Dual Use of VA and Medicare Associated with Substantial Increase in Risk of Potentially Unsafe Opioid Use among Veterans
BACKGROUND:
While enrollment in both VA and Medicare (dual use) may increase access to care, it also creates the opportunity for unsafe opioid use due to care fragmentation. As much as the Centers for Medicare and Medicaid Services (CMS) and VA have individually done to address opioid misuse and abuse, they have limited capability to assess prescriptions that beneficiaries receive in the other system. This is especially true given that there is no comprehensive interface between electronic health records across systems and little communication by prescribers or pharmacies. This study sought to estimate the prevalence and consequences of receiving prescription opioids from both VA and Medicare Part D for all dually-enrolled Veterans who filled a prescription opioid in either system in calendar year 2012 (n=539,473). Overall, 135,643 (25%) received opioids from VA only, 332,630 (62%) from Part D only, and 71,200 (13%) from both VA and Part D (dual use). Primary outcomes included three measures of potentially unsafe high dosage opioid use, each associated with opioid-related adverse events and overdose. Investigators calculated these three measures using morphine milligram equivalents (MME): 1) proportion receiving >100 MME for >1 day, 2) mean days receiving >100 MME, and 3) proportion receiving >120 MME for 90 consecutive days. Measures were also compared by source of opioids.
FINDINGS:
- Among Veterans dually enrolled in Medicare Part D and VA and receiving prescription opioids in 2012, more than 1 in 8 received opioids from both systems, in many cases concurrently
- Compared to VA-only use of opioids, dual use was associated with a 3-fold higher risk of high-dose opioid exposure and more than twice the risk of long-term high-dose opioid exposure. Dual use also was associated with a 60-90% greater risk of these exposures than Part D only use.
IMPLICATIONS:
- VA is evolving into a less integrated delivery system with more community care options. As these options increase, the prevalence of poorly coordinated dual-system care (e.g., overlapping opioids and other drug interactions and duplication) also will likely increase.
- The availability of prescription drug monitoring programs (PDMPs) may not be enough to address dual use of opioids unless the PDMPs are consistently used and their data integrated into decision support. PDMPs will not address other non-opioid drug interactions and duplications.
LIMITATIONS:
- Data were from 2012 – the most recent year available – and do not represent the current state of opioid use across VA and Medicare.
- Outcomes were based on safety measures and not medical outcomes.
- Investigators were unable to capture prescriptions paid for in cash dispensed outside VA – illicit or non-illicit – and were unable to know whether patients took the dispensed opioid as prescribed.
AUTHOR/FUNDING INFORMATION:
This study was funded by HSR&D. Drs. Gellad, Thorpe, Zhao, and a majority of co-authors are part of HSR&D's Center for Health Equity Research and Promotion (CHERP) in Pittsburgh.
Gellad W, Thorpe J, Zhao X, et al. Impact of Dual Use of VA and Medicare Part D Drug Benefits on Potentially Unsafe Opioid Use. American Journal of Public Health. February 2018;108(2):248-55.
