By Brenda L. Mooney

Mark Ilgen, PhD, a research investigator at the VA’s Center for Clinical Management Research and an associate professor of psychiatry at UM.

ANN ARBOR, MI — Thanks to a national initiative begun at the VHA in 2013, fewer veterans are receiving prescriptions for risky dosages of opioid painkillers.

Over a two-year period, according to a recent study, high-dose opioid prescribing declined by 16% and very-high-dose opioid prescribing dropped by 24% at the healthcare system. Furthermore, the number of patients receiving both opioids and sedatives, which can be lethal when combined, dropped by 21%.

The report published ahead of print in the journal Pain looks at the effect of the Opioid Safety Initiative (OSI) launched by the VHA in late 2013 to promote safer opioid prescribing. The study reviews implementation of the initiative across all of the nation’s 141 VA hospitals.¹

As part of the OSI, the VHA created a “dashboard” tool using its national computerized medical record system, which allowed local clinical leaders to systematically review opioid prescribing and give feedback to physicians.

The hope is that other large healthcare systems will begin to use their electronic medical systems as part of the fight against painkiller overdoses and opioid addictions, according to study authors from the VA Ann Arbor, MI, Healthcare System, the University of Michigan Medical School and Institute for Healthcare Policy and Innovation, both in Ann Arbor, MI, and Yale University in New Haven, CT.

The study of VA opioid prescribing actually begaN before the OSI rolled out and then extended through the program’s first year. While the national VA system had tried other efforts to stem risky opioid use, including guidelines for prescribing, the new research shows OSI greatly accelerated the downward trend.

“As our nation as a whole is learning, it’s important to reduce risky opioid-related prescribing,” explained first author Lewei Allison Lin, MD, an addiction fellow in the UM Department of Psychiatry who trained in the VA system. “We hope that these findings, showing the VA OSI was associated with a reduction in risky prescribing will encourage others to consider similar healthcare system interventions to address this complex issue.”

High Daily Thresholds

The study focused on patients with prescriptions above particularly high daily thresholds: 100 and 200 morphine equivalents (MEQ). Results indicated that OSI was associated with 331 fewer patients a month receiving prescriptions with daily doses above 100 MEQ and 164 fewer patients a month being prescribed a daily dose above 200 MEQ.

Overall, 55,722 veterans had received daily opioid dosages greater than100 MEQ in October 2012, but that decreased to 46,780 in September 2014.

Because accidental overdoses among patients on opioids that interact with other drugs have increased, the OSI also included the use of benzodiazepine sedatives, finding that 781 fewer patients each month received both an opioid and a benzodiazepine after implementation of the initiative.

The success wasn’t across the board, however. The new data shows variation among VA hospitals in OSI’s effect, with a minority of hospitals actually increasing high-dose opioid prescribing during the study period.

“These results highlight the importance of addressing provider behaviors in our efforts to address the opioid epidemic and the need for large health systems to develop and implement systematic approaches that are flexible enough to allow clinicians to make individual decisions while still reducing the overall prevalence of potentially risky prescribing,” pointed out senior author Mark Ilgen, PhD, a research investigator at the VA’s Center for Clinical Management Research and an associate professor of psychiatry at UM.

The OSI uses an “audit and feedback” model, which has been used successfully in other efforts to improve healthcare quality and safety. Because the national VA system uses a single computerized electronic medical record system, it was a good candidate for the dashboard approach so that each hospital’s OSI “champion” could easily see how opioids and related medications were being prescribed at their hospital and by each doctor who prescribed them. That information could then be compared with national and regional data.

In addition to the previous guidelines and the dashboard, the opioid initiative encouraged local hospital leaders to provide education about pain care and opioid prescribing. At the same time, the data and tools could be tailored to individual patient needs.

One issue in reducing the use of high-dose opioids is that changing the dose must be done gradually and carefully, especially when a patient has been accustomed to higher doses over a longer period of time. Lin said that further evaluation of OSI data will be needed to determine how dosages were reduced and to measure the effects of newer components of the OSI program.

1. Lin LA, Bohnert A, Kerns R, Clay MA, et. al. Impact of the Opioid Safety Initiative on opioid-related prescribing in veterans. Pain. Published ahead of print. Post Acceptance: Jan. 4, 2017. doi: 10.1097/j.pain.0000000000000837