7th Annual BU‐CTSI SymposiumAddition Medicine 2018

VA’s Response to the Opioid Epidemic:Translational Science in Action

John A. Renner, Jr., MDProfessor of Psychiatry, Boston University School of MedicineAssociate Chief of Psychiatry, VA  Boston Healthcare System

Thanks to A. Burgo‐Black, E. Oliva, F. Sandbrink, J. Himstreet, K. Drexler VACO

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VHA is a Major Contributor to the Nation’s Healthcare

Provides medical care to > 6 million veterans, 9 million enrolled in VHA,22 million US Veterans

Largest direct care provider for 

homeless persons in the country

One of the largest and most productive 

research organizations in the country

Serves as the largest single provider of health professional training in the world

Healthcare

Disaster Relief

HomelessResearch

Healthcare Workforce

Principal Federal asset for medical assistance in large‐scale disasters

Scope of Substance Use Among Veterans

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Veterans have similar or lower rates of substance use and SUD than matched non-Veterans (SAMHSA, 2016)

Veterans Non‐Veterans

Alcohol use disorder 6.3% 6.8%

Illicit drug use disorders 1.5% 1.7%

Illicit drug use 8.4%* 10.5%*

Non‐medical use of pain relievers 2.4%* 3.0%*

*Significant at p<0.01     

Veterans at age 18 - 25 years have higher rates of non-medical use of pain relievers-14.8% vs 12.9%

Opioid Pain Medication‐Related Adverse EventsUS Opioid Analgesic Sales, Overdose Deaths, & OUD

2005: Veterans at Higher Risk of Overdose Deaths

https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm

Bohnert et al, Medical Care 2011

SUD and OUD in VHA 

Prevalence (in FY 2015): of the 6 Million Veterans in VHA

SUD: 10%, about 600,000 VeteransOUD: 1.1%, about 60,000; of these about 1/3 on MAT

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Gellad, Good CB, and Shulkin. JAMA Intern Med. 2017 May 1;177(5):611-612

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In Veterans, chronic pain is the most common physical concern

– Experienced by • more than 50% of older Veterans • 60% of Veterans from Middle East conflicts• Up to 75% of female Veterans 

– More than 2 million Veterans with ≥ one  pain diagnosis in VA (in 2012, about  1/3  were on opioids)

– Musculoskeletal pain most common (joint, back/neck)– Pain is among the most costly  disorders treated in VHA– In VHA, most patients with chronic pain (≥ 90%) are managed by Primary Care (Patient Aligned Care Teams)

The Pain Challenge in VHA

TIMELINE OF VA INITIATIVES TO IMPROVE OPIOID SAFETY

Gellad Good & Shulkin- JAMA 2017

2017Academic Detailing OUD Campaign        PDSI Phase 3      VA‐DoD CPG Opioid Therapy for Chronic Pain & CPG Low Back Pain

2016VA‐DoD CPG on Management of Substance Use Disorders Comprehensive Addiction and Recovery Act (CARA)

2014Targeted interventions for opioid reduction and opioid overdose education and naloxone distribution (OEND)

2013Launched the Opioid Safety Initiative (OSI) and Psychotropic Drug Safety Initiatives (PDSI)

2011Created standardized metrics for pain management therapies to pilot opioid safety initiative in 2012

2010VA‐DoD Clinical Practice Guideline (CPG) Opioid Therapy in Chronic Pain (FIRST)

2008                                                                                        2009Policy required access to medication for opioid use disorder VA Pain Directive ‐ established Stepped Care Model for Pain

2007Launched the Buprenorphine in VA (BIV) Initiative  Opioid High Risk Medication Initiative

VA/DoD Clinical Practice Guidelines

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https://www.healthquality.va.gov/index.asp

VA Opioid Data Description and Example

https://www.data.va.gov/story/department-veterans-affairs-opioid-prescribing-data,

S.T.O.P. P.A.I.N. Highlights 8 VA Best Practices

S – Stepped Care Model for Opioid Use Disorder & Pain T – Treatment alternatives/Complementary care O – Ongoing monitoring of usage P – Practice Guidelines P – Prescription monitoring A – Academic Detailing I – Informed Consent N – Naloxone distribution

https://www.va.gov/opa/pressrel/pressrelease.cfm?id=2934

Opioid Monitoring/Risk Mitigation ToolsSystems support for monitoring and improving safe opioid prescribing and tapering

OSI Dashboard – PBM (2012) • By VISN/Facility/Provider

• Composite score for each facility, trend over time

• Separate specialty provider report

Opioid Therapy Risk Report – OTRR from Primary Care • in Primary Care Almanac in CPRS , allows PCPs to review their panel in real‐time ; multiple 

parameters tracked; updated every 24 hours

• Specialty care can access via Dashboard

Stratification Tool for Opioid Risk Monitoring ‐ STORM• Examines risk factors associated with opioid‐related negative outcomes, and states the probability 

of adverse event within next 3 years (suicide and overdose, +/‐ serious falls)

Medication Take‐Back Initiative • VA offers free medication take back services to Veterans though mail‐back envelopes and on‐site 

receptacles compliant with Drug Enforcement Administration (DEA) regulations

• As of September 30, 2017, Veterans have returned over 107,000 pounds (53 tons or 18 elephants) of unwanted/unneeded medication that have been destroyed in an environmentally responsible manner 

1. Opioid use 2. Benzo co‐prescribing3. UDS (last year)4. High dose opioid (>100)

Veterans Prescribed Opioids Over Time

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Opioid + Benzo: 70% Opioid Long-term: 47% Opioid High Dose: 60%

Veterans with opioid prescription (excludes tramadol): 41% Veterans with opioid dispensed in reporting quarter as percentage of all Veterans with pharmacy activity

17.2%

9.7%

• For patients on opioids and when considering opioid therapy• Leverages VA national data and predictive modeling to identify patients at‐risk for overdose‐/suicide‐related adverse 

events (including death) in the next year• Provides patient‐centered opioid risk mitigation strategies• Risk score is designed to support treatment planning. The goal should be to design a treatment plan that addresses risk 

factors and is appropriate for the patient’s risk level.Key features: 

• Lists risk factors that place patients at‐risk (e.g., co‐Rx benzos, previous adverse events, mental health and medical diagnoses, MEDD)

• Displays risk mitigation strategies, including non‐pharmacological treatment options, that have been employed and/or could be considered 

• Displays upcoming appointments and current treatment providers to facilitate care coordination• Updated nightly

Opioid Risk Assessment and Mitigation:Stratification Tool for Opioid Risk Monitoring – STORM

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# PDMP Queries# Veterans Dispensed a Controlled Substance Prescription

National: State Prescription Drug Monitoring Program (PDMP) Queries and the Number of Veterans Dispensed a Controlled Substance Prescription*

*Queries are underestimated because documentation was not standardized system-wide prior to publication of VHA Directive 1306

Querying State Prescription Drug Monitoring Programs (PDMP) VHA Directive 1306 Published October 19, 2016

NALOXONE PRESCRIPTION FILLS BY STATE (3/12/18; TOTAL 141,194 RX FILLS)

Scope of Substance Use Among Veterans

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Veterans overall have similar or lower rates of substance use and substance use disorders than matched non-Veterans (SAMHSA, 2016)

Veterans Non‐Veterans

Alcohol use disorder 6.3% 6.8%

Illicit drug use disorders 1.5% 1.7%

Illicit drug use 8.4%* 10.5%*

Non‐medical use of pain relievers

2.4%* 3.0%*

*Significant at p<0.01       **Significant at p,0.05

In FY2015, of the 6 million Veterans who utilized healthcare services, about 64,000 or 1.1% were treated for opioid use disorder (OUD).

Veterans age 18 – 25 have higher rates of non-medical use of pain relievers- 14.8% vs 12.9%**

Veterans’ rate of drug overdose is almost twice that of non-Veterans (Bohnert, 2011)

MEDICATION FOR OPIOID USE DISORDER (OUD)

OPIOID USE DISORDER (OUD) TREATMENT

• Mental Health & Suicide Prevention:• Develops policy/guidelines & facilitates

evidence-based OUD services

• Key Accomplishments:• 2007- Buprenorphine in VA Initiative• 2008- VHA Handbook 1160.01 requires

access to opioid agonist therapy (OAT) for those with OUD

• 2009- VHA Handbook 1160.04 requires prescriber in SUD specialty care teams

• 2013- Psychotropic Drug Safety Initiative (PDSI)

• 2017- Academic Detailing OUD campaign & PDSI Phase 3

Starting in FY14, Extended-Release Naltrexone was counted as a medication assisted treatment for OUD

# of Veterans with OUD receiving MAT

Academic Detailing Service Interventions

Training: Standardized training to assist AD in conducting their outreach visits to target the 

prescribing habits of providers 

Educational Materials: Create educational materials for both providers and patients

Data Tools: Created suite of data tools to assist in identifying high risk patients 

Workload Recording: Utilized software to ensure workload was tracked to document topics covered, time, # of providers/visits, etc.

Evaluation: Evaluation of workload and outcomes 

Questions

john.renner@va.gov