By Annette M. Boyle
WASHINGTON—The White House’s announcement this summer of new steps to address the prescription opioid and heroin epidemic had a mixed message for the VA: While the administration specifically praised the VA’s new opioid prescribing policies for healthcare providers, it also referenced the ongoing challenges in addressing opioid abuse among veterans.
In the aftermath of the July announcement, the VA has ramped up multiple programs to simultaneously better manage pain and opioid use.
“A number of changes in pain care delivery, which were already underway in VA, were both reinforced and accelerated by the president’s recent proposals,” said Lucile Burgo, MD, national co-director of the VA’s Post-Deployment Integrated Care Initiative and assistant clinical professor at the Yale School of Medicine in New Haven, CT. “These VA programs and initiatives were focused not only on addressing concerns related to opioid prescribing and addictions treatment, but also on shifting from pain care that relied heavily on potentially risk medications and procedures to pain care that was more ‘Whole Health’ oriented.”
Those programs include a new policy at VA that requires prescribers to check state prescription monitoring databases (PMDP) “at least annually when renewing or issuing a new outpatient prescription to continue therapy with a controlled substance, or anytime such a query is clinically indicated,” said Steve Hunt, MD, national co-director of the VA’s Post-Deployment Integrated Care Initiative.
Local policies might dictate that prescribers query the state PMDBs more often, however, Hunt told U.S. Medicine, which would be in keeping with guidelines established elsewhere. The Indian Health Service, for instance, requires prescribers and pharmacists to check the state PMDB every three months for opioid prescription renewals. Every state except Missouri has a PMDB, which enables prescribers to see whether patients are filling multiple prescriptions for painkillers from different physicians.
Opioid Safety, Education
The VA is continuing to expand its opioid safety and education initiatives, as well. Those programs take a multistep approach to reducing unnecessary opioid prescriptions and closely monitoring use of narcotics when prescribed. According to Hunt and Burgo, the steps include prioritizing nonpharmacological approaches and avoidance of opioids unless they are unequivocally indicated and using evidence-based approaches when opioids are used, such as ensuring appropriate evaluations and diagnoses for use of opioids and having written informed consent from each veteran who will be taking opioids.
To promote safe practices and identify potentially risky behavior, the VA uses urine drug screens and closely monitors opioid use, dosages and reported pain relief over time. The steps also improve pain management, as research increasingly indicates that long-term opioid therapy could increase pain, rather than relieve it.
The VA also has adopted academic detailing to help change prescriber behavior regarding opioids. In this context, academic detailing monitors prescribing habits, provides feedback to providers and incorporates education and training in safer, more-effective pain management techniques. The academic detailing guidelines encourage prescribers to perform a urine drug test, check the state PMDB, obtain informed consent and agree on treatment goals prior to prescribing. At each visit, prescribers are encouraged to assess for changes in function and pain, evaluate progress toward treatment goals, assess for aberrant behaviors and side effects, and stop and reassess opioid prescribing, if the patient exhibits no improvement or aberrant behavior. The approach seems to be working.
Previous studies had found that VA prescriptions for hydrocodone, oxycodone, methadone and morphine nearly tripled between 2001 and 2012, paralleling the rise in opioid use nationwide. At the time, about 1 million veterans received opioid prescriptions each year, and more than half became chronic users. The numbers were particularly alarming, because veterans are twice as likely to die from accidental overdose as nonveterans.1,2
By 2015, the number of veterans receiving opioids had dropped by 115,575, and the number on long-term opioid therapy had declined by 100,074, according to a VA report. The number receiving high dosage opioid prescriptions had dropped by nearly 14,000, and almost 87,000 more veterans were having urine screens to guide treatment decisions.
Still, some veterans continue to misuse or abuse prescription or illicit opioids, and the VA has taken aggressive steps to keep accidental overdoses from killing veterans. The Opioid Overdose Education and Naloxone Distribution (OEND) program trains veterans to prevent, recognize and respond to an opioid overdose with the opioid-reversal agent naloxone. So far, the department has distributed more than 37,800 naloxone kit prescriptions to veterans, according to Elizabeth Oliva, PhD, VHA national coordinator of the OEND Program.
“Naloxone distribution is just one component of the VA’s overarching strategy to address misuse or abuse of prescribed and illicit opioids,” said Eleanor Lewis, PhD, deputy director of the VA’s Program Evaluation and Resource Center. “VA also ensures that veterans have access to other effective treatments and interventions that can reduce their risk for opioid overdose, including opioid agonist treatment, substance use disorder treatment, mental health treatment and urine drug screening for illicit drug use and prescription adherence monitoring.”
The VA has not formalized reporting of naloxone kit use, but Tom Emmendorfer, deputy chief consultant, VA Pharmacy Benefits Management told U.S. Medicine that, as of February, “at least 172 lives have been saved as documented through spontaneous reporting of opioid overdose reversal events with VA naloxone kits.”
1 Sullivan M, Hudson T, Bradley CM, Edlund M, Fortney J, et.al. 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 Bohnert AS, Ilgen MA, Galea S, McCarthy JF, Blow FC. Accidental poisoning mortality among patients in the Department of Veterans Affairs Health System. Med Care 2011;49: 393–396.