Then and Now: Medications for Opioid Use Disorder in VA
BACKGROUND:
Among Veterans receiving VA healthcare, there has been a sharp rise in the number of patients diagnosed with opioid use disorder (OUD): from 25,031 in 2003 to 69,142 in 2017. As the largest provider of substance use disorder treatment in the nation, VA has taken proactive steps to increase access to medications indicated for 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.
FINDINGS:
- There has been a slow but steady increase in medications prescribed for OUD in the VA healthcare system.
- Of all VA patients diagnosed with OUD in 2004, 25% received a medication to treat that disorder. By 2017, 35% of patients diagnosed with OUD had received medication for that diagnosis: 34% were treated with either buprenorphine or methadone, and .9% were treated with injectable naltrexone.
- Despite system-wide mandates and directives, uneven uptake of medication prescribing for OUD persists across VA facilities.
- In 2008, facility-level rates of prescribing for Veterans diagnosed with OUD ranged from 0% to 66%. By 2012, wide facility-level variability continued, with rates ranging from 1%-68%.
- Patient-level factors found to decrease the likelihood of receiving indicated medication for OUD include female gender, African-American race, older age, the absence of a mental health diagnosis, rural residence, homeless status, and disability due to military service.
- Studies have identified resource (i.e., adequate spacing and staff), demand (i.e., patient and provider interest), and philosophical factors (i.e., stigma) that influence OUD prescribing, as well as implementation strategies that may facilitate successful outcomes related to prescribing (i.e., having an organizational leader/champion).
IMPLICATIONS:
- VA has been a leader in the treatment of OUD. However, substantial challenges persist, such as the underuse of medications, wide variability in prescribing rates, and capacity to supply methadone, which will require further research and resource investments.
AUTHOR/FUNDING INFORMATION:
This study was funded by HSR&D, and Dr. Lovejoy was supported by an HSR&D Career Development Award. Drs. Wyse, Dobscha (Director), and Lovejoy are part of HSR&D's Center to Improve Veteran Involvement in Care (CIVIC), Portland, OR.
Wyse J, Gordon A, Dobscha S, et al., and Lovejoy T. Medications for Opioid Use Disorder in the Department of Veterans Affairs (VA) Health Care System: Historical Perspective, Lessons Learned and Next Steps. Substance Abuse. March 29, 2018; Epub ahead of print.
