VA Primary Care Intervention Decreases High-Dose Prescription of Opioids for Veterans with Non-Cancer Pain
Among people receiving opioids for chronic pain, a growing body of literature has demonstrated increasing risk of serious harms as the dose of opioids increases. In October 2013, VA initiated a nationwide Opioid Safety Initiative (OSI) that includes goals of decreasing high-risk opioid prescribing practices, including prescribing of high-dose opioids. Prior to this national initiative, the Minneapolis VA Health Care System implemented a primary care population-based OSI aimed primarily at reducing high-dose opioid prescribing. The OSI consisted of a one-year preparatory phase that included planning, pain management education and training, and baseline evaluation that was followed by the implementation phase, in which active support for Veterans and primary care providers was provided and opioid dose reduction strategies were implemented. At the start of the implementation phase, the Chief of Staff issued a memorandum to all PCPs establishing a health system goal that all Veterans receiving long-term opioids for chronic non-cancer pain should have their daily dose reduced to less than 200 MED (morphine-equivalent mg). Thus, the primary outcome of this study was prescribing of high-dose opioid therapy, defined as >200 MED daily. Prescribing of specific opioid drugs (e.g. oxycodone SA, morphine SA, methadone) over time was examined as a secondary outcome.
- Following implementation of the OSI in the Minneapolis VA Health Care System, the number of Veterans prescribed >200 MED daily decreased from 342 to 65. Overall, the number of unique pharmacy patients who received at least one opioid prescription within 90 days decreased from 6,942 on 4/1/2011 to 5,981 on 10/01/2014 (14% decrease).
- The number of Veterans receiving oxycodone SA decreased from 292 to 3 over the study time period. The number of Veterans receiving other long-acting opioids, as well as hydrocodone-acetaminophen, hydromorphone, and oxycodone/acetaminophen also decreased.
- The proportion of primary care providers who agreed that it was reasonable for the medical center to set a 200 MED/day limit was 76% at baseline and 87% at follow-up. The two most commonly endorsed barriers to lowering doses <200 MED/day were patients becoming upset (62% baseline and 64% follow-up) and pressure from patient service representatives or the administration (59% baseline and 22% follow-up).
- This was an uncontrolled evaluation of a quality improvement project that describes prescribing changes over time at one health system level, not among a specific cohort of patients.
- Investigators cannot exclude secular effects or other confounding factors as the cause of observed changes; likely, growing general awareness of opioid-related harms contributed to changes.
- The study did not measure patient outcomes, thus it cannot answer whether reducing high-dose opiod prescribing increased patient safety or affected pain control or patient satisfaction.
Dr. Krebs is part of HSR&D's Center for Chronic Disease Outcomes Research in Minneapolis; her effort was supported by HSR&D. All authors are at the Minneapolis VA Health Care System.
Westanmo A, Marshall P, Jones E, Burns K, and Krebs E. Opioid Dose Reduction in a VA Health Care System – Implementation of a Primary Care Population-Level Initiative. Pain Medicine. February 3, 2015;e-pub ahead of print.