New VA Initiative Seeks to Reduce Opioid Use

Studies Show Chronic Use Common after Prescription

By Brenda L. Mooney

MINNEAPOLIS — A new initiative to reduce the use of opioids at the VA already is demonstrating some success at eight launch sites in Minnesota, where high-dose use of the painkillers has been reduced more than 50%.

The initiative, the Opioid Safety Initiative (OSI), emphasizes patient education, intensive patient-monitoring with frequent feedback and complementary and alternative medicine practices such as acupuncture to lower dependency on opioids. Involved in the initiative at each VAMC are interdisciplinary pain medicine specialty teams and consult services, facility pain committees, pharmacy staff and primary care/patient aligned care team (PACT) participants.

“We have developed and implemented joint pain management guidelines which encourage the use of other medications and therapies in lieu of habit-forming opiates,” said Secretary of Veterans Affairs Eric K. Shinseki. “Early results give us hope that we can reduce the use of opioids for veterans suffering with chronic pain and share these best practices across our healthcare networks.”

A patient receives acupuncture treatment at the Washington DC VAMC. The procedure is used for a variety of conditions, including pain treatment, and is considered to be one alternative to prescribing opioids. VA photo.

A patient receives acupuncture treatment at the Washington DC VAMC. The procedure is used for a variety of conditions, including pain treatment, and is considered to be one alternative to prescribing opioids. VA photo.

Announcement of the initiative, which launched in October 2013, came a few weeks after new studies presented at the 30th Annual Meeting of the American Academic of Pain Medicine described the scope of opioid use at the VA. Most of the nearly 1 million veterans prescribed opioids for painful conditions continued to use them chronically or beyond 90 days, according to presentations at the conference.1, 2

With funding from the National Institute on Drug Abuse, researchers from the University of Washington in Seattle, the University of Arkansas Medical Sciences in Little Rock, AR, and the Research Triangle Institute in Research Triangle Park, NC, sought to determine how addiction and abuse issues develop in veterans. Using VA data and limiting the study to veterans who had at least two outpatient visits at a VHA facility in 2009, they identified 959,226 veterans who had received an opioid prescription for at least 90 days in a 180-day period.

With opioid discontinuation defined as no use for at least six months, they determined that 502,634, or 52.4%, of the group used opioids chronically. Among the factors linked to chronic opioid use were post-traumatic stress disorder (PTSD), tobacco use, being married, having multiple chronic pain conditions, the use of multiple opioids and opioid dose above 100 mg per day.

Clarifying Risks

Noting that veterans have high rates of painful conditions and show elevated levels rates of chronic opioid use, the researchers said, “Understanding rates and predictors of discontinuation will clarify the risks for opioid abuse and dependence among this population.”

The results did not completely track previous research, however.

“Unlike other samples, it appears that mental-health disorders and substance-use disorders are associated with increased rates of discontinuation in the VA,” said lead author Mark Sullivan, MD, PhD. “The exception is tobacco use, which is associated with a decreased likelihood of discontinuation.”

In examining how to predict opioid discontinuation, the researchers looked at demographic and clinical characteristics as well as treatment choices. Pain characteristics and diagnoses related to medical conditions, mental health and substance abuse were taken into consideration along with other medications used by the patients, such as non-opioid pain relievers and those used to treat mental-health disorders.

opioid graphic

Results indicated that chronic opioid users took the painkillers for an average of 242.08 days, compared with 29.22 days among nonchronic users. The mean daily dose among chronic users, meanwhile, was 38 mg morphine equivalent dose (MED), compared with 22 mg among nonchronic users. Only 5% of patients were found to have a mean daily dose greater than 90 mg MED.

The study noted that substance use disorders were diagnosed in 23% of chronic users and 20% of nonchronic users, although, among nonchronic users in FY 2009, 16.6% used opioids chronically in FY 2010.

The researchers said they lacked reliable or interpretable data to look at pain levels as predictors of opioid discontinuation or why some patients had received high doses of opioids, Sullivan said.

“Chronic opioid use is very common among veterans, but mean doses are modest. In contrast to other samples, no increase in rates of chronic opioid use were found in those with diagnosed substance use disorders,” the authors concluded.

In addition to the most recent initiative, the VA has directed significant resources toward management of pain and the drugs used to treat it. For example, Pain Coach is a pain-management application available for download by patients receiving pain-management treatments, and, also online, veterans have access to a Patient/Family Management Toolkit, and resources for pain management on My HealtheVet.

“The Opioid Safety Initiative is an example of VHA’s personalized, proactive and patient-centered approach to healthcare. We are also using a full range of support treatments for Veterans, including Complementary and Alternative Medicine,” said Robert Petzel, MD, VA’s Under Secretary for Health. “We are delivering healthcare with the patient’s long-term personal health goals at the forefront.”

1 Sullivan M, Hudson T, Bradley CM, Edlund M, Fortney J, National Analysis of Opioid Use Among Veterans. Poster session presented at: the 30th Annual Meeting of the American Academic of Pain Medicine; 2014 March 6-9, Phoenix, AZ.
2 Sullivan M, Hudson T, Bradley CM, Edlund M, Fortney J, National Study of Discontinuation of Chronic Opioid Therapy Among Veterans. Poster session presented at: the 30th Annual Meeting of the American Academy of Pain Medicine; 2014 March 6-9, Phoenix, AZ.

Comments (8)

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  1. GK says:

    In our VA it is very difficult to get approval for nonformulary medications such as cymbalta for chronic pain yet there is no problem with hydrocodone.

  2. john chambers says:

    Where are the veterans who take the minimal amount of opioids just to be able to be comfortable enough to be able to take walks, exercise, socialize,etc? What if everything else, including an electric nerve stimulator does not work to relieve the pain? And the veteran has had so many procedures on his spine that injections no longer can no longer be done because arachnoiditis. Why should this patient have to suffer? I have been battling pain for 28 years and have never had an addiction issue. Why should I be denied relief?

    • steve S says:

      John. Im a veteran whos 90% IU. Ive got DDD, spinal stenosis, cervical fusion c-2, t-1. Ive been on 45 mg morphine for 3 yrs, which is barely making life livable. Im in a wheelchair, because ,my legs don’t work due to chronic acute lower back pain. ive used a TENS, heat/cold, steroids, and pain shots to the spine. the only thing that works are constant hot/cold packs, different distractions, ie( internet research, reading, tv, leatherwork, etc, to keep my mind off the pain that drives me nuts. and now the Frikkin DEA/VA wants to reduce my level of opiods by 50%, without offering any alternatives. Like you, ive signed the contracts, never had addiction issues, .How dare they take my life from me, after we signed up to protect the flag.

      • Mike Jarrett says:

        Hey Steve, I see what conditions you have and am wondering if you ever received any kind of specialty care from anyone at VA for your conditions? I have severe spinal stenosis,DDD,facet joint syndrome,osteoarthrosis of entire spine and several discs protrusions but yet all of the mri’s do not indicate nerve impingement.So I get referred to neurosurgery clinic.Doctor comes in room and does seated leg raise test and feels my scar from prior lumbar surgery.Then he asked me if I was there to get surgery done on my back. I tell him I don’t really want to have surgery if I can keep from it. He then states that my mri films don’t show any nerve impingement so there is nothing he can do for me. I was totally flabbergasted by his lack of an examination and just his attitude in general.He acted as if I were wasting his time by being there.I always get med records from visits and when I got records of visit with this doc he had written in my record that he had done a complete neurological exam on me and some other testswhich were all just outright lies.So I reported it to patient advocate and had records change to indicate the truth. I found out that 2 months after visit with this doc that he had been fired by VA for doing same things to other veterans.
        Have you had any luck in getting good care by neurosurgery/orthopedic clincs for your conditions or have they just been treating your pain alon with opioids ?
        Good luck to you going forward
        Mike Jarrett

        [email protected]

  3. Robert Perez says:

    I agree with John Chambers, why do we have to suffer , just because some politician decided it was costing too much money ? I suffer from a multitude of injuries , with the help of opiate pain medication I have been able to live a somewhat normal life. But now I see absolutely no future at all. Who can enjoy life in such pain. This is a National Shame ! An outrage ! ” thank you for your service ” yea right !

  4. nicknac says:

    Well been awhile since anyone posted!! Here is what I say, Pain Pain go away and do not come back today. The contracts and consent forms should be there to protect the VA. If you die due to your pain usage then so be it if you consent. They continually do research and try to bend it to support their claims of improving lives through non opioids. Yet on the front lines every narco’s are the first line of defense against pain. If you do not complain about your use of opioids because they keep you from pain then you should be allowed to live as you choose… you’ve earned it!!!!!

  5. Tenja Daniels says:

    At the end of the day after jumping through every hoop, blood tests, pill counts, discussion of the “danger” of low dose hydrocodone long term pain treatment, Pain classes (both medically inaccurate and worthless), years of PT, and Non-steroidal medication I gave up. Went to a private Dr. through our insurance. Now receive my medicine like a normal person with follow ups for the joint injury and treatment (as well as my opioid pain medicine. This was a long term service connected injury. I guess it is becoming true that those left at the VA will be those with no other options.

  6. 100% SC Vet says:

    This OSI program was not thoroughly thought thru nor was it executed in a manner that has any respect nor consideration for the Veterans involved. I had my right foot ripped off and reattached, right leg 1″ shorter, L3-L5 laminectomy/discectomy, left knee bone on bone, spinal stenosis, bulging disks, DDD and extensive nerve damage. Everything hurts, I cannot even walk straight upright any longer. I now am having some type of pain that is directly behind my sternum in the middle of my back, the pain causes me shortness if breath as if I try to breath normally it is too pain. I was told in Dec 2015 that my meds were being reduced, I pitched a fit but managed to make it through. I now never have any extra just in case the mail does not arrive in a timely manner. Dec 2016, got a not her new Doctor who after 2 months is putting me on a 9 month COMPLETE opioid cutoff.
    I have been tried EVERYTHING the VA has ever asked me to try, each one has caused me additional pain. The OSI was originally meant for HIGH DOES chronic opioid users. 200+MG a day, my dosage was only 90mg and 20mg percolating for breakthrough pain. It has been work FABULOUSLY and I have been able to mow my yard, go shopping, mop my floors, clean the bathtub/toilet (we all hate that one) and work on crap in my garage.
    My doctor DID NOT even tell me, I found out when I recieved my medication and the scripts were still worded the same but each had less medication than what was prescribed for the monthly amount. How does a 24 day supply last 28 days?

    The OSI is horrible, terrible tragedy that inflicting unnecessary pain on chronically I’ll veterans that once stood tall to protect the very institution that now harms them!

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