VA Health Care:

Progress Made Towards Improving Opioid Safety, but Further Efforts to Assess Progress and Reduce Risk Are Needed

GAO-18-380: Published: May 29, 2018. Publicly Released: May 29, 2018.

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Contact:

A. Nicole Clowers
(202) 512-7114
clowersa@gao.gov

 

Office of Public Affairs
(202) 512-4800
youngc1@gao.gov

The VA has been working to address opioid safety for veterans and has made progress in reducing opioid prescriptions. For example, VA has started a program to educate providers on best practices related to pain management and the optimal use of opioids.

However, we found that VA has not fully met all of its opioid safety goals. Its health care providers also are not consistently adhering to evidence-based opioid risk mitigation strategies (such as annual urine drug screenings).

We made a number of recommendations to help the VA improve opioid safety.

 

A photo of the Department of Veterans Affairs headquarters building.

A photo of the Department of Veterans Affairs headquarters building.

Additional Materials:

Contact:

A. Nicole Clowers
(202) 512-7114
clowersa@gao.gov

 

Office of Public Affairs
(202) 512-4800
youngc1@gao.gov

What GAO Found

The Veterans Health Administration (VHA) has made progress improving opioid safety through its Opioid Safety Initiative (OSI). Launched in 2013, the OSI aims to help ensure that veterans are prescribed opioids in a safe and effective manner. Since the OSI began, VHA has seen reductions in opioid prescribing rates. For example, from the fourth quarter of fiscal year 2013 to the first quarter of fiscal year 2018, the percentage of patients dispensed an opioid decreased from about 17 percent to about 10 percent, or by about 267,000 veterans. Also, available evidence suggests VHA has accomplished six of nine OSI goals established in 2014; however, it is unclear whether the remaining three goals have been fully met. For example, in the case of OSI goal four (establishing safe and effective regional tapering programs for patients on opioids and benzodiazepines), GAO found that VHA lacked documentation that its regional networks established these programs. VHA also did not establish measures of safety or effectiveness under this goal. These limitations prevent VHA from fully evaluating progress and accurately determining the extent to which its efforts to help ensure safe and effective prescribing of opioids have been successful.

In a review of a nongeneralizable sample of 103 veterans' medical records at five selected VHA medical facilities, GAO found that VHA providers did not always adhere to key opioid risk mitigation strategies, which are required by VHA policy or relevant to OSI goals. For example, among 53 veterans who were prescribed long-term opioid therapy (defined as a 90-day supply in the last 6 months), GAO found that

40 veterans did not have their names queried in a state-run prescription drug monitoring program database. The databases are used to identify patients who are receiving multiple prescriptions that may place them at greater risk for misusing opioids or overdosing;

21 veterans did not have a urine drug screening within the year prior to having their prescription filled. The screenings are used to determine whether veterans are taking their opioid medications as prescribed; and

12 veterans did not provide written informed consent. Informed consent is a formal acknowledgement that the veteran has been educated on the risks and benefits of opioid use prior to initiating long-term opioid therapy.

GAO found several factors that may have contributed to inconsistent adherence to key opioid risk mitigation strategies at the selected VHA facilities. For example, four of the five selected facilities did not have a pain champion (a primary care position required by VHA that can help providers adhere to opioid risk mitigation strategies), and not all facilities had access to academic detailing, a program in which trained clinical pharmacists work one-on-one with providers to better inform them about evidence-based care related to the appropriate treatment of relevant medical conditions. In addition, three of the five facilities did not consistently review veterans' medical records to ensure provider adherence to these strategies. To the extent that these factors affect all VHA facilities, VHA will continue to face challenges ensuring that its providers prescribe opioids in a safe and effective manner.

Why GAO Did This Study

The Comprehensive Addiction and Recovery Act of 2016 and Senate Report 114-57 included provisions for GAO to report on VHA's OSI and the opioid prescribing practices of its health care providers.

This report examines, among other issues, (1) the extent to which VHA has met OSI goals established in 2014 and (2) the extent to which VHA providers adhere to key opioid risk mitigation strategies. To do this work, GAO reviewed data and documents related to OSI efforts and goals and interviewed VHA officials. In addition, GAO reviewed a random, nongeneralizable selection of medical records for 103 veterans who were prescribed opioids at five selected VHA medical facilities from March 2016 through March 2017. GAO selected the facilities to obtain diversity in geography and rates of opioid prescribing. At the selected facilities, GAO reviewed facility data and documents related to opioid safety and interviewed officials.

What GAO Recommends

GAO is making five recommendations to VHA, including that it document actions and develop measurable outcomes related to its OSI goals, ensure that providers are adhering to opioid risk mitigation strategies, and ensure that all its regional networks have implemented academic detailing programs and that all VHA medical facilities have a designated primary care pain champion, as required. The Department of Veterans Affairs concurred with GAO's recommendations and described steps it will take to implement them.

For more information, contact A. Nicole Clowers at (202) 512-7114 or clowersa@gao.gov.

Recommendations for Executive Action

  1. Status: Open

    Comments: VA concurred with the recommendation. To fully implement this recommendation, VHA needs to provide information about the new documentation requirements described in the November 2019 update.

    Recommendation: The Undersecretary for Health should ensure that Central Office, Veterans Integrated Service Networks (VISN), and medical facilities document the actions they take towards achieving OSI goals. (Recommendation 1)

    Agency Affected: Department of Veterans Affairs

  2. Status: Open

    Comments: VA concurred with the recommendation. To fully implement this recommendation, VHA needs to provide information about specific actions, described in the November 2019 update, taken to address the recommendation including documentation showing the actions taken to review the OSI goals and documentation of new OSI goals, metrics, and timelines.

    Recommendation: The Undersecretary for Health should ensure that any OSI goals that have not been met have clearly defined, measurable outcomes, including milestones or numerical targets, as appropriate, and timeframes. (Recommendation 2)

    Agency Affected: Department of Veterans Affairs

  3. Status: Closed - Implemented

    Comments: GAO recommended that the Undersecretary for Health track the use of OTRR--or any subsequent opioid-safety tool, such as the Stratification Tool for Opioid Risk Mitigation, or STORM--by providers prior to initiating opioid therapy. VA concurred with this recommendation and in November 2019 reported taking actions to address it. Specifically, VHA issued Notice 2019-15, Conduct of Data-Based Case Reviews of Opioid-Exposed Patients with Risk Factors. Patients who are identified as being in the "very high-opioid prescription" risk category in STORM must receive a case review by an interdisciplinary opioid risk review team. VHA tracks these reviews using a specific note title in its electronic medical record. VHA data from June 2019 show that all facilities are conducting these reviews. These reviews will help VHA ensure that providers are following three key opioid risk mitigation strategies when prescribing an opioid medication to a veteran: conducting an annual urine drug screening, querying a PDMP, and obtaining written informed consent from the veteran.

    Recommendation: The Undersecretary for Health should track the use of the Opioid Therapy Risk Report (or any subsequent tool) by providers prior to initiating opioid therapy. (Recommendation 3)

    Agency Affected: Department of Veterans Affairs

  4. Status: Closed - Implemented

    Priority recommendation

    Comments: GAO recommended that the Undersecretary for Health ensure that all VISNs implement an academic detailing program that supports all medical facilities in the VISN and that all VHA medical facilities have a designated primary care pain champion. VA concurred with this recommendation and in June 2020 reported taking actions to address it. Specifically, VISN officials from all 18 VISNs attested to the Undersecretary for Health that each VISN had fully implemented an academic detailing program. VHA academic detailing workload data for the third quarter of fiscal year 2019 show that all medical centers across each VISN recorded at least one visit from an academic detailer. VISN officials from all 18 VISNs also attested that each facility had designated a primary care pain champion. The implementation of an academic detailing program in each VISN and designation of a primary care pain champion at each VAMC will help VA improve adherence to key opioid risk mitigation strategies.

    Recommendation: The Undersecretary for Health should ensure that all VISNs have implemented an academic detailing program that supports all medical facilities in the VISN and that all VHA medical facilities have a designated primary care pain champion as required. (Recommendation 4)

    Agency Affected: Department of Veterans Affairs

  5. Status: Closed - Implemented

    Comments: GAO recommended that the Undersecretary for Health require VHA medical facilities to take steps to ensure provider adherence to opioid risk mitigation strategies, including querying PDMPs, obtaining written informed consent, and conducting urine drug screening. VA concurred with this recommendation and in November 2019 reported taking actions to address it. Specifically, VHA implemented a national Clinical Reminder Order Check (CROC) to alert the prescriber at the time of prescribing an opioid or a benzodiazepine that the patient is already receiving an opioid or benzodiazepine. Similar CROCs have been developed to alert providers about pending opioid risk mitigation strategies, such as a urine drug screening, at the time of opioid prescribing. VHA updated informed consent information for patients and providers to include the risks and benefits of long-term opioids and provide information about alternatives to opioid therapy. VHA created a pre-clinic planning tool in VHA's electronic medical record to provide risk mitigation information for primary care providers. This tool includes the date of the last PDMP check, the date of the last urine drug screening, the date informed consent was signed, and the date naloxone was prescribed.

    Recommendation: The Undersecretary for Health should require VHA medical facilities to take steps to ensure provider adherence to opioid risk mitigation strategies, including querying prescription drug monitoring programs, obtaining written informed consent, and conducting urine drug screening. For example, these steps could include creating alerts in the electronic medical record system to remind primary care teams when these actions should be completed or strengthening facility monitoring of providers. (Recommendation 5)

    Agency Affected: Department of Veterans Affairs

 

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