VHA Makes Progress in Improving Safety of Opioid Prescribing

by Sandra Basu

August 5, 2018

WASHINGTON — VHA medical facilities should ensure that its providers are following three key opioid risk mitigation strategies, including conducting urine drug screening, a recent report recommended.

“Specifically, increasing the use of urine drug screening is an explicit goal of the Opioid Safety Initiative, and providers should generally ensure that an annual urine drug screening has been conducted,” according to the Government Accountability Office (GAO).

The recommendation was part of a GAO report on VA’s efforts to improve opioid safety. Overall, the GAO noted that VHA has made progress improving opioid safety through its Opioid Safety Initiative (OSI) and has seen reductions in prescribing rates for the narcotic painkillers.

“For example, from the fourth quarter of fiscal year 2013 to the first quarter of fiscal year 2018, the percentage of patients dispensed an opioid decreased from about 17% to about 10%, or by about 267,000 veterans,” the report noted.

Still, the report stated that its review “of selected VHA medical facilities shows that providers do not always follow three key opioid risk mitigation strategies, two of which are required under VHA policy.”

Those strategies are:

  • Providers must query state Prescription Drug Monitoring Programs (PDMP) at least annually when prescribing opioids to determine if the veteran has obtained opioid medications or other controlled substances from a non-VA provider, and
  • Written informed consent must be obtained from patients about the risks of initiating long-term opioid therapy.

For the review, GAO looked at a “nongeneralizable sample” of 103 veterans’ medical records at five selected VHA medical facilities. Based on its review, the report found that “75% of the veterans in our sample had an annual urine screening, 26% had their names queried in a PDMP, and 70% provided informed consent.”

Prescription Monitoring Issues

Among the challenges that GAO cited as contributing to inconsistent adherence was that four of the five selected medical facilities faced PDMP access issues.

“Officials at two facilities told us that not all facility staff can access state PDMPs due to state laws and regulations that do not allow access to all types of providers, such as nurses and pharmacists,” report authors pointed out.

Other issues were that four of the five selected facilities did not have a staff member designated as “pain champion,” and three of the five facilities did not always review veterans’ medical records to ensure provider adherence to these strategies.

Additionally, “not all facilities had access to academic detailing, a program in which trained clinical pharmacists work one-on-one with providers to better inform them about evidence-based care related to the appropriate treatment of relevant medical conditions,” the report explained.

Another factor that might limit adherence was that “none of the selected facilities employ electronic reminders to help remind primary care nurses of strategies that have not been completed,” GAO authors emphasized, adding, “Primary care nurses are typically responsible for ensuring adherence to these strategies, and VHA facilities often employ electronic alerts to notify providers when certain tasks need to be completed, such as regular screenings for depression and traumatic brain injury.”

The GAO also looked at the extent to which VHA has met its OSI goals since establishing the program in 2014. Available evidence suggests VHA has accomplished six of nine OSI goals established in 2014 but that it was unclear “whether the remaining three goals have been fully met,” the oversight agency noted.

“For three OSI goals, it is unclear if the goal has been fully met because VHA lacks documentation showing that it has implemented the required action under the goal or the required action is still in progress,” the report explained.

For example, on the OSI’s goal of “establishing safe and effective regional tapering programs for patients on opioids and benzodiazepines,” GAO found that VHA lacked documentation that its regional networks established these programs.

VA concurred with GAO’s five recommendations. The report recommended that the undersecretary for health should:

  • Ensure that actions that are taken toward achieving OSI goals are documented by Central Office, Veterans Integrated Service Networks (VISN) and medical facilities;
  • Ensure that any unmet OSI goals have clearly-defined, measurable outcomes;
  • Track the use of the Opioid Therapy Risk Report (or any subsequent tool) by providers prior to starting opioid therapy;
  • Ensure that all VISNs have implemented an academic detailing program that supports all medical facilities in the VISN and that all VHA medical facilities have a designated primary care pain champion as required; and
  • Require VHA medical facilities to take steps to ensure provider adherence to opioid risk mitigation strategies, including querying PDMPs, obtaining written informed consent, and conducting urine drug screening.

“These steps could include creating alerts in the electronic medical record system to remind primary care teams when these actions should be completed or strengthening facility monitoring of providers,” GAO authors added.

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