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The American Journal of Managed Care November 2018
A Randomized, Pragmatic, Pharmacist-Led Intervention Reduced Opioids Following Orthopedic Surgery
David H. Smith, PhD, RPh; Jennifer L. Kuntz, PhD; Lynn L. DeBar, PhD, MPH; Jill Mesa; Xiuhai Yang, MS; Jennifer Schneider, MPH; Amanda Petrik, MS; Katherine Reese, PharmD; Lou Ann Thorsness, RPh; David Boardman, MD; and Eric S. Johnson, PhD
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Anupam B. Jena, MD, PhD; Jacquelyn W. Chou, MPP, MPL; Lara Yoon, MPH; Wade M. Aubry, MD; Jan Berger, MD, MJ; Wayne Burton, MD; A. Mark Fendrick, MD; Donna M. Fick, RN, PhD; David Franklin, BA; Rebecca Killion, MA; Darius N. Lakdawalla, PhD; Peter J. Neumann, ScD; Kavita Patel, MD, MSHS; John Yee, MD, MPH; Brian Sakurada, PharmD; and Kristina Yu-Isenberg, PhD, MPH, RPh
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Overdose Risk for Veterans Receiving Opioids From Multiple Sources
Guneet K. Jasuja, PhD; Omid Ameli, MD, MPH; Donald R. Miller, ScD; Thomas Land, PhD; Dana Bernson, MPH; Adam J. Rose, MD, MSc; Dan R. Berlowitz, MD, MPH; and David A. Smelson, PsyD
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Patricia R. Salber, MD, MBA; Christobel E. Selecky, MA; Dirk Soenksen, MS, MBA; and Thomas Wilson, PhD, DrPH
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Jinyoung Shin, MD, PhD; Hyeonyoung Ko, MD, MPH; Jeong Ah Kim, BS; Yun-Mi Song, MD, PhD; Jin Seok Ahn, MD, PhD; Seok Jin Nam, MD, PhD; and Jungkwon Lee, MD, PhD

Overdose Risk for Veterans Receiving Opioids From Multiple Sources

Guneet K. Jasuja, PhD; Omid Ameli, MD, MPH; Donald R. Miller, ScD; Thomas Land, PhD; Dana Bernson, MPH; Adam J. Rose, MD, MSc; Dan R. Berlowitz, MD, MPH; and David A. Smelson, PsyD
Among veterans in Massachusetts, receipt of opioids from multiple sources, with or without benzodiazepines, was associated with worse opioid-related outcomes.

Objectives: The aim of this study was to evaluate whether veterans in Massachusetts receiving opioids and/or benzodiazepines from both Veterans Health Administration (VHA) and non-VHA pharmacies are at higher risk of adverse events compared with those receiving opioids at VHA pharmacies only.

Study Design: A cohort study of veterans who filled a prescription for any Schedule II through V substance at a Massachusetts VHA pharmacy. Prescriptions were recorded in the Massachusetts Department of Public Health Chapter 55 data set.

Methods: The study sample included 16,866 veterans residing in Massachusetts, of whom 9238 (54.8%) received controlled substances from VHA pharmacies only and 7628 (45.2%) had filled prescriptions at both VHA and non-VHA pharmacies (“dual care users”) between October 1, 2013, and December 31, 2015. Our primary outcomes were nonfatal opioid overdose, fatal opioid overdose, and all-cause mortality.

Results: Compared with VHA-only users, more dual care users resided in rural areas (12.6% vs 10.6%), received high-dose opioid therapy (26.3% vs 7.3%), had concurrent prescriptions of opioids and benzodiazepines (34.8% vs 8.2%), and had opioid use disorder (6.8% vs 1.6%) (P <.0001 for all). In adjusted models, dual care users had higher odds of nonfatal opioid overdose (odds ratio [OR], 1.29; 95% CI, 0.98-1.71) and all-cause mortality (OR, 1.66; 95% CI, 1.43-1.93) compared with VHA-only users. Dual care use was not associated with fatal opioid overdoses.

Conclusions: Among veterans in Massachusetts, receipt of opioids from multiple sources was associated with worse outcomes, specifically nonfatal opioid overdose and mortality. Better information sharing between VHA and non-VHA pharmacies and prescribers has the potential to improve patient safety.

Am J Manag Care. 2018;24(11):536-540
Takeaway Points

Fragmented coordination of care has been shown to be associated with adverse opioid-related outcomes.
  • The present study suggests that veterans receiving opioids at both Veterans Health Administration (VHA) and non-VHA pharmacies are at higher risk of opioid overdoses compared with veterans receiving prescriptions at VHA pharmacies only.
  • Findings have implications for patient safety and the Veterans Choice program, which offers services from non-VHA providers to veterans living outside of VHA catchment areas.
  • Managed care decision makers should query the dual use of pharmacy services—specifically with regard to opioids—in their systems of care and its association with opioid overdoses.
Concomitant use of opioids with benzodiazepines significantly increases the risk of adverse outcomes. Specifically, rates of overdose death among those who were codispensed benzodiazepines and opioid analgesics were 10 times higher than among those who were dispensed opioid analgesics alone in a prospective cohort study.1 Similarly, among veterans using opioids, coprescribing of benzodiazepines was associated with an increased risk of opioid-related overdoses, injuries, and mortality.2 In another veteran-based study, nearly half of drug overdose deaths occurred among those concurrently prescribed benzodiazepines and opioids.3 Effective prescription monitoring programs (PMPs) have been shown to change such prescriber behavior by bringing about a reduction in opioid prescribing.4 Robust PMPs, as measured by assessing local and federal laws for prescribing controlled substances, have shown to be associated with fewer opioid overdose deaths than weaker PMPs.5 However, strong laws cannot overcome fragmented or uncoordinated care, which can still be a barrier to the effective use of PMPs.

Fragmented care results in increased medical errors, hospital readmissions, emergency department (ED) visits, and healthcare costs.6,7 Specifically, this holds true in the area of pain management, where the risk of opioid misuse may be compounded when patients obtain opioid prescriptions from multiple prescribers and/or pharmacies.8-10 Such fragmented or uncoordinated care has been shown to be associated with adverse opioid-related outcomes, including hospital admissions associated with opioid use11 and increased risk of opioid overdose.12

The impact of care coordination on opioid-related outcomes has not been fully examined among veterans who have “dual care use” of pharmacy benefits both within and outside of the Veterans Health Administration (VHA).13,14 Veterans may have a higher risk of overdose given their prevalence of chronic pain disorders, which are often treated with opioids,15,16 and that risk might be further aggravated with the coprescribing of benzodiazepines.

A recent cross-sectional study using the Kentucky PMP found that compared with those with VHA payments only, veterans with multiple payment sources for opioid prescriptions were more likely to receive risky opioid therapy, defined as combination opioid/benzodiazepine or high-dose opioid therapy.17 Besides the fact that it did not examine whether veterans were more likely to experience adverse events, the study also examined VHA as a payer, whereas our current study examines it as a dispenser.

Here, we fill this void in the literature by reporting on whether Massachusetts veterans receiving opioids and/or benzodiazepines from VHA and non-VHA pharmacies are at higher risk of nonfatal opioid overdose, fatal opioid overdose, or all-cause mortality compared with those receiving these prescriptions from VHA pharmacies only. Further, we report on whether risk is associated with the number of transitions between VHA and non-VHA systems.


The study was conducted on a cohort of veterans with opioid and/or benzodiazepine prescriptions recorded in the Massachusetts Department of Public Health (MDPH) Chapter 55 data set.

Data Source

Chapter 55 Acts of 2015 mandated the analysis of data from several Massachusetts government agencies to report trends on fatal and nonfatal opioid overdoses. The database included 16 administrative sources covering approximately 98% of the Massachusetts population 11 years and older. In our study, we used 6 data sets: PMP, Massachusetts All-Payer Claims Database (APCD), Acute Care Hospital Case Mix Database, death records, Massachusetts Ambulance Trip Record Information System, and Office of the Chief Medical Examiner toxicology data. The PMP maintains information on filled prescriptions for Schedule II through V controlled substances from Massachusetts clinics, hospitals, and retail pharmacies, including out-of-state deliveries to Massachusetts residents. It also includes prescriptions by mail order pharmacies that deliver to patients residing in Massachusetts. Our study data span from October 2013, when VHA data were first systematically reported to the PMP, until December 2015. Other VHA data beyond those reported to the PMP (eg, demographics, diagnosis codes, laboratory test results, or pharmacy records) were not available to us because they have not been linked to the Chapter 55 data sets. The Chapter 55 initiative was mandated by law and conducted by a public health authority. No institutional review board (IRB) review was required by MDPH, and it was deemed exempt from research review by the Bedford VA Medical Center IRB.

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