High-dose opioid use dropping in the VA, but opioids frequently discontinued involuntarily, studies find
Recent studies from the Veterans Health Administration looked at voluntary and involuntary opioid reduction; high-dose, long-term opioid therapy; and quality improvement efforts for opioid use disorder treatment.
Strategies to reduce opioid prescribing have not always considered patients' needs and pain severity, and quality improvement programs can increase treatment of opioid use disorder, according to recent articles from Veterans Health Administration (VHA) facilities.
Three studies published Nov. 3 by the Journal of General Internal Medicine addressed use of opioids and opioid use disorder treatment.
An analysis of a national sample of veterans on long-term opioid therapy found that many of them had their opioid doses reduced involuntarily, and that opioid dose reductions, whether involuntary or voluntary, were not associated with changes in pain severity. The prospective observational cohort study included 290 primary care patients treated with long-term opioid therapy in the VHA.
Past-year opioid reduction or discontinuation was reported by 63% of patients (184 of 290), about half involuntary (88 of 290) and half voluntary (96 of 290). There were no significant differences in pain severity at baseline by whether patients had involuntary opioid reduction (mean Pain, Enjoyment, General Activity [PEG] scale score, 7.08) , voluntary opioid reduction (mean PEG scale score, 6.73) or no opioid reduction (mean PEG scale score, 7.07). There were also no significant differences among the groups for change in PEG scale score from baseline to 18 months.
Another retrospective study found that high-dose, long-term opioid therapy (HLOT) prescriptions in the VHA decreased from 2014 to 2018. Researchers looked at data for more than 1.2 million outpatients with at least a one-day opioid prescription between fiscal years 2014 and 2018. They excluded patients receiving palliative care or diagnosed with metastatic cancer. A three-month moving average of 90 or more daily morphine milligram equivalent (MME) was defined as HLOT and a three-month average MME of zero counted as discontinuation.
Discontinuation among patients with HLOT increased from 6.3% in 2014 to 7.8% in 2018. Patients who discontinued HLOT were younger, less likely to be married, and more likely to have comorbid conditions related to substance use disorders than patients who continued to receive HLOT. Discontinuation rates among those with HLOT increased in more than half (64%) of the 129 medical centers.
A third study reported on a successful evidence-based quality improvement program to implement medicine for opioid use disorder and complementary and integrative health efforts such as acupuncture and meditation. Interviews before the launch of a quality improvement program at two VHA facilities uncovered facility-level and clinician-level barriers to prescribing buprenorphine, including strong primary care clinician resistance. Both facilities developed action plans that included educational meetings such as grand rounds and medication waiver trainings. After 15 months, both facilities increased their prescribing of opioid use disorder treatments to the 90th percentile or above among VHA medical centers nationally.
A separate commentary discussed four ways to expand access to medications for opioid use disorder: implement patient-centered medication delivery systems; fix medication delivery gaps; broaden the medication delivery system beyond traditional clinical settings to places of worship, street medicine programs, and syringe exchange programs; and expand medication options beyond buprenorphine and methadone.
Another commentary focused on changing how clinicians consider opioid prescribing from pill counts and long- or short-term prescribing to patient function and pain relief, because “nationally adopted quality metrics have convinced some patients with pain that their survival and functioning are no longer concerns for the systems in which they receive care.”
A third commentary summarized policy recommendations of VHA workgroups and highlighted issues related to telehealth, care coordination, and stepped care model implementation.
For more on prescribing medication for opioid use disorder in primary care, read coverage in the November/December ACP Internist, “‘Gold Standard’ Underused for Substance Misuse.”