Medication-assisted therapy has been underused at the VA, especially for patients with opioid use disorders, according to recent research. That is likely to change, however, with powerful support for expansion of those programs and more availability of pharmaceuticals to help veterans overcome drug addiction.
CANANDAIGUA, NY—Medication-assisted treatment is underused at the VA, according to a recent study, with only 6.7% of veterans with opioid use disorders given access to drugs that can help them manage their addiction.
MAT combines behavioral therapy and medications to treat substance use disorders, including opioid misuse, which has been a strong focus at the VA. A presentation at the 80th annual scientific meeting of the College on Problems of Drug Dependence this past summer reported, however, that only 26.1% of veterans who received MAT had an opioid use disorder.1
A study led by Lisham Ashrafioun, PhD, of the VA VISN 2 Center of Excellence for Suicide Prevention, sought to determine characteristics of veterans initiating medication assisted treatment among patients seeking pain services. To do that, the study team used the National Veterans Health Administration electronic medical record data to identify veterans initiating VHA specialty pain services from fiscal year 2012 to 2014. Those specifically using MAT for opioids were identified using procedure and billing codes.
Overall, researchers found 209,191 veterans who met the criteria, with 2,294 (1.1%) having received MAT in the year following the index visit. Only 599 of the 8,980 veterans with an opioid use disorder received MAT, the study found.
The authors noted that, in adjusted analyses, opioid use disorders (Odds Ratios [OR]=5.84, 95% Confidence Interval [CI]=5.22-6.53) and opioid prescriptions (OR=2.35, 95% CI=2.11-2.61) were significantly associated with greater odds of receiving MAT following pain treatment services.
“While depression was associated with greater odds of receiving MAT (OR=1.26, 95% CI=1.15-1.38), PTSD was associated with greater odds of not receiving it (OR=0.89, 95% CI=0.80-0.97). Furthermore, alcohol use disorder diagnoses were associated with greater odds of not receiving MAT (OR=0.87, 95% CI=0.77-0.98), yet drug use disorders were associated with greater odds of receiving it (OR=1.32, 95% CI=1.17-1.49),” the researchers explained.
A one-point increase in a patients’ six-month mean pain intensity also was associated with a 7.8% increase in odds of receiving MAT (95% CI=1.06-1.10).
“Several clinical features differentiate veterans who are receiving MAT compared to those who do not, however, a substantial proportion of veterans with pain and comorbid OUD are not receiving MAT despite its potential benefits,” the study authors concluded. “Additional research is needed to identify specific barriers to MAT among veterans experiencing pain.”
Interestingly, another study found that the VA is doing better than most other U.S. healthcare systems in keeping adherence levels high for medications used to treat addiction.
The report in the American Journal of Addiction noted, “Despite the promise of extended release naltrexone in the treatment of the opioid and alcohol use disorders, challenges with initiation and subsequent adherence have limited its potential. The purpose of this study is to identify the patient and treatment characteristics associated with adherence to extended release naltrexone.”
A study team involving researchers from the VA Boston Healthcare System, the Harvard Medical School and the Boston University School of Medicine conducted a retrospective cohort study of 155 veterans who initiated the medication in FY 2014 and FY 2015. To do that, researchers abstracted medical records for patient and treatment data, including preferred drug and utilization of substance use treatment in the year before and after medication initiation.
Participants were 94% male, 70% domiciled, 60% without current legal problems and 30% employed. Most of them, 55%, had opioids as their preferred drug, with the remainder having alcohol use issues.
Results indicated that the mean of five extended release naltrexone injections did not differ by preferred drug. Treatment variables associated with medication adherence included concurrent substance use residential, individual, group and psychiatric therapies, the study emphasized, and resulted in halving inpatient detoxification admissions halved afterward.
“Whereas most studies of extended release naltrexone have focused on patients with either alcohol or opioid use disorders for 6 months, this study allowed for a direct comparison of adherence in both groups over a year,” study authors wrote. “The average treatment persistence in this veteran sample is greater than described in other public sector studies and may illustrate the importance of concurrent psychosocial therapies.”
The researchers added, “Results extend the findings of other studies and add to an emerging appreciation of the factors associated with treatment retention for extended release naltrexone.”
A 2017 study in JAMA Psychiatry confirmed that maintaining short-term opioid abstinence with extended-release naltrexone “should be considered an equal treatment alternative to buprenorphine-naloxone as medication-assisted treatment for opioid-dependent individuals.”3
VA Responds to Crisis
VA Secretary Robert Wilkie recently discussed how the agency has approached the opioid crisis, stating in an editorial appearing in Newsday last fall, “The Department of Veterans Affairs is a recognized leader in pain management and opioid safety, and its success in reducing the use of opioids can be emulated by other health systems through VA’s proven strategies.”
Wilkie pointed out that severe pain is 40% more common in veterans compared to non-veterans, adding that nearly 60% of veterans who have served in the Middle East and more than 50% of older veterans live with some form of chronic pain.
The editorial described VA’s multifaceted approach, the Opioid Safety Initiative. “Since its launch,” he said, “the program managed a 45 percent reduction in veteran patients receiving opioids from July 2012 to June 2018. That’s more than 300,000 fewer veterans on opioids. The same program in the same months reduced veterans on long-term opioid therapy by 51 percent and veterans on high-dose opioid therapy by 66 percent.”
The efforts extend beyond the VA, however. Scott Gottlieb, commissioner of the Food and Drug Administration, said his agency should encourage more widespread innovation and development of medication for use in medication-assisted treatments.
Gottlieb pointed out that three FDA-approved MAT drugs now are available—methadone, buprenorphine and naltrexone—and are “safe and effective in combination with counseling and psychosocial support to stabilize brain chemistry; reduce or block the euphoric effects of opioids; relieve physiological cravings; and normalize body functions. Yet, despite having these treatment options, we know more needs to be done. For example, we know that not every patient seeking treatment is offered all three of these options.”
1 Ashrafioun, L. Medication-assisted treatment for opioids among veterans being treated for pain. Presented at the 80th annual scientific meeting of the College on Problems of Drug Dependence, June 9-14, 2018. San Diego, CA.
2 Chang G, Crawford M, Pitts M, Schein AZ, Goodwin K, Enggasser JL. Adherence to extended release naltrexone: Patient and treatment characteristics. Am J Addict. 2018 Sep;27(6):524-530. doi: 10.1111/ajad.12786. Epub 2018 Aug 14. PubMed PMID: 30106489.
3 Tanum L, Solli KK, Latif Z, et al. Effectiveness of Injectable Extended-Release Naltrexone vs Daily Buprenorphine-Naloxone for Opioid Dependence: A Randomized Clinical Noninferiority Trial. JAMA Psychiatry. 2017;74(12):1197–1205. doi:10.1001/jamapsychiatry.2017.3206
Hydrocodone Combination Prescriptions Dropped Significantly at VHA
IOWA CITY, IA—In the decade ending in 2010, opioid prescribing quadrupled in the United States, so that more than 1 in 3 patients were prescribed an opioid by 2015. The result was the death of one American from opioid overdose approximately every 16 minutes, according to a recent study.
The report in the American Journal of Health System Pharmacy noted that hydrocodone, one of the most prescribed medications in the United States, has played a pivotal role in the trends.1
Researchers from the Iowa City VA Healthcare System explained that the frequent use of hydrocodone combination products was at least partly due to their original classification as Schedule III under the Controlled Substance Act of 1970. That made them easier to prescribe than Schedule II opioids by reducing administrative burdens and allowing refills up to six months instead of the 90 days permitted for most other opioids.
The article pointed out that the increasing number of opioid overdoses in the United States during the early 2000s prompted the Drug Enforcement Administration to reevaluate the literature and ultimately reclassify HCPs as Schedule II in October 2014. The study team described the significant effect hydrocodone reclassification had on analgesic prescribing at the VHA.
For the retrospective observational study, the volume of opioid medication dispensed was calculated quarterly from October 2011 to September 2015 using national VHA administrative data. Four volume measures were examined—prescription count, tablets dispensed, days’ supply dispensed, and unique patients—for four opioid groups:
- Other opioid combination products,
- Tramadol, and
- Single-agent Schedule II opioids.
Researchers determined that HCP prescriptions declined by 172,535 (19.4%) in the quarter after reclassification, but other opioid categories remained unchanged. Specifically, they noted, the number of HCP prescriptions decreased by 10.7% among patients with short-term opioid receipt and by 23.3% and 19.4% for intermediate- and long-term receipt groups, respectively.
For 13,416 veterans who discontinued receiving long-term HCPs, replacement analgesics were not identified in 8,055 (60.0%) of them. Alternative opioid prescriptions were documented in 3,557 (26.5%) and nonopioids in 2,753 (20.5%).
“HCP dispensing in VHA declined by 19.4% in the quarter after reclassification, which was driven largely by patients receiving long-term therapy,” study authors concluded. “More than 13,000 veterans discontinued receipt of long-term HCP therapy after reclassification and the majority did not receive a replacement analgesic through VHA.”
1 Steckler TJ, Mosher HJ, Desloover-Koch Y, Lund BC. Impact of hydrocodonereclassification on analgesic prescribing in the Veterans Health Administration. Am J Health Syst Pharm. 2019 Mar 15. pii: zxy090. doi: 10.1093/ajhp/zxy090. [Epub ahead of print] PubMed PMID: 30873558.
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