Fewer Veterans Prescribed Risky Opioid Doses

A new digital tracking system is helping to decrease the over-prescription of opioids

By Kara Gavin
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After a national initiative took aim at high opioid doses and potentially dangerous drug combinations, the number of veterans receiving such prescriptions dropped, a new study finds.

Over a two-year period, high-dose opioid prescribing declined by 16 percent, and very-high-dose opioid prescribing dropped by 24 percent. The number of patients receiving both opioids and sedatives, which can be lethal when combined, dropped by 21 percent.

The study, published in the journal Pain, looks at the effect of the Opioid Safety Initiative, which the Veterans Health Administration rolled out in late 2013 to promote safer opioid prescribing. The study examines implementation of the OSI across all of the nation’s 141 VA hospitals.

Under the OSI, the VHA created a dashboard tool, using its national computerized medical record system, to allow local VA clinical leaders to systematically review opioid prescribing and give physicians feedback.

The research team compared VA opioid prescribing for OSI's first year and the year prior. The new research shows OSI greatly accelerated the downward trend, which came on the heels of other system attempts to combat risky opioid use, including guidelines for prescribing.

"As our nation as a whole is learning, it’s important to reduce risky opioid-related prescribing," says Lewei Allison Lin, M.D., the first author of the new study and an addiction fellow in the U-M Department of Psychiatry who trained in the VA system. "We hope that these findings, showing the VA OSI was associated with a reduction in risky prescribing, will encourage others to consider similar health care system interventions to address this complex issue."

Deaths and cases of substance use disorders linked to opioid painkillers have risen to epidemic levels nationally, with more than 14,000 deaths from prescription opioids in 2014 according to the Centers for Disease Control and Prevention, the most recent year for which data is available. Accidental overdoses among people taking opioids that interact with other drugs have also been on the rise.

Encouraging Findings With a Dose of Caution

Although there are many kinds of opioid painkillers, the potency of each one can be measured in morphine equivalents, or MEQs. The study focused on patients with prescriptions above particularly high daily thresholds: 100 MEQ and 200 MEQ.

The study found a decreasing trend in high-dosage opioid prescribing across VHA facilities nationwide, with 55,722 patients receiving daily opioid dosages above 100 MEQ in October 2012, which decreased to 46,780 in September 2014; the numbers for doses above 200 MEQ were 19,952 in October 2012 and 15,121 in September 2014. The OSI was associated with an additional decrease, compared to pre-OSI trends, of 331 patients per month receiving opioids above 100 MEQ and a decrease of 164 patients per month receiving opioids above 200 MEQ.

The OSI effort also focused on use of benzodiazepine sedatives, which can interact dangerously with opioids. The study found that 781 fewer patients each month received both an opioid and a benzodiazepine under the OSI.

But the new data show variation among VA hospitals in OSI’s impact. In a minority of hospitals, high-dose opioid prescribing actually went up during the study period.

Although the findings are encouraging, researchers caution that further efforts to drive down risky opioid prescribing will need to continue to take patients’ pain, mental health and addiction care needs, as well as physicians’ decision-making, into account.

To that point, senior author Mark Ilgen, Ph.D., says, "These results highlight the importance of addressing provider behaviors in our efforts to address the opioid epidemic, and the need for large health systems to develop and implement systematic approaches that are flexible enough to allow clinicians to make individual decisions while still reducing the overall prevalence of potentially risky prescribing." Ilgen is an associate professor of psychiatry at U-M and research investigator at the VA's Center for Clinical Management Research.

More About OSI

The OSI is based on an approach called “audit and feedback,” which has been used successfully in other efforts to improve health care quality and safety.

That the national VA system uses a single computerized electronic medical record system allowed it to create the dashboard approach. Each hospital’s OSI “champion” could see how opioids and related medications were being prescribed at their hospital, and who prescribed them. They could compare that information with national and regional data. 

Besides the dashboard, and the VA’s opioid prescribing guidelines introduced in 2010, the OSI also encouraged local hospital leaders to provide education to clinicians about pain care and opioid prescribing. Each OSI champion could decide how best to use the OSI data and tools to address opioid prescribing to ensure that tailored individual patient care remained the priority.

Once opioids and sedatives have been prescribed, changing the dose must be done gradually and carefully, especially when a patient has been accustomed to higher doses over a longer period of time.

Lin notes that further evaluation of OSI data will be needed to determine how dosages were reduced and to see the impact of newer components of the OSI program.

Researchers from the University of Michigan Medical School and Institute for Healthcare Policy and Innovation, the VA Ann Arbor Healthcare System and Yale University conducted the study, which the VA Quality Enhancement Research Initiative funded.