Reducing Long-term Opioid Use in the Veterans Health
Taeko Minegishi, MS
and Austin Frakt, PhD
VA Boston Healthcare System, Boston, MA, USA;
Boston University School of Public Health, Boston, MA, USA;
Bouvé College of Health Sciences,
Northeastern University, Boston, MA, USA;
Harvard T.H. Chan School of Public Health, Boston, MA, USA.
J Gen Intern Med 33(6):781–2
n 2015, 25% of US adults had at least one opioid prescrip-
tion. In the same year, over 33,000 people died of opioids
and approximately 40% were attributed to opioid prescrip-
contributing to what the Centers for Disease Control
and Prevention (CDC) termed an Bepidemic.^ Long-term
opioid use is particularly problematic, associated with much
higher rates of misuse and overdose than short-term use.
we reconsider the appropriate role of opioids in medical care,
experts have called for an effort to minimize the initiation of
long-term use and to taper long-term patients off opioids,
The opioid crisis is also evident at the Veterans Health
Administration (VHA). Fifty percent of chronic non-cancer
pain patients at the VHA received at least one opioid prescrip-
tion each year between 2009 and 2011.
Compared to the
general US population, VHA patients had nearly twice the
rate of fatal accidental poisoning and opioid use disorder is
seven times higher among VHA patients compared to private
Greater risk of opioid use within the VHA than
in the broader health system can be explained by the fact that
VHA patients are more likely to suffer from chronic pain (50%
do so) and more of its patients have psychiatric comorbidities.
Among US veterans of Iraq and Afghanistan, mental health
diagnoses, especially post-traumatic stress disorder, were as-
sociated with an increased risk of receiving opioids for pain,
high-risk opioid use, and adverse clinical outcomes.
There is some encouraging news that suggests we may be
turning the tide on overuse of prescription opioids. Both nation-
ally and in the VHA, since 2012, opioid prescribing has de-
creased. In 2015, it was down 13% nationally, and in 2016, it
was down 25% in the VHA, both relative to 2012 levels.
Nevertheless, the number of opioid prescriptions remains high
by historical standards. Three times more opioids were pre-
scribed in 2015 than in 1999. Nationally, the recent reduction
in prescribing is attributed to lower rates of short-term use.
Long-term use remains high and a significant concern.
This is where the VHA’s experience offers considerable
hope. Based on a cohort of patients with any prescriptions
(about five million patients per year), the study by
Hadlandsmyth et al.
shows that the VHA’s reduction in
opioid prescribing has been led by lower rates of long-term
opioid use. The investigators classified the duration of opioid
use into four categories: no use, short-term use (single opioid
prescription or two prescriptions separated by > 90 days),
long-term use (> 90 days), and intermediate-term use (any-
thing else). Between 2010 and 2016, reduced long-term use
among VHA patients accounted for 83% of the downturn in
Consistent with national trends, Hadlandsmyth et al.
that the prevalence of overall opioid prescribing declined
between 2010 and 2016, from 21 to 16%. Short-term prescrib-
ing fell only 1.6%, but long- and intermediate-term prescribing
fell 25 and 32%, respectively. More than 90% of the reduction
in the VHA long-term opioid use can be attributed to the
reduction in the number of new long-term users, not discon-
tinuation of existing long-term users.
To what can we attribute the VHA’s apparent greater success
in reduced long-term opioid use, relative to the national trend?
First, VHA clinicians may be better equipped with resources
that discourage them from initiating long-term opioid therapy.
The joint Department of Veterans Affairs/Department of De-
fense Clinical Practice Guideline for Management of Opioid
Therapy for Chronic Pain recommends against initiating long-
term opioid therapy. And, in 2009, VHA leadership issued
directives that expanded access to complementary treatments
and multimodal therapy for chronic pain.
Second, leveraging the VHA’s data capabilities, the VHA
Opioid Safety Initiative (OSI) included an effort to promote
safer opioid-related prescribing. The Initiative tracks urine
drug screens, incorporates state prescription drug monitoring
databases, and aims to reduce high-dose and concurrent ben-
zodiazepine prescribing within the VHA.
Third, the VHA provides academic detailing—a service for
clinicians by clinical pharmacy specialists that provides indi-
vidualized, face-to-face outreach to encourage evidence-based
decision-making to improve veterans’ health.
VHA academic detailing may promote the use of an opioid
taper decision tool and of follow-up and support during opioid
Published online February 15, 2018
© Society of General Internal Medicine (outside the USA) 2018