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This Issue: The Aging Veteran | Table of Contents: Summer 2017 | Download this issue

Editorials from VA Research Scientists

Dr. Walid Gellad Dr. Walid Gellad

"Medicare could learn a thing or two from VA: A well-functioning formulary lets Veterans get the medications they need with low copayments," Walid F. Gellad, M.D., Wall Street Journal, June 15, 2017.

VA researcher Dr. Walid Gellad published an op-ed in the Wall Street Journal that proposed using the VA drug formulary as a national model to address runaway prescription drug prices in the United States. According to Gellad, who is co-director for the Center for Pharmaceutical Policy and Prescribing at the University of Pittsburgh and an investigator at the VA Center for Health Equity Research and Promotion (CHERP), the VA formulary system has much to commend it.

Given that VA employs a single electronic health record across all 152 health care centers, there is ease of communication and transparency for prescribing physicians and pharmacists. Because VA is able to negotiate drug prices, a course of treatment with a high-cost drug like Harvoni (used to treat hepatitis C) means a Veteran could pay just $33 out of pocket, not the roughly $6,000 that a patient using Medicare Part D could. And just as in most private insurance plans, VA patients are generally prescribed lower-cost medications first that are part of the VA formulary, but have the option to use a non-formulary drug if it is appropriate and recommended by their physician.

Dr. Kurt Kroenke Dr. Kurt Kroenke

"Management of chronic pain in the aftermath of the opioid backlash," Kurt Kroenke, M.D., and Andrea Cheville, M.D., JAMA, May 11, 2017.

The United States has reached a crisis state in opioid medication overuse and dependency. In response, the medical community has severely restricted prescribing guidelines for physicians who treat chronic pain, suggesting that only a limited number of opioids should be prescribed to patients. Dr. Kurt Kroenke, a physician and VA researcher at the Center for Health Information and Communication (CHIC) in Indianapolis, said there still remains an urgent need to appropriately address pain management for the more than 25 million Americans who live with daily, chronic pain.

He and his colleague Dr. Andrea Cheville, a physician with the department of physical medicine and rehabilitation at the Mayo Clinic, have written an editorial in JAMA that highlights the necessity for continued research into pain management and the development of new treatments. The authors go on to caution that the use of opioid medications should not be eliminated entirely. There are select patients for whom opioid pain management works well, they said, given the limited effectiveness of analgesics like acetaminophen and NSAIDs for lower-back pain. Together with nondrug approaches like cognitive behavioral therapy, mindfulness or meditation, and yoga, opioids still have a place in the physician's armament.

Dr. Scott Kinlay Dr. Scott Kinlay

"Claudication: pay for structured exercise or go take a hike," Neal N. Sawlani, M.D., M.P.H, and Scott Kinlay, M.B.B.S., Ph.D., JACC: Cardiovascular Interventions, Vol. 10, No. 7, 2017.

Claudication quite literally means "a pain in the leg" that happens during exercise when blood flow is obstructed to a lower limb. Often, it can be a symptom of peripheral artery disease (PAD), said Dr. Neal Sawlani, a cardiologist and researcher with the VA Boston Healthcare System. Together with his colleague Dr. Scott Kinlay, a VA investigator in the cardiology division at the West Roxbury Campus, Sawlani advised patients to "take a hike" when it comes to their leg pain, in an editorial published in the July issue of JACC.

He is actually being quite serious: When compared to endovascular surgery, structured exercise is an effective treatment for PAD, with equivalent patient outcomes. Sawlani cited a meta-analysis that compared the benefits of surgical intervention to structured exercise. When compared to the latter, surgery improved the ratio of blood pressure between the lower legs and upper arms, he said, but did not improve walking impairment or the need for repeat surgery. However, structured exercise is rarely used in clinical practice because it is not covered by health insurance and many patients find it difficult to attend three classes a week. In lieu of a formal exercise program, Sawlani suggests a structured home-based exercise program could be used as an initial or adjunct therapy for PAD.

Dr. Stefan Kertesz Dr. Stefan Kertesz

"Will strict limits on opioid prescription duration prevent addiction?" Mallika L. Mundkur, M.D., MPH, Adam J. Gordon, M.D., M.P.H., and Stefan G. Kertesz, M.D., M.Sc., Substance Abuse, June 2017.

In 2016, the Centers for Disease Control and Prevention published the "CDC Guideline for Prescribing Opioids for Chronic Pain," in an attempt to address the growing problem of opioid dependence and addiction in the U.S. The guideline recommended that opioids prescribed for acute pain should be given for no more than seven days. In an editorial published in Substance Abuse, Dr. Stefan Kertesz, a primary care physician at the Birmingham VA Medical Center in Alabama, and his co-authors pointed out that an across-the-board restriction of opioid duration could harm patients with acute or chronic pain, and that available research data do not show such initiatives would prevent addiction.

In order to better define the correlation between initial opioid prescription and long-term use, Kertesz and his colleagues recommended assessing several factors. They said it is necessary to identify physician prescribing intent (short- vs. long-term) and factors that influence prescribing, like patient diagnosis and mental and/or physical comorbidities. They further caution that some regulatory efforts focused on prescription control have stigmatized pain patients while neglecting rising harm from heroin and fentanyl addiction.

* Listen as Erica Sprey of VA Research Communications speaks with Dr. Stefan Kertesz about the movement to severely limit the number and duration of opioid prescriptions to address addiction. (Transcript)

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