Pauline Anderson

March 30, 2017

ORLANDO — The Opioid Safety Initiative (OSI) launched by the US Department of Veterans Affairs (VA) in 2013 has reduced reliance on opioids among veterans across the country and expanded access to nonopioid therapies.

New research reveals that the initiative led to a 31% reduction in the number of veterans prescribed opioids between mid-2012 and the end of 2016.

Friedhelm Sandbrink, MD, a neurologist at the Washington DC VA Medical Center, reported on the success of the OSI during the American Academy of Pain Medicine (AAPM) 2017 Annual Meeting.

The initiative includes education of providers as well as expanded access to nonpharmacologic treatments, particularly behavior options and complementary modalities.

"It makes the totality of opioid use visible within the VA, and it provides feedback to VA leaders and stakeholders in regard to key parameters of opioid prescribing system-wide," Dr Sandbrink told meeting delegates.

As well, the initiative provides opportunities for counseling, education and support of providers, and opioid risk mitigation strategies to support veterans prescribed these medications.

Total Reduction

The total number of veterans prescribed opioids decreased from 679,376 in July 2012 to 471,340 in December 2016 — a reduction of 31%.

In 2012, the number of veterans receiving opioid medications varied widely across the 146 VA medical facilities: from as high as greater than 25% to as low as 5%. Since then, "each and every medical center has reduced opioid prescribing," said Dr Sandbrink.

The decrease has been even greater — 36% — for the number of patients receiving long-term opioid therapy (from 428,329 in 2012 to 281,029 in 2016).

Several checks and balances have been introduced for patients receiving long-term opioid therapy, including informed consent and mandatory drug screens at least annually, said Dr Sandbrink.

And in October of 2016, a policy was implemented that requires prescription drug monitoring program (checks for all patients receiving a prescription for more than 5 days — or for refills — of a controlled substance.

Taking opioids together with benzodiazepines is a "well-established" risk factor for opioid-related death, Dr Sandbrink told his audience. The OSI led to a 56% reduction in prescribing this combination of drugs, he said.

As for prescriptions of high-dose opioid (more than 100 mg of morphine equivalent a day) within the VA system, Dr Sandbrink reported that "the number has gradually come down."

The VA is committed to educating patients, their caregivers, and families about risks of opioid overdose, he said. "We have dispensed over 60,000 naloxone kits so far."

The OSI provides a number of educational initiatives for clinicians. One of these targets opioid prescriber "outliers," said Dr Sandbrink. In addition, the VA, together with the Department of Defense, recently issued a new clinical practice guideline for opioid therapy.

In addressing opioid tapering, Dr Sandbrink said this should be individualized. "Every veteran requires individualized biopsychosocial assessment to optimize his or her pain care. A sudden reduction of opioids should be avoided; this is not a race to the bottom."

A sudden reduction of opioids should be avoided; this is not a race to the bottom. Dr Friedhelm Sandbrink

Another important element of the initiative is the close collaboration with mental health providers. "Many of our veterans have comorbid health conditions, and access to addiction medicine has to be available," said Dr Sandbrink.

Feeling "Abandoned"?

The presentation was followed by a lively question-and-answer session. One delegate asked whether there's evidence that veterans are seeking treatment elsewhere.

"A limitation of the Opioid Safety Initiative is that we only know about opioid prescribing within the VA system," said Dr Sandbrink.

The same delegate wondered whether the functional status of veterans has been sacrificed in order to reduce their opioid intake. Some veterans, he said, feel "abandoned" by the opioid safety program.

"There are several ongoing efforts to implement functional assessments," including use of pain severity scores, said Dr Sandbrink. "Certain parts of the VA have started to use those measures and we are discussing how to roll that out."

He added that no evidence suggests that the reducing opioid dosages has worsened pain care. And he noted that the initiative includes expanded access to nonopioid, nonpharmacologic therapies.

Asked for tapering tips, Dr Sandbrink stressed the need for gradual weaning and for assessment of opioid use disorder, as this may manifest during tapering.

Responding to a query about the effect of the initiative on overdoses among veterans, Dr Sandbrink said he and his colleagues are collecting data to determine whether implementation of the OSI "truly" reduces the risk for opioid overdose deaths.

Dr Sandbrink has disclosed no relevant financial relationships.

American Academy of Pain Medicine (AAPM) 2017 Annual Meeting. Poster 206. Presented March 17, 2017.

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