Federal Pharmacists Play Role in Dramatic Decline

By Annette M. Boyle

SALT LAKE CITY—In January, the VA became the first hospital system in the United States to publicly post opioid prescribing rates. Veterans, clinicians and the public can see the current rates—and the decline at each facility since 2012—on an interactive map. Information will be updated in January and July of each year going forward.

“The VA is committed to transparency and added the opioid prescribing data to the VA data website, data.va.gov, because of the importance of the opioid problem,” said Laurence J. Meyer, MD, PhD, the VA’s national director of Genomic Medicine and chief officer of Specialty Care Services. “There was significant interest from both Veterans and the public in the VA response to the opioid crisis.”

Alaska National Guard Sgt. Elijah Gutierrez, a civil operator with the Counterdrug Support Program, discusses the procedures for using the Narcan kit with Alaska State Trooper James Lester at the Edward G. Pitka Sr. Airport in Galena, AK, last year. Army photo by Staff Sgt. Balinda ONeal Dresel

In the five years since the VA launched the Opioid Safety Initiative, the rate of opioid prescribing has dropped 41% across the health system, with 99% of facilities recording a drop in prescriptions.

“Only one facility did not see a drop in the initial reporting period, Manilla,” Meyer told U.S. Medicine. “It started at the lowest rate of any VA facility, and though it increased, this represented few prescriptions. It also has no inpatients,” he noted.  

The VAMCs in San Juan, Puerto Rico and Cleveland , posted the lowest prescribing rates, at 3%. The medical centers in El Paso, TX, and Fayetteville, NC, showed the greatest improvement, with both cutting their opioid prescription rates by two-thirds.

The VA has not set a target rate for opioid prescribing. “Opioids have appropriate uses, and the specific rate appropriate for any facility depends on the patient and case mix of that facility. We do have guidelines for both use of opioids and for decreasing the use of opioids for those already receiving chronic opioids,” Meyer said.

Reducing opioid prescriptions at the VA has taken a concerted effort, complicated by the high rates of chronic pain among veterans. The Opioid Safety Initiative and updated VA/DoD guidelines for the use of opioids and for decreasing the use opioids among patients who have been taking them on a long-term basis provide a variety of options and algorithms to help clinicians reduce prescribing rates and improve care of veterans with chronic pain.

Alternatives for pain management include physical therapy and complementary and integrative health options, including meditation, yoga and cognitive behavioral therapy. Clinicians and veterans can identify options and learn from others who have found ways to help veterans overcome the challenge of chronic pain through the VA’s “significant system to take best practices and share them across the system,” Meyer added.

Still, “while VA offers other pain-management options to reduce the need for opioids, it is important that we are transparent on how we prescribe opioids, so veterans and the public can see what we are doing in our facilities and the progress we have made over time,” said VA Secretary David J. Shulkin, MD.

The VA isn’t the only health system in federal medicine to begin to corral the use of opioids. The Army has seen a similar decline in opioid prescriptions, with a 45% reduction in chronic opioid use and 19% drop in the number of soldiers given any opioid prescription between 2010 and 2016.

Army pharmacists play a key role in reducing the use of opioids. Using an opioid registry developed by the Enterprise Intelligence Division, clinical pharmacists can readily see which patients are at risk for various issues associated with opioid use.

Prior to the clinic’s morning huddle, pharmacists receive a list of patients who will be seen that day, which they can run through the automated screen. That allows them to “identify patients who you want to talk to, based on current or previous dose, other medications and comorbidities,” said Col. Kevin Roberts, PharmD, pharmacy consultant to the surgeon general of the Army and director of USA MEDCOM Pharmacy Service Line.

With the advance information, pharmacists are “ready when the patient arrives, rather than after the appointment, so they can conduct a pretty significant Q&A with the patient,” Roberts told U.S. Medicine. Questions might cover the duration of the prescription, how the opioid is working or probe a patient’s awareness of interactions between their pain medications and other drugs they take.

Pharmacists might also follow up with physicians, noting that there is a potential opportunity to look more closely at the issue of opioid use by a particular patient. Because patients see pharmacists more often than providers, pharmacists have more opportunity to both talk with patients and identify those at risk, Roberts said.

When they do see someone at risk, Army pharmacists now have the ability to provide naloxone where it might be needed. “The analytics tool developed by the Enterprise Intelligence Division at the Defense Health Agency combines prescription information and patient information and generates a score that indicates whether the patient at the window is at risk of abuse, has respiratory issues [or] chronic disease that affects metabolism of medications,” Roberts said.

If the score indicates a high risk, the pharmacist may say, “Sir/Ma’am, based on other medical issues and your dose, you may be at risk for an overdose. We’d like to offer you naloxone. Almost every patient knows what naloxone is,” he added. Pharmacists encourage patients to keep the naloxone on their person at all times. “We’d rather that the caregiver be there to receive medication, because the patient won’t be administering it themselves, but that’s not realistic.”

Roberts explained that the program initially required scoring patients by hand while at the window. Now the score is calculated automatically. The program will be rolled out to all Army MTFs by the end of the year and, as it is sponsored by the DHA, will be available to all services.

In an effort to make opioids harder to obtain without a prescription and the risk of accidentally taking the wrong medication, the Army introduced a drug disposal program two years ago that’s “fairly ubiquitous at Army MTFs,” Roberts said. Patients can come into Army facilities and dispose of unwanted and unused medications in a box at the facility. “We also provide envelopes that patients can take home and use to mail to [a] separate entity that destroys the medications.”

In the next phase of improving use of opioids, the Army will be looking at benchmarks used in commercial settings to enhance safety and effectiveness of opioid therapy, according to Roberts. Those include measures of opioid dosing, number of prescriptions per provider and alerts to opioid/benzodiazepine co-prescribing.