A new study in the Journal of General Internal Medicine, published by Springer, shows that opioid prescribing has dropped after a peak in 2012. Lead author Katherine Hadlandsmyth of the Iowa City VA Healthcare System and the University of Iowa in the US further noted that the decline was mostly due to decreases in long-term opioid prescribing, which carries much greater risk for harmful side effects, addiction and overdose, relative to short-term prescribing. In contrast, studies of general US health care outside the VHA have shown decreases in short-term opioid use, but potential increases in long-term use.
Hadlandsmyth and her team analyzed VHA prescription data from 2010 to 2016, which included more than four million veterans per year. In 2010, opioids were prescribed at least once to 20.8 percent (962,193 out of around 4.63 million) of them. By 2016, this figure dropped to 16.1 percent (803,888 of 4.99 million) of veterans who received outpatient prescriptions for opioid products such as hydrocodone, oxycodone and fentanyl.
After describing overall opioid prescribing, more detailed examination of the data focused on long-term opioid use, which accounted for about 90 percent of VHA opioid prescriptions during the study period. This analysis revealed a decrease in the percentage of veterans who received long-term opioid treatment in the VHA system from 9.5 percent in 2012, to 6.2 percent in 2016. According to Hadlandsmyth, this was not because many existing long-term users stopped taking opioids, but principally because fewer veterans receiving new opioid prescriptions went on to become long-term opioid users. The likelihood of a veteran becoming a new long-term opioid user decreased overall from 2.8 percent in 2011 to 1.1 percent in 2016.
Hadlandsmyth argues that the improved prescribing patterns might be the result of recent initiatives by the VHA emphasizing opioid safety and non-opioid alternatives for chronic pain treatment. Since 2010, VHA has provided clinical practice guidelines to medical practitioners about how best to use opioids to manage chronic pain, and how to select and monitor patients. These guidelines include suggestions on how to wean patients off opioid medications if treatment goals are not reached.
The VHA now also considers complementary treatments and multimodal therapy options for pain management, including behavioral, chiropractic and stepped care. In addition, the VA Opioid Safety Initiative implemented in 2013 sets out specific clinical safety targets aimed at reducing high-dose opioid use and concurrent benzodiazepine prescription, as well as the monitoring of patients via urine drug screens and inspection of state prescription drug monitoring databases.
"Future work to understand precisely which initiatives have most positively impacted opioid prescribing would be necessary to maintain effective approaches within VHA," adds Hadlandsmyth, who further believes that other healthcare systems might learn from the VHA example.
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Katherine Hadlandsmyth et al, Decline in Prescription Opioids Attributable to Decreases in Long-Term Use: A Retrospective Study in the Veterans Health Administration 2010–2016, Journal of General Internal Medicine (2018). DOI: 10.1007/s11606-017-4283-8