The Veterans Health Administration (VHA) takes pride in being a learning healthcare system. Our recent paper exemplifies how the VHA translates that broad principle into action. Building on a decade of opioid safety related efforts, the paper—which found increased risk associated with stopping opioid treatment by length of opioid treatment—reflects VHA’s commitment to identifying factors associated with outcomes for patients who have been prescribed opioids. [1] More important, however, is how VHA uses this information to improve care for patients. 

The integrated nature of VHA’s healthcare system allows it to move quickly on new evidence and guideline recommendations to improve care. For instance, after a number of studies identified risks associated with high dose opioid prescribing, VHA launched an opioid safety initiative in 2013 targeting high dose opioid prescribing. VHA’s opioid safety initiative focused not only on opioid prescribing factors (i.e., high dose, co-prescribing with benzodiazepines), but also on risk mitigation (i.e., urine drug screening). These focus areas were based on internal evaluation. We had developed metrics to measure and promote adherence to the 2010 Department of Veterans Affairs/Department of Defense Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain. [2,3] Regarding suicide and overdose risk, we found facility sedative co-prescribing rates associated with higher risk and urine drug screening rates associated with lower risk [4,5].

VHA acted quickly to reshape care based on these findings and in parallel we disseminated findings more broadly through publication. When studies suggested benefits of overdose education and naloxone distribution, VHA supported a national overdose education and naloxone distribution programme [6]. Since the inception of VHA’s overdose education and naloxone distribution programme in 2014, over 200 000 veterans have received naloxone, which has resulted in more than 700 documented opioid overdose reversals. [7] 

Likewise, VHA moved quickly on these new findings of overdose/suicide risk associated with opioid cessation. After briefing VHA leaders, frontline facility leaders and clinical providers were educated through multiple communication channels. A medication use evaluation on opioid tapering was launched by VHA to further assess opioid cessation. In addition, clinical decision support systems have been updated to help identify and safely manage patients with recent opioid cessation.

While the finding that there were risks after opioids were stopped may be surprising, our prior work prepared us for the results. VHA developed and nationally deployed the Stratification Tool for Opioid Risk Mitigation (STORM) that uses predictive analytics to identify patients at risk for overdose or suicide and provides individualized recommendations for risk mitigation strategies. [8] As shown by STORM, opioid dose was a weak predictor of overdose or suicide outcomes when other clinical risk factors were taken into consideration (e.g. previous overdose, mental health and substance use disorder comorbidities, medical comorbidities, prescribing risk factors). This finding was consistent with other predictive models [9,10].

Based on these findings, VHA expanded the opioid safety initiative to consider risk factors from a whole patient perspective rather than focusing on the opioid prescription itself. VHA formed teams at all VA medical centres to review and coordinate the care of veterans with opioid therapy who are predicted to be at highest risk for overdose or suicides, embedding a randomized evaluation into the implementation. [11].

A key take-home message is that addressing the opioid crisis requires us to move beyond solely focusing on opioids. [1] Factors associated with increased risk when patients are prescribed opioids are also associated with risk when opioids are no longer part of the patient’s treatment plan (e.g. mental health disorders, medical complexity, other medications). Tools like STORM can help identify and stratify patients by risk. By using data iteratively to guide, evaluate, and redesign care, we can target services to improve patient safety and wellbeing. These efforts exemplify what it means to be a learning healthcare system.  

Elizabeth M Oliva,

Friedhelm Sandbrink,

Jodie A Trafton.

Competing interests: Please see linked research paper.

References

1. Gellad WF, Good CB, Shulkin DJ. Addressing the opioid epidemic in the United States: lessons from the Department of Veterans Affairs. JAMA Intern Med. 2017;177:611-2. doi:10.1001/jamainternmed.2017.0147
2. Midboe AM, Lewis ET, Paik MC, Gallagher RM, Rosenberg JM, Goodman F, Kerns RD, Becker WC, Trafton JA. Measurement of adherence to clinical practice guidelines for opioid therapy for chronic pain. Transl Behav Med. 2012;2(1):57–64. doi:10.1007/s13142-011-0104-5
3. Buscaglia AC, Paik MC, Lewis E, Trafton JA; VA Opioid Metric Development Team. Baseline Variation in Use of VA/DOD Clinical Practice Guideline Recommended Opioid Prescribing Practices Across VA Health Care Systems. Clin J Pain. 2015;31(9):803–812. doi:10.1097/AJP.0000000000000160
4. Brennan PL, Del Re AC, Henderson PT, Trafton JA. Healthcare system-wide implementation of opioid-safety guideline recommendations: the case of urine drug screening and opioid-patient suicide- and overdose-related events in the Veterans Health Administration. Transl Behav Med. 2016;6(4):605–612. doi:10.1007/s13142-016-0423-7
5. Im JJ, Shachter RD, Oliva EM, Henderson PT, Paik MC, Trafton JA, PROGRES Team. Association of Care Practices with Suicide Attempts in US Veterans Prescribed Opioid Medications for Chronic Pain Management. J Gen Intern Med. 2015;30(7):979–991. doi:10.1007/s11606-015-3220-y
6. Oliva EM, Christopher MLD, Wells D, Bounthavoung M, Harvey M, Himstreet J, Emmendorfer T, Valentino M, Franchi M, Goodman F, Trafton JA, Veterans Health Administrations Opioid Overdose Education and Naloxone Distribution National Support and Development Workgroup. Opioid overdose education and naloxone distribution: Development of the Veterans Health Administration’s national program. J Am Pharm Assoc (2003). 2017;57(2S):S168–S179.e4. doi:10.1016/j.japh.2017.01.022
7. Office of Public and Intergovernmental Affairs. VA equips 200,000 Veterans with lifesaving naloxone. New Release. November 5, 2019. https://www.va.gov/opa/pressrel/pressrelease.cfm?id=5349.
8. Oliva EM, Bowe T, Tavakoli S, Martins S, Lewis ET, Paik M, Wiechers I, Henderson P, Harvey M, Avoundijian T, Medhanie A, Trafton JA. Development and applications of the Veterans Health Administration’s Stratification Tool for Opioid Risk Mitigation (STORM) to improve opioid safety and prevent overdose and suicide. Psychol Serv. 2017;14(1):34–49. doi:10.1037/ser0000099
9. Zedler B, Xie L, Wang L, Joyce A, Vick C, Brigham J, Kariburyo F, Baser O, Murrelle L. Risk factors for serious prescription opioid-related toxicity or overdose among Veterans Health Administration patients. Pain Med. 2014;15:1911-29. doi:10.1111/pme.12480
10. Glanz JM, Narwaney KJ, Mueller SR, Gardner EM, Calcaterra SL, Xu S, Breslin K, Binswanger IA. Prediction Model for Two-Year Risk of Opioid Overdose Among Patients Prescribed Chronic Opioid Therapy. J Gen Intern Med. 2018 Oct;33(10):1646-1653. doi: 10.1007/s11606-017-4288-3.
11. Minegishi T, Frakt AB, Garrido MM, Gellad WF, Hausmann LRM, Lewis ET, Pizer SD, Trafton JA, Oliva EM. Randomized program evaluation of the Veterans Health Administration Stratification Tool for Opioid Risk Mitigation (STORM): A research and clinical operations partnership to examine effectiveness. Subst Abus. 2019;40(1):14–19. doi:10.1080/08897077.2018.1540376