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Veterans Receiving Prescriptions Through Both VA and Medicare Are More Likely to Be Taking Opioids and Benzodiazepines


BACKGROUND:
VA and CDC guidelines recommend against the concurrent use of prescribed opioids and benzodiazepines. Among Veterans cared for in the VA healthcare system, clinical assessment of concurrent opioid and benzodiazepine use can be complicated by co-prescribing from outside VA, as a large majority of Veterans have other sources of insurance and may receive prescriptions outside VA. This study sought to assess the association between receiving medications from both VA and Medicare Part D (dual use) and the receipt of overlapping opioid and benzodiazepine prescriptions. Study investigators combined data from Medicare Part D and VA Pharmacy Benefits Management (PBM) for Veterans receiving 2 or more opioid prescriptions from either source (n=368,891) during calendar year 2013. Among this group, 67,472 (18%) received medications from VA only; 111,641 (30%) from Medicare only; and 189,778 (51%) were dual-users. Two primary outcomes were examined: 1) Percentage of patients meeting the PQA (Pharmacy Quality Alliance) definition of opioid/benzodiazepine overlap [receiving 2 or more prescriptions for benzodiazepines filled on 2 or more days with at least 30 days of overlap with a prescription opioid.]; 2) Percentage of patients with high-dose opioid (>120 MME) and benzodiazepine overlap for at least 30 days.

FINDINGS:

  • In adjusted analyses, receiving prescription medications from both VA and Medicare Part D was associated with a 27% increased risk of overlapping opioids and benzodiazepines – and more than twice the risk of overlapping high-dose opioids with benzodiazepines – compared to receiving prescriptions from VA alone. Receipt of prescriptions from both VA and Medicare also was associated with a greater risk of opioid/benzodiazepine overlap compared to Medicare alone, although the difference was smaller.
  • The proportion with opioid/benzodiazepine overlap was larger for the dual use group (23%) versus VA only (17%) and Medicare only (17%) groups. The proportion with high-dose overlap also was larger for the dual-use group (5%) versus VA only (2%) and Medicare only (3%) groups.

IMPLICATIONS:
Receipt of medications from more than one healthcare system is a key risk factor for unsafe prescribing practices, highlighting the need to enhance coordination of care across healthcare systems to optimize the quality and safety of prescribing.

LIMITATIONS:

  • Data are from 2013 and cannot capture medications purchased without insurance.
  • Unmeasured confounding may remain in this cross-sectional study.

AUTHOR/FUNDING INFORMATION:
This study was funded by HSR&D. Drs. Carico, Zhao, Thorpe, and Gellad are part of HSR&D's Center for Health Equity Research and Promotion (CHERP) in Pittsburgh, PA.


Carico R, Zhao X, Thorpe C, et al., and Gellad W. Receipt of Overlapping Opioid and Benzodiazepine Prescriptions among Veterans Dually Enrolled in Medicare Part D and the Department of Veterans Affairs. Annals of Internal Medicine. October 9, 2018;epub ahead of print.

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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.