Decline in Prescription Opioids Attributable
to Decreases in Long-Term Use: A Retrospective Study
in the Veterans Health Administration 2010–2016
Katherine Hadlandsmyth, PhD
, Hilary Mosher, MD
, Mark W. Vander Weg, PhD
Brian C. Lund, PharmD
Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Healthcare System, Iowa City, IA, USA;
Department of Anesthesia, Carver College of Medicine, University of Iowa, Iowa City, IA, USA;
Department of Internal Medicine, Carver College
of Medicine, University of Iowa, Iowa City, IA, USA.
BACKGROUND: Improved understanding of temporal
trends in short- and long-term opioid prescribing may
inform efforts to curb the opioid epidemic.
OBJECTIVE: To characterize the prevalence of short- and
long-term opioid prescribing in the Veterans Health Ad-
ministration (VHA) from 2010 to 2016.
DESIGN: Observational cohort study using VHA
PARTICIPANTS: All patients receiving at least one outpa-
tient prescription through the VHA during calendar years
2010 through 2016.
MAIN MEASURES: Prevalence of opioid use from 2010
through 2016, stratified by short-term, intermediate-
term, and long-term use. Temporal trends in discontinu-
ation among existing long-term users and initiation of
new long-term use and the net impact on rates of long-
term opioid use. Relative likelihood of transitioning to
long-term opioid use contrasted with use patterns in the
KEY RESULTS: The prevalence of opioid prescribing was
20.8% in 2010, peaked at 21.2% in 2012, and declined
annually to 16.1% in 2016. Between 2010 and 2016,
reductions in long-term opioid prescribing accounted for
83% of the overall decline in opioid prescription fills. Com-
paring data from 2010–2011 to data from 2015–2016,
declining rates in new long-term use accounted for more
than 90% of the decreasing prevalence of long-term opioid
use in the VHA, whereas increases in cessation among
existing long-term users accounted for less than 10%. The
relative risk of transitioning to long-term use during 2016
was 6.5 (95% CI: 6.4, 6.7) among short-term users and
35.5 (95% CI: 34.8, 36.3) among intermediate users, rel-
ative to patients with no opioid prescriptions filled during
CONCLUSIONS: Opioid prescribing trends followed simi-
lar trajectories in VHA and non-VHA settings, peaking
around 2012 and subsequently declining. However,
changes in long-term opioid prescribing accounted for
most of the decline in the VHA. Recent VA opioid initiatives
may be preventing patients from initiating long-term use.
This may offer valuable lessons generalizable to other
KEY WORDS: opioid; veteran; prevalence.
J Gen Intern Med 33(6):818–24
Rapid and widespread escalation in long-term opioid prescrib-
ing over recent decades have revealed a spectrum of harms
including opioid use disorder, transition to heroin use, bowel
dysfunction, endocrine dysfunction, excess sedation, vehicu-
lar accidents, respiratory depression, and fatal overdoses.
Growing awareness has led prescribers, policymakers, and the
lay community to enact numerous efforts to Bturn the tide^ on
the opioid epidemic, including prescription drug monitoring
the 2016 Centers for Disease Control and
Prevention (CDC) guidelines on opioids in chronic pain man-
the Comprehensive Addiction and Recovery Act,
and an array of local awareness campaigns.
A recent study using data from nearly 90% of US pharmacies
reported a key reversal in per capita opioid prescribing, shifting
to a downward trend in 2012.
Despite this encouraging en-
dorsement of efforts to curtail use and availability, opioid
prescribing remained approximately three times as high in
2015 as in 1999. Moreover, decreases were limited to opioid
prescriptions of <30 days’ supply, whereas prescriptions for
≥30 days’ supply continued increasing through 2015. In com-
posite, the average days’ supply per prescription rose from 13.3
in 2006 to 17.7 in 2015. These patterns suggest that recent
decreases in opioid prescribing were attributable to decreases in
incident prescribing, largely driven by treatment of acute pain.
In contrast, expansion in prescriptions of ≥30 days’ supply
suggests that long-term opioid use, likely for chronic pain,
has persisted and perhaps even increased in recent years.
Secular trends in opioid prescribing have also impacted the
Veteran Health Administration (VHA), the largest nationally
integrated health system in the US. From 2004 to 2012, the
prevalence of opioid prescribing nearly doubled.
time, VHA has employed several strategies to combat the
Received August 30, 2017
Revised November 16, 2017
Accepted December 14, 2017
Published online January 29, 2018
© Society of General Internal Medicine (outside the USA) 2018