New Prescriptions for Narcotics Down Sharply at VA
MINNEAPOLIS — The good news: The VA reduced opioid prescribing by 64% from 2012 to 2020, from more than 679,000 veterans to 247,000 through its Opioid Safety Initiative and other efforts. The bad news: the number of veterans diagnosed with opioid use disorder continued to rise.
More than 25,000 veterans had a diagnosis of opioid use disorder (OUD) in 2003. By 2017, the number exceeded 69,000, according to the VA’s Quality Enhancement Research Initiative.
The rise in OUD reflects factors unique to veterans as well as national trends. “Collectively, uncontrolled pain, distress and functional impairments can reduce the quality of life for veterans and their families, increasing the risk for overdose, substance use disorders and suicide,” said VA Secretary Robert Wilkie. “More than one third of veterans in the VA health care system live with some form of chronic pain, and given the opioid crisis, it is our duty to do everything we can to help veterans avoid opioid overdose and provide them with alternative pain management treatment.”
The VA has adopted a four-pronged strategy to reducing opioid use: providing non-pharmacological alternatives to long-term opioids for veterans with chronic pain, educating clinicians and veterans on options to opioids for other indications, managing opioid use risk, and offering addiction treatment.
As the other three have shown more success, focus has shifted to the fourth prong and increasing access and utilization of addiction treatment, particularly medication for opioid use disorder (MOUD). “Although rates of MOUD are increasing, only a little more than 40% of patients with OUD in VHA receive such treatment, with substantial variation across VA facilities and patient characteristics,” said Barbara Plantt, outreach coordinator for the VHA Office of Community Care.
That’s a significant problem. “Veterans treated in VHA die of drug overdose at almost twice the national rate of the general population,” said VA Assistant Undersecretary for Health Renee Oshinski.
In a directive to all VA medical facilities in September 2020, she noted that “[m]edication for OUD, commonly referred to as medication assisted treatment, reduces the risk of overdose and all-cause mortality and is strongly recommended as first-line treatment by VA-Department of Defense Clinical Guidelines, but it is not universally offered within VHA points of care outside of Substance Use Disorder (SUD) treatment programs.”
Oshinski’s notice called on all facility directors and providers to eliminate prohibitions of OUD treatment outside of SUD specialty care settings, remove prescribing of buprenorphine as a delineated privilege, and ensure providers prescribing buprenorphine have the appropriate DEA X-waiver license (also called a DATA-waiver). In addition, facilities were instructed to remove any modifiable barriers to OUD treatment and ensure every veteran who would benefit from medication for OUD is evaluated and offered treatment. She also urged facilities to offer incentive payments to clinicians who prescribe MOUDs, reduce caseloads for these prescribers and review staffing to meet the needs for expanded care for veterans with OUD.
The Minneapolis VA Health Care System had a jump on the new directive to expand access. In 2017, the system’s leadership team and pain management committee launched a clinical pharmacist care management (CPCM) program to increase use of pharmacotherapy for OUD, according to a December 2020 article on the program in the American Journal of Health-System Pharmacy.1
“Primary care [clinical pharmacy specialist] practice at MVAHCS has been repeatedly expanded to include management of additional disease states,” lead author Beth DeRonne, PharmD, Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, and her colleagues noted. “This history was a significant facilitator of successful implementation of the CPCM program. Use of the CPCM model did not require modifications to clinic structure, workflow, or documentation and did not necessitate the hiring of new CPSs or other clinicians.”
A clinical pharmacy specialist led an interdisciplinary group that included prescribers, nurses, psychologists, and other pharmacists in primary care, pain management, and mental health that analyzed barriers to OUD care and strategized ways to improve access and delivery of MOUD. Prescribers said that working with a clinical pharmacist would increase their comfort with prescribing MOUD, while veterans expressed reluctance to seek care in an addiction clinic.
The team determined that expanding use of pharmacotherapies for OUD in primary care clinics would help overcome some of the stigma veterans associated with addiction treatment. A collaborative care model based on a partnership already in place in the addiction clinic would enable a clinical pharmacist to support and extend qualified prescribers in both primary care and general mental health clinic settings.
The program kicked off with several well attended educational programs on opioids, addiction, and OUD as well as a session tailored to mental health psychologists on MOUD, identifying patients with OUD, and how to refer to the program. Pharmacists also undertook academic detailing visits focused on OUD management with mental health and primary care providers. The physician champion pitched the program to colleagues. The team coordinated DATA-waiver training for interested prescribers and pharmacists and created provider and patient guides and health record templates.
The program focused on buprenorphine but could also be used to support other drugs approved for OUD such as long-acting injectable naltrexone and methadone. Federal regulations limit methadone treatment to the opioid treatment program in the addiction clinic, however.
Eight pharmacists participated in the program. DATA-waivered physicians signed buprenorphine prescriptions and met with patients at least once a year, while the pharmacists conducted other visits. Veterans already prescribed buprenorphine or naltrexone by addiction psychiatrists transitioned to pharmacist care for ongoing management. Stable patients received treatment through primary care, while more challenging patients were managed by a mental health clinical pharmacist in the mental health clinic.
Between the third quarter of fiscal year 2017 and the fourth quarter of FY 2019, an interim analysis of the program showed that the percentage of veterans in care at MVAHCS with OUD who received medication for the disorder rose from 33.8% to 46.7%, beating the initial goal of a 10% increase. Pharmacists directly facilitated initiation of MOUD in 47 patients, 12 in the primary care setting and 35 in the mental health practice. Patient visits lasted about 20 minutes in primary care and just under half an hour in the mental health setting.
Overall, the pharmacists saw 109 veterans for a total of 625 visits. Of those, 94 received care in the mental health practice setting, accounting for 532 visits. Compared to those who received treatment through primary care, these patients tended to be younger and have higher rates of post-traumatic stress disorder as well as alcohol use disorder and cannabis use disorder. They also typically received a higher dosage of MOUD.
In addition to increasing the percentage of patients receiving evidence-based medication therapy for OUD, “[t]he program also expanded access to MOUD within primary care and mental health practice settings,” the authors concluded. “The number of patient visits has steadily increased, and continued efforts by the pharmacists and DATA-waivered collaborating prescribers have sustained improvements in MOUD treatment.”
- DeRonne BM, Wong KR, Schultz E, Jones E, Krebs EE. Implementation of a pharmacist care manager model to expand availability of medications for opioid use disorder. Am J Health Syst Pharm. 2020 Dec 16:zxaa405. doi: 10.1093/ajhp/zxaa405. Epub ahead of print. PMID: 33326564.