September 2018

In This Issue: Improving Opioid Safety
» Table of Contents

Primary Care Intervention to Reduce Prescription Opioid Overdoses

Feature Article

Previous studies by this research team indicate:

• VA patients have approximately twice the risk of opioid overdose compared to the general population after accounting for age and sex.
• VA patients prescribed higher doses of opioids have a markedly elevated risk for overdose; and
• Of the VA patients who die of an opioid medication overdose, 76% were seen in primary care in the year prior to death.

While efforts are underway to address prescriber behavior related to opioids (i.e., VA’s Opioid Safety Initiative), concurrent strategies that address patient behaviors are needed.

Investigators in this ongoing (2015–2019) HSR&D-funded randomized controlled trial (RCT) will evaluate a brief, tailored motivational enhancement intervention to reduce overdose risk behavior and aberrant opioid use among Veterans seen in VA primary care and Primary Care-Mental Health Integration (PC-MHI) settings. While motivational enhancement has demonstrated efficacy in numerous RCTs across a range of behaviors, to date, motivational enhancement has not been applied to overdose risk behaviors or aberrant opioid use in any VA setting. This intervention will:

• Incorporate motivational enhancement, as well as cognitive-behavioral strategies, to provide tailored feedback regarding risks associated with opioid use,
• Elicit commitment talk to reduce patients' overdose risk behavior and over-reliance on opioids for pain management, and
• Impart specific cognitive and behavioral "tools" related to pain management and safe use of opioids.

Motivational enhancement therapy (MET) is designed to evoke internally motivated change by helping people with addictions learn how to change their thoughts and behaviors. MET includes five specific strategies that have been found to encourage motivational change:

• Developing and expressing empathy (i.e., how their actions affect others);
• Acknowledging the disparity between thoughts and reality;
• Avoiding arguments;
• Accepting resistance as part of the process; and
• Supporting a recovery addict’s self-efficacy (i.e., belief in ability to achieve goals).

The objectives of this RCT are to examine if patients randomly assigned to a motivational enhancement brief intervention for overdose prevention report reduced overdose risk behavior over one year of follow-up compared to an enhanced usual care condition (EUC). Investigators also will assess whether or not Veterans randomly assigned to a motivational enhancement brief intervention report reduced prescription opioid use over one year of follow-up compared to a usual care condition.

Findings:
Recruitment has begun, and data collection is underway.

Impact:
The study will increase our understanding of strategies to reduce adverse outcomes related to opioid medication use and misuse, including the risk of overdose among VA primary care patients. Study findings also are likely to have broad implications for improving the safety of opioid use and, consequently, the quality of pain care for current and future VA patients.

Principal Investigator: Amy Bohnert, PhD, MHS, is part of HSR&D’s Center for Clinical Management Research (CCMR) in Ann Arbor, MI, and is a former HSR&D’s Career Development Awardee.

Additional Resources

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