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Impacts on Care

With new initiatives, VA aims to turn the corner on escalating opioid use

February 26, 2015

Reliance on opioid painkillers is trending downward thanks to several initiatives in VA and in U.S. medical care at large. (Photo: MorgueFile)

Reliance on opioid painkillers is trending downward thanks to several initiatives in VA and in U.S. medical care at large. (Photo: MorgueFile)

Opioid prescriptions in VA skyrocketed over an eight-year period, according to a VA study, although the results predate several major initiatives to address the issue. The study, published online in the Journal of General Internal Medicine on Dec. 18, 2014, found wide variation in the way opioids were prescribed based on geographic region, age, and sex from 2004 to 2012.

Women, for example, had higher rates of opioid receipt than men in 2012: about 42 percent versus 33 percent among all VA outpatients. Younger Veterans were also more likely to be prescribed opioids: Among Veterans between 18 and 34 years, 18 percent received opioids, whereas among those 80 and older, the figure was under 8 percent.

Overall from 2004 to 2012, opioid receipt among VA outpatients increased by nearly 77 percent. As of 2012, some 33 percent of Veterans in VA care received opioids for pain management.

"While opioids may be appropriate in acute pain, the safety and effectiveness of long-term use remain unproven," says the study's lead author, Dr. Hilary Mosher. "In the last few decades there has been an increased emphasis on treating pain in patients. While this is a valuable patient-centered goal, medications alone are likely not the answer in chronic pain. The companies making these medications have had substantial success in creating a perception that they're safe and effective for long-term use."

Mosher, a hospitalist, is with the Center for Comprehensive Access and Delivery Research and Evaluation at the Iowa City VA Healthcare System. She is also a clinical assistant professor with the University of Iowa.

Drugs fail to improve function

Opioids, which include narcotics such as morphine, are commonly used to treat acute pain, such as one might experience after surgery or from cancer. In recent years their use has been expanded to treat chronic pain. There is a substantial overlap between chronic pain and PTSD, anxiety, and depression, says Mosher, increasing the chances of opioid-related harms.

What's more, according to Mosher, it's unclear if long-term opioid use really improves a patient's well-being even when side effects like addiction or testosterone depression are avoided.

"We haven't been able to show that using opioids for chronic care improves patients in terms of their physical function, their social function, or their ability to go back to work and achieve their goals," says Mosher. "The concern is that using opioids both fails to improve function and may actually work against functional improvement."

The picture is not entirely dire, though, as the new study does provide important insights for VA, and there may even be some reason for optimism. For example, when it comes to opioid prescriptions, the old adage "location, location, location" seems to hold true. Whether or not a Veteran received an opioid prescription depended largely on where he or she sought care. Of the 137 VA healthcare systems, the lowest prescribing facility had an opioid rate of only around 14 percent in 2012. The highest: over 50 percent.

Part of the reason for the geographic variation might lie in differing demographics. Individual facility culture may also play a large role. That said, those cultures have been changing.

Indeed, the data used in Mosher's study predate several initiatives, both in VA and in U.S. medical practice in general, meant to stem the prescription of opioids.

Culture change in the works

"About 20 years ago there was a big change," says Dr. Erin Krebs, women's health medical director at the Minneapolis VA and a co-author on the study. "There was increasing emphasis on the use of opioids for all kinds of indications, and it's only now that opioid prescribing has become much more common that we've started to see evidence of the serious harms. And so now we're seeing a culture change of a different sort."

Krebs, who is also an associate professor in the department of medicine at the University of Minnesota, recently collaborated on research into implementation of VA's Opioid Safety Initiative (OSI) at the Minneapolis VA.

Established in 2011, the Minneapolis OSI aimed to decrease high-risk opioid prescribing practices. Through a combination of educational seminars and specific training for pharmacists and caregivers, as well as classes for patients, it aimed to improve the safety of opioid prescribing while providing high-quality pain care for Veterans.

"The first step was getting everyone on the same page," says Krebs. "Early on, patient advocates and Veteran Service Organizations were involved so that Veteran concerns could be incorporated. It's a hard transition for a lot of people."

The results of the study, published online in Pain Medicine on Feb. 3, 2015, suggest OSI is capable of producing dramatic results.

Following OSI implementation, the number of Veterans prescribed greater than 200 morphine-equivalent milligrams worth of opioids decreased from 342 to 65. Overall the number of unique pharmacy patients who received at least one opioid prescription decreased by almost 1,000, to 5,981, and the number of Veterans receiving oxycodone dropped from 292 to 3 over the study time period.

Transition difficult for many patients

That's not to say the transition was always easy, says Krebs. "It's a hard sell to tell someone in pain that we're going to take something away from you but we don't necessarily have anything to give you in its place."

At the time the study began, Krebs says, the Minneapolis VA didn't have enough resources in place to offer non-drug pain management, an issue that is being addressed. The Minneapolis VA has since established a state-of-the-art chronic pain rehabilitation program, which is still expanding its reach.

"It's more than just saying opioids aren't the main way to manage pain," says Krebs. "We need to have new approaches to manage chronic pain." Krebs points to increases in mindful meditation, cognitive-behavioral therapy, and exercise programs like yoga that are sprouting up throughout VA as viable options to long-term opioid prescriptions.

One example is VA's Stepped Care Model of Pain Management, which aims to treat pain effectively through evidence-based pain management approaches and improved access to specialty pain services. In one study on the initiative, published in the Journal of General Internal Medicine on Dec. 29, 2014, researchers found high-dose opioid prescriptions decreased over a four-year period from nearly 28 percent to just under 25 percent. Meanwhile, referrals to physical therapy and chiropractic care increased significantly.

On a national scale, VA's Office of Research and Development has teamed with VA Pharmacy Benefits Management to develop an "opioid dashboard" for tracking prescriptions and dosages as part of the national OSI effort to reduce the number of Veterans receiving high-dose or multiple prescriptions.

Such efforts are welcome news to Mosher. She says she is glad to see that the language around opioids is changing.

"I'm optimistic that we're starting to see a flattening or down-trending, and that it reflects either patients being aware that these medications aren't going to help them in the way they want to be helped, or clinicians being more hesitant to prescribe them. When we repeat this analysis in a few years and look at 2012 through 2018, it won't be surprising if we see a downtrend."

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