September 2018

In This Issue: Improving Opioid Safety
» Table of Contents

State Prescription Monitoring Program to Evaluate Concurrent VA and Non-VA Opioid Prescriptions

Feature Article

Controlled prescription drug overdose, primarily from opioids, is a leading cause of death in the United States. Moreover, Veterans who use VA healthcare have twice the risk of medication overdose deaths than non-Veterans, but reasons for the increased risk are unknown. It is possible that Veterans who receive VA prescriptions simultaneously receive controlled prescriptions (e.g., opioids, benzodiazepines) from non-VA prescribers. State prescription drug monitoring programs (PDMPs) can help reduce prescription drug overdose by providing data on controlled medications across providers and systems. However, little is known about the prevalence of dual VA-community prescriber use among Veterans, their full range of medication-related adverse events (i.e., those treated inside or outside VA), and mechanisms to increase use of state PDMPs within VA.

This ongoing HSR&D study (2016–2019) will:

• Quantify and characterize patterns of dual use of VA and community prescribers of opioids and benzodiazepines among Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF)/Operation New Dawn (OND) Veterans in Oregon;
• Describe rates, types, and risk factors for all opioid/benzodiazepine-related adverse events among OEF/OIF/OND Veterans in Oregon; and
• Identify barriers and facilitators to state PDMP use among VA opioid/benzodiazepine prescribers in Oregon.

Investigators will link VA data to multiple state databases to identify controlled prescriptions (VA and community) that OEF/OIF/OND Veterans are receiving, as well as their risk of overdose and other adverse events treated inside or outside VA. Data from 2011 – the year the Oregon PDMP was implemented – through 2016 will be used to identify patterns, rates, and risk factors for dual VA/community prescriber use, as well as fatal and nonfatal medication-related adverse events. Investigators will interview and survey Oregon VA prescribers about barriers and facilitators to using the state PDMP. They will also examine organizational and patient factors associated with VA-documented PDMP queries among Veterans receiving long-term opioid therapy (LTOT) in VISN 20.

Findings:
Thus far, study results show—

• Among Veterans treated within VISN 20 and receiving LTOT from 2015-2016, 64% had a PDMP query documented in their medical record.
  • This proportion varied widely by VA site and by primary care provider.
• Veterans were more likely to have a documented PDMP query if prescribed opioids by their primary care physician than by another clinician, if prescribed higher doses, or if diagnosed with a pain disorder.
  • There was no association between benzodiazepine co-prescribing and PDMP queries.
• Among Oregon Veterans who received a VA opioid prescription between 2014 and 2016, 15% received a concurrent non-VA opioid prescription.
  • Among Veterans who received long-term opioid therapy from VA between 2012 and 2016, 32% received concurrent non-VA opioid prescriptions.
• Veterans were more likely to have concurrent VA and non-VA prescription fills if they had a 50% or higher VA service connection, were a participant in the Veterans Choice Program, or had diagnoses of PTSD, pain, depression, traumatic brain injury, or substance use disorder.

Impact:
This work will support interventions that improve the systematic use of state PDMPs to inform prescribing decisions and, ultimately, reduce opioid-related adverse events among Veterans.

Principal Investigator: Kathleen Carlson, MD, PhD, is part of HSR&D’s Center to Improve Veteran Involvement in Care (CIVIC) in Portland, OR.

Publications: Carlson K, Gilbert T, Morasco B, et al. Linkage of VA and state prescription drug monitoring program data to examine concurrent opioid and sedative-hypnotic prescriptions among Veterans. Health Services Research. Epub ahead of print: August 2, 2018.

Additional Resources

• VHA Pain Management. Opioid Safety Initiative Toolkit.
• Veterans Crisis Line 1-800-273-8255 (press 1) or Text message to 838255.