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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
Understanding and Improving Value Frameworks With Real-World Patient Outcomes
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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Glen D. Stettin, MD
A Narrow View of Choosing Wisely
Daniel B. Wolfson, MHSA, Executive Vice President and COO, ABIM Foundation
Cost of Pharmacotherapy for Opioid Use Disorders Following Inpatient Detoxification
Kathryn E. McCollister, PhD; Jared A. Leff, MS; Xuan Yang, MPH, MHS; Joshua D. Lee, MD; Edward V. Nunes, MD; Patricia Novo, MPA, MPH; John Rotrosen, MD; Bruce R. Schackman, PhD; and Sean M. Murphy, PhD
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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
Predicting 30-Day Emergency Department Revisits
Kelly Gao; Gene Pellerin, MD; and Laurence Kaminsky, PhD
Patients' Adoption of and Feature Access Within Electronic Patient Portals
Jennifer Elston Lafata, PhD; Carrie A. Miller, PhD, MPH; Deirdre A. Shires, PhD; Karen Dyer, PhD; Scott M. Ratliff, MS; and Michelle Schreiber, MD
Impact of Dementia on Costs of Modifiable Comorbid Conditions
Patricia R. Salber, MD, MBA; Christobel E. Selecky, MA; Dirk Soenksen, MS, MBA; and Thomas Wilson, PhD, DrPH
Hospital Cancer Pain Management by Electronic Health Record–Based Automatic Screening
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.

Descriptive characteristics of veterans were compared across groups (Table). 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%), had documented opioid use disorder (6.8% vs 1.6%), and were homeless (1.5% vs 0.7%), and they had higher mean physical (3.0 vs 1.3) and mental (0.6 vs 0.2) comorbidity scores (P <.0001 for all). In terms of outcomes, dual care users had more nonfatal overdoses (160 [2.1%] vs 114 [1.2%]) and higher all-cause mortality (711 [9.3%] vs 390 [4.2%]) (P <.0001 for both comparisons).

All 3 study outcomes were more common among dual care users in the unadjusted models (Figure). Adjustment for demographics, high-dose opioid therapy, and concurrent opioid/benzodiazepine use attenuated the estimates for nonfatal overdose (OR, 1.29; 95% CI, 0.98-1.71), fatal overdose (OR, 1.32; 95% CI, 0.64-2.70), and all-cause mortality (OR, 1.66; 95% CI, 1.43-1.93). Adjustment for homelessness and comorbidities further attenuated the point estimates (data not shown). There was no significant interaction between dual care use and homelessness. The number of switches between VHA and non-VHA prescriptions was not associated with any outcome. Similar effects were obtained for dual care users with opioid prescriptions only.


The study is the first collaborative effort of MDPH and VHA to examine VHA and non-VHA care coordination among veterans at risk of opioid overdose. Findings suggest that those receiving opioid and/or benzodiazepine prescriptions from both VHA and non-VHA pharmacies have higher odds of nonfatal opioid overdose and all-cause mortality compared with veterans receiving controlled substances from the VHA only. Although we found stronger effects of dual care use on nonfatal opioid overdose and all-cause mortality in unadjusted analyses, the multivariate adjustment process reduced this risk, as the variables controlled for may be inherently related to the mechanism of harm. For example, adjusting for rural residence of veterans, shown to be associated with both dual care24 (the predictor) and opioid overdose25 (the outcome), might have lessened the risk of nonfatal opioid overdose in multivariate models. Although we found that the risks of opioid-related deaths among dual care users did not reach statistical significance, potentially due to the small number of events, there remains concern that this group is at higher risk of opioid-related mortality. Further, as is evident from the striking differences in baseline characteristics between the 2 groups in regard to receipt of high-dose opioid therapy (26.3% vs 7.3%), concurrent prescriptions for opioids and benzodiazepines (34.8% vs 8.2%), and opioid use disorder (6.8% vs 1.6%), it may be that individuals who seek dual sources of medications are often essentially different than those who do not (and that covariation cannot account for that) and that is the causal direction.

Our finding of association between dual care use and adverse outcomes in Massachusetts veterans is consistent with a previous report suggesting that having multiple payment sources, including VHA, cash, and noncash (Medicare, Medicaid, and private insurance), was associated with increased risky patterns of opioid therapy (overlap with benzodiazepines and/or high-dose opioid therapy) after controlling for age and sex in veterans in the Kentucky PMP.17 Our study went further, however, by examining outcomes and adjusting for a wider range of potentially confounding variables. Associations of dual pharmacy use with adverse opioid-related outcomes have also been reported in non-VHA populations. Multiple pharmacy use (defined as >2 pharmacies) predicted opioid overdose in Medicaid patients,12 and obtaining opioid prescriptions from multiple healthcare providers was associated with higher rates of hospital admission related to opioid use.11

The proportion of dual care users between VHA and non-VHA pharmacies in our study was approximately 45%. In a recent study, the prevalence of veterans receiving prescription opioids from both VHA and Medicare Part D was reported to be 13.2%.26 Although fatal opioid overdose was not significantly associated with dual care use in our model, possibly due to limited statistical power, we found that a higher proportion of dual care users had opioid-related mortality compared with VHA-only users (0.30% vs 0.18%). In the context of these findings, our study highlights the importance of PMPs as a potential tool to reduce fractured care, especially regarding opioids, among multiple providers, pharmacies, and healthcare systems both within and across VHA and non-VHA facilities. Through the implementation of its Opioid Safety Initiative in 2013, VHA required contribution of its controlled substance prescribing and dispensing data to state PMPs.27 In turn, PMPs have been found effective in both reducing adverse events associated with opioid use28 and reducing prescriptions from multiple providers.29 Further, the statutory requirements for VHA under the Comprehensive Addiction and Recovery Act (CARA; PL 114-198) enacted in July 2016 mandate a designated Pain Management Team, consisting of healthcare professionals at each facility, responsible for coordinating and overseeing pain management therapy for patients experiencing acute and chronic pain that is not cancer-related. Pursuant to CARA and VHA Directive 1306,30 in October 2016 it was further required that state PMP databases are queried for VHA patients who are receiving prescriptions for controlled substances on a minimum of an annual basis and that the results of those queries are documented in the VHA medical record.

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