potentially remote MST. Findings call attention to the need for additional research in this understudied population, and the importance of trauma-informed care approaches for women across the lifespan.
Date: November 11, 2019
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VA Opioid Treatment Outcomes Vary Significantly among Homeless and Unstably Housed Veterans
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 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 opioid use disorder (OUD). Findings showed that among the subgroup of homeless Veterans with an OUD history, opioid dose prescribing practices and rates of medication for addiction treatment (MAT) and naloxone receipt varied significantly. 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+. 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.
Date: August 1, 2019
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Dual use of VA and Medicare Drug Benefits Associated with Potentially Unsafe Medication Prescribing among Veterans
Previous research shows that dual VA-Medicare Part D prescription drug use is a risk factor for potentially unsafe medication (PUM) exposure in Veterans with dementia and opioid users. Thus, this study evaluated the association of dual prescription use through VA and Part D (vs. VA-only use) with the prevalence of PUM exposure in a national cohort of dually-eligible older Veterans. Findings showed that dual use of VA and Part D prescription drug benefits was associated with an almost 2-fold increase in the odds of exposure to any PUM compared with VA-only use and more than 3 times the odds of exposure to severe drug-drug interactions. PUM exposure was lowest among VA-only users, and PUM exposure peaked in Veterans receiving prescriptions in near-equal proportions (50/50) from VA and Part D. To mitigate the potential risks associated with unsafe medication prescribing, policies intended to expand access to non-VA providers must ensure patient information is shared and integrated into routine practice for all patients seeking care across multiple healthcare systems.
Date: July 22, 2019
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Substantial Variation in Opioid Prescribing Rates among ED Providers in the Same VA Healthcare Facility
The study team examined the extent to which variation in individual ED physicians’ opioid prescribing was independently associated with long-term opioid use in Veterans. Using VA data, investigators identified Veterans with an index ED visit at any VA facility in 2012 – and who were opioid naïve (without opioid prescriptions in the prior 6 months). Findings showed that there was a three-fold variation in the rates of opioid prescribing by ED physicians within the same VA facility (21% vs. 6%), regardless of patients’ severity of pain or primary diagnosis. The frequency of long-term opioid use was higher among opioid-naïve Veterans treated by high vs. low-quartile ED prescribers, though above the threshold for statistical significance (1.39% vs. 1.26%). Though the increase in long-term opioid use among Veterans treated by the highest-prescribing ED providers was not significant in the overall sample, it was significant among important patient subgroups, including those with back pain, musculoskeletal pain, or depression. High-intensity prescribers were more likely to prescribe opioids across the spectrum of pain intensity, while low-intensity prescribers were less likely to prescribe opioids across the spectrum.
Date: May 29, 2019
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Links Between Opioid Use and Suicide
This review describes what is known about the links between suicide and overdoses, with a focus on pathways through opioid use, issues of intent, risk factors, prevention strategies, and unresolved issues. Many factors promote the initiation and persistence of opioid use, but several specific pathways toward vulnerability to overdose and suicide are highlighted. Interventions that address shared causes and risk factors, such as programs to improve the quality of pain care, expanding access to psychotherapy, and increasing access to medication-assisted treatment for opioid use disorders, have the potential to be high-value investments by addressing both problems.
Date: January 3, 2019
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Link between Length of Prescription for Initial Exposure to Opioids and Long-Term Use
This study examined the association between initial opioid exposure and subsequent long-term use in two national VA cohorts from 2011 and 2016. Findings showed a strong relationship between initial opioid exposure and the future likelihood for long-term use. Cumulative days’ supply of prescription opioids emerged as the strongest predictor of long-term opioid use, which occurred in only 2% of Veterans dispensed 7 days’ or less supply, and in 28% of patients dispensed greater than 30 days’ supply. Comparing 2011 and 2016 data, the association between day’s supply and long-term use persisted, even as the overall rate of long-term opioid use decreased. Findings suggest that limiting initial opioid exposure may reduce risk for long-term opioid use. Moreover, examination of early opioid exposure may offer an opportunity to recognize when a patient is in the process of starting long-term opioid use.
Date: November 5, 2018
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Pharmacotherapy for Opioid Use Disorder Highly Variable across VA Residential Substance Abuse Treatment Programs
Pharmacotherapy, including methadone, buprenorphine, and naltrexone, is both efficacious and cost-effective for treating opioid use disorder (OUD), however it is infrequently prescribed in VA. Investigators in this study sought to describe barriers to and facilitators of pharmacotherapy provided to a national cohort of VA patients with OUD in VA residential substance use disorder (SUD) treatment programs in FY2012. Findings showed that implementation of pharmacotherapy for OUD is highly variable across VA residential SUD treatment programs. Across all 97 treatment programs, the average rate of receipt of pharmacotherapy for OUD in FY2012 was 21% and ranged from 0% to 67%. There were 11 programs where 0% of patients received pharmacotherapy for OUD. Barriers included program or provider philosophy against pharmacotherapy and a lack of care coordination with non-residential treatment settings. Facilitators included education for staff and patients and having a prescriber on staff. Intensive educational programs, such as academic detailing, and policy changes such as mandating buprenorphine waiver training for VA providers, may help improve receipt of pharmacotherapy for OUD.
Date: November 1, 2018
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Then and Now: Medications for Opioid Use Disorder in VA
As the largest provider of substance use disorder treatment in the nation, VA has taken proactive steps to increase access to medications indicated for opioid use disorder (OUD), which is an essential component of evidence-based care. This article examines the history of those medications (methadone, buprenorphine, and injectable naltrexone) within VA, as well as early and ongoing efforts to increase access to and build capacity for the treatment of OUD, which included adding buprenorphine to the VA formulary in 2006, educational and quality improvement initiatives, targeted resources, national policy, and “big data” initiatives. This article also summarizes research on barriers and facilitators to prescribing and medication receipt.
Date: March 29, 2018
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Dual Use of VA and Medicare Associated with Substantial Increase in Risk of Potentially Unsafe Opioid Use among Veterans
This study sought to estimate the prevalence and consequences of receiving prescription opioids from both VA and Medicare Part D for all dually-enrolled Veterans who filled a prescription opioid in either system in calendar year 2012. Findings showed that among Veterans dually enrolled in Medicare Part D and VA and receiving prescription opioids in 2012, more than 1 in 8 received opioids from both systems, in many cases concurrently. Compared to VA-only use of opioids, dual use was associated with a 3-fold higher risk of high-dose opioid exposure and more than twice the risk of long-term high-dose opioid exposure. Dual use also was associated with a 60-90% greater risk of these exposures than Part D only use. VA is evolving into a less integrated delivery system with more community care options. As these options increase, the prevalence of poorly coordinated dual-system care (e.g., overlapping opioids and other drug interactions and duplication) also will likely increase.
Date: February 1, 2018
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Declining Rates in VA Prescriptions for Long-Term Opioids
This study sought to characterize the overall prevalence of opioid prescribing in the VA healthcare system from 2010 through 2016 by duration of use. Findings showed that opioid prescribing trends followed similar trajectories in VA and non-VA settings, peaking around 2012 and subsequently declining. The prevalence of VA opioid prescribing was 20.8% in 2010, 21.2% in 2012, and declined annually to 16.1% in 2016. Changes in long-term opioid prescribing accounted for 83% of the decline seen in VA patients. Comparing data from 2010-2011 to data from 2015-2016, declining rates in new long-term use accounted for more than 90% of the decreasing prevalence of long-term opioid use among Veterans, whereas increases in cessation among existing long-term users was less than 10%.
Investigators observed a decrease in overall opioid prevalence between 2012 and 2015 of 16% in VA healthcare settings, compared to 13% reported in non-VA settings. Recent VA opioid initiatives may be preventing patients from initiating long-term use.
Date: January 29, 2018
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Higher Risk of Suicidal Ideation and Suicidal Self-Directed Violence following Discontinuation of Long-term Opioid Therapy
The primary objective of this study was to identify predictors of suicidal ideation (SI) and non-fatal suicidal self-directed violence (SSV) following clinician-initiated discontinuation of long-term opioid therapy. Findings showed that a substantial proportion of Veterans with substance use disorder diagnoses and similar matched patients experienced suicidal ideation or suicidal self-directed violence following discontinuation of long-term opioid therapy by their opioid-prescribing clinicians, most of whom represent new onset cases. Approximately 12% of patients in this sample had SSV and/or SI documented in the medical record in the 12 months following discontinuation of opioid therapy: 47 patients had SI only, while 12 had SSV. Half of patients with SSV attempted suicide by overdose, most commonly with benzodiazepines. Mental health diagnoses associated with having SI/SSV included PTSD and psychotic disorders. The majority of patients (75%) were discontinued from opioid therapy due to aberrant behaviors. Healthcare providers should pay special attention to safety when patients are discontinued from long-term opioid therapy, particularly patients with PTSD or psychotic disorders.
Date: July 1, 2017
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Opioid Use among Afghanistan and Iraq War Veterans
This study sought to understand current opioid use in OEF/OIF/OND Veterans who are regular users of VA care and did not have a cancer diagnosis at the time of this study. Findings showed that opioid use among OEF/OIF/OND Veterans is characterized by moderate doses that are used over relatively long periods of time by a minority of Veterans. Approximately 23% of all OEF/OIF/OND Veterans received opioids, with 7-8% receiving them chronically. The prevalence of high-dose opioids, concurrent use of multiple opioids, and use of long-acting opioids was fairly low. Diagnoses of PTSD, major depressive disorder, and tobacco use disorder were strongly associated with chronic opioid use. Back pain also was strongly associated with chronic use. Findings suggest that the use of opioids is less common among OEF/OIF/OND Veterans compared with Veterans as a whole, and provide a strong baseline for evaluating the impact of recently implemented opioid-related policies.
Date: March 25, 2017
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Discontinuation of Long-Term Opioid Therapy among Veterans is Overwhelmingly Initiated by VA Clinicians
The aim of this study was to compare reasons for discontinuation of long-term opioid therapy (LTOT) between Veterans with and without substance use disorder (SUD) receiving care within the VA healthcare system in the years following release of 2009 and 2010 clinical practice guidelines. Findings showed that the majority of Veterans (85%) discontinued opioid use because their clinician stopped prescribing, rather than the patients deciding to stop. For patients whose clinicians initiated discontinuation, 75% were discontinued due to opioid-related aberrant behaviors (i.e., suspected substance abuse, aberrant urine drug test). Veterans with SUD diagnoses were more likely to discontinue LTOT due to aberrant behaviors, particularly abuse of alcohol or other substances, compared to Veterans without SUD. High proportions of patients received diagnoses for mental health disorders in the year prior to discontinuation of LTOT, including PTSD, anxiety disorders other than PTSD, and depressive disorders (25%). Increasing rates of opioid discontinuation are likely to occur due to policies and programs that encourage close monitoring of Veterans on LTOT for opioid misuse behaviors. Integrating non-opioid pain therapies and SUD treatment into multiple settings such as primary care and specialty SUD care is one possible approach to enhance their care.
Date: March 1, 2017
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Safety Risk for Veterans Receiving Overlapping Buprenorphine, Opioid, and Benzodiazepine Prescriptions from VA and Medicare Part D
Ensuring safe buprenorphine prescribing is especially challenging for VA, which treats a substantial number of Veterans with chronic pain and opioid use disorder, as well as an increasing number of patients who receive concurrent care in the private sector (i.e., Medicare Part D). This study identified Veterans dually enrolled in VA and Medicare Part D who filled a buprenorphine prescription in 2012 from either healthcare system and identified the proportion of Veterans with overlapping prescriptions from either system. Findings showed that more than one in four Veterans who received a VA prescription for buprenorphine – and one in five Veterans who received a Medicare prescription for buprenorphine – also received overlapping prescriptions for opioids from a different healthcare system. Among Veterans receiving buprenorphine from VA, 1% received an overlapping benzodiazepine prescription from Medicare, while among those receiving buprenorphine from Medicare, 16% received an overlapping benzodiazepine prescription from VA. Among VA and Part D buprenorphine recipients who had cross-system opioid overlap, 25% and 35%, respectively, had >90 days of overlap. Findings indicate a previously undocumented safety risk for Veterans dually enrolled in VA and Medicare who are receiving prescriptions for buprenorphine and overlapping prescriptions for opioids and/or benzodiazepines.
Date: December 7, 2016
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Prescription Opioid Use among Patients with Recent History of Depression Increases Risk of Recurrence
This study examined whether patients in depression remission who were prescribed opioids for non-cancer pain had an increased risk of depression recurrence. Investigators analyzed two patient populations: Veterans treated in the VA healthcare system, and patients treated by a non-profit integrated healthcare system located in Texas. Findings showed that prescription opioid use among patients with a recent history of depression increased the chance of depression recurrence, and this effect was independent of pain diagnoses and pain intensity scores. Patients with remitted depression who were exposed to opioid analgesics at any point during the follow-up period were 77% to 117% more likely to experience a recurrence of depression than those who remained opioid free, after controlling for other factors. Among VA patients with depression remission, those who received opioids during follow-up were younger, had more psychiatric comorbidities, and had more painful conditions and higher pain scores than those who didn’t receive opioids.
Date: April 1, 2016
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Prescription Use of Codeine Associated with Greater Risk of New Onset Depression among Veterans
This study sought to determine whether the hazard of new depression diagnosis differs among VA patients prescribed only codeine, only hydrocodone, or only oxycodone. Findings showed that Veterans prescribed only codeine for 30 days or longer had a 29% increased risk of a new diagnosis of depression compared to Veterans prescribed only hydrocodone for 30 days or longer. Those prescribed only oxycodone for 30 days or longer were not significantly more likely to develop a new depression diagnosis compared to patients prescribed hydrocodone only. Opioid use of 30-90 days was most common among oxycodone users, and opioid use of more than 90 days was most common among hydrocodone users. The distribution of individual comorbid conditions did not significantly differ across the three types of opioids.
Date: March 22, 2016
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Chronic Opioid Therapy Common among Hospitalized Veterans, Associated with Increased Risk of Death and Re-Admission
This study sought to determine the prevalence of prior chronic opioid therapy (COT) among hospitalized medical patients, in addition to examining characteristics associated with inpatients that had previous opioid therapy compared to those with no opioid therapy prior to hospital admission. Findings showed that COT is common among hospitalized Veterans; moreover, occasional and chronic opioid use was associated with increased risk of hospital readmission and COT was associated with increased risk of death. Nearly 1 in 4 hospitalized Veterans had current or recent COT at the time of hospital admission for non-surgical conditions, and nearly half had been prescribed any opioids. Among the Veterans in this study, 26% had received COT in the prior 6 months, and 20% had occasional opioid therapy. Diagnoses more common in Veterans with COT included COPD, complicated diabetes, PTSD, and other mental health disorders.
Date: December 6, 2013
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Opioid Prescribing for Veterans with Chronic Non-Cancer Pain
This study sought to describe patterns of prescription opioid initiation, identify correlates of opioid initiation, and examine correlates of receipt of chronic opioid therapy (COT) among Veterans with persistent non-cancer pain. Findings showed that the initiation of opioid drug therapy is common among Veterans with persistent pain, but most Veterans are not prescribed opioids long-term. During the study year, 35% of Veterans in the sample received an opioid prescription: 30% were prescribed opioids on a short-term basis (<90 days), and 5% received chronic opioid therapy (>90 days). Clinical factors associated with initiating COT include increased pain intensity, nicotine dependence, substance use disorders, and major depression diagnoses. Nearly one-quarter of Veterans prescribed COT also received prescriptions for benzodiazepine medications, which is a concern given that overdose deaths have been linked to the use of multiple sedating medications. Two-thirds of opioid prescriptions resulting in COT were initiated by primary care clinicians. The authors suggest that this supports the development of guidelines geared toward primary care practice. It also supports the provision of interventions and structures in primary care that facilitate proactive planning around opioid use and its monitoring.
Date: February 1, 2013
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Mental Health Diagnoses Associated with Opioid Prescription, High-Risk Use, and Adverse Outcomes among OEF/OIF Veterans
Among OEF/OIF Veterans with pain, mental health diagnoses, especially PTSD, were associated with an increased risk of receiving opioids, high-risk opioid use, and adverse clinical outcomes. Compared to those without mental health diagnoses, Veterans with PTSD who were prescribed opioids were more likely to receive higher-dose opioids (16% vs. 23%), receive two or more opioids concurrently (11% vs. 20%), receive sedative hypnotics concurrently (8% vs. 41%), and to obtain early opioid refills (20% vs. 34%). Receiving prescription opioids (vs. not) increased risk for serious adverse clinical outcomes for Veterans (10% vs. 4%) across all mental health categories and was most pronounced in Veterans with PTSD. Of the 141,029 Veterans with pain diagnoses, 15,676 (11%) received prescription opioids for = 20 consecutive days; 77% of which were prescribed by VA primary care providers. Veterans with PTSD and mental health diagnoses excluding PTSD were significantly more likely to receive opioids for pain (18% and 12%) compared to Veterans without mental health diagnoses (7%).
Date: March 7, 2012
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Majority of OEF/OIF Veterans with Chronic Non-Cancer Pain are Prescribed Opioids by VA Outpatient Providers
This study sought to describe the prevalence of prescription opioid use, types and doses of opioids received, as well as factors associated with the prescription of opioids among OEF/OIF Veterans. Findings showed that about two-thirds of OEF/OIF Veterans with chronic non-cancer pain were prescribed opioids over a one-year timeframe. Of Veterans prescribed any opioids, 59% were prescribed opioids ‘short-term’ compared to 41% prescribed opioids ‘long-term’ (more than 90 days). The mean duration of opioid prescription was 61 days for Veterans in the short-term group and 285 days for Veterans in the long-term group. Several findings suggest a need for improvement in adherence to pain and opioid treatment guidelines. For example, among long-term opioid users, 51% were prescribed short-acting opioids only (guidelines recommend transitioning to long-acting opioids); only 31% were administered one or more urine drug screens (guidelines suggest more frequent drug screening); and 33% were also prescribed sedative-hypnotic medications (monitoring by prescribing physicians is recommended to prevent possible overdose or death). Diagnoses associated with an increased likelihood of receiving an opioid prescription included: low back pain, migraine headache, PTSD, and nicotine use disorder.
Date: September 7, 2011
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