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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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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.
Strengths and Limitations

An important strength of our study was the use of a rich and unique data set, which captured prescribing of opioids both inside and outside of the VHA. To our knowledge, no other data resource would have supported such an analysis. Further, this study addresses a key issue, dual care use, which is leading to greater likelihood of uncoordinated care among veterans across the United States compared with commercially insured civilians who benefit from PMPs and other strategies known to work in anyone at high risk of overdose. However, like any state, Massachusetts has its own cultural, demographic, and socioeconomic environment, possibly limiting the generalizability of these findings to other states. More importantly, findings from this veteran study cannot be generalized to the general population. Further, we lacked complete information on medical utilization and comorbidities in our VHA-only group, which could confound the associations. Our attempts to include them in the analysis were limited by the recognition that differential completeness in the data between VHA-only patients and dual care use patients may result in bias and that their inclusion in the models might not lead to accurate results. Another limitation of the Chapter 55 data set was that pharmacy-specific variables such as distance to the pharmacy and number of non-VHA pharmacies could not be included in the model due to lack of patient address, geocoding of pharmacies, and unique pharmacy identifier. Further, in our study, we did not exclude patients with a cancer diagnosis. The findings of this study investigating opioid overdose may not be completely generalizable to the cancer population. A final limitation is that nonfatal overdoses may be underascertained in the study, as not all nonfatal opioid overdoses may involve an encounter with the healthcare system.

CONCLUSIONS

As the VHA is expanding its use of non-VHA care and providers through the Veterans Choice program,31 compounding the issue of coordination of care across systems, these findings are timely. The present study expands our understanding of opioid-related outcomes. Findings suggest the need not only to continue to share data between VHA and state PMPs but also to take further steps. These steps could include implementing prescription drug disposal, safe opioid prescribing education, aggressive dispensing of naloxone to veterans and their families, including specific alerts in PMPs regarding patients with previous histories of dual care use, and providing these dual care users more resources and closer care coordination, especially with regard to opioids. 

Acknowledgments

The authors acknowledge the participation and contributions of Dr Keith McInnes, Dr Avron Spiro, the late Dr James F. Burgess Jr, Dr Craig Coldwell, and Dr Karen Drexler. They acknowledge the Massachusetts Department of Public Health for creating the unique cross-sector database used for this project and for providing technical support for the analysis.

Author Affiliations: Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Rogers Memorial VA Medical Center (GKJ, DRM, DRB, DAS), Bedford, MA; Department of Health Law, Policy and Management, Boston University School of Public Health (GKJ, OA, DRB), Boston, MA; Executive Office of Health and Human Services, Department of Public Health, The Commonwealth of Massachusetts (TL, DB), Boston, MA; University of Massachusetts School of Medicine (TL), Worcester, MA; Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine (AJR), Boston, MA; Department of Psychiatry, University of Massachusetts Medical School (DAS), Worcester, MA.

Source of Funding: The research reported/outlined here was supported by the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development (HSR&D) Service. Dr Jasuja is a VA HSR&D Career Development awardee at the Bedford VA (CDA 13-265). The views expressed in this article are those of the author(s) and do not necessarily represent the views of the Department of Veterans Affairs.

The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and the decision to submit the manuscript for publication.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (GKJ, OA, DRM, TL, DB, AJR, DRB, DAS); acquisition of data (GKJ, OA, TL, DB, DRB, DAS); analysis and interpretation of data (GKJ, OA, DRM, TL, AJR, DRB, DAS); drafting of the manuscript (GKJ, OA, TL, DB, DAS); critical revision of the manuscript for important intellectual content (GKJ, OA, DRM, TL, DB, AJR, DRB); statistical analysis (OA, DRM, TL); administrative, technical, or logistic support (TL); and supervision (GKJ).

Address Correspondence to: Guneet K. Jasuja, PhD, Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, 200 Springs Rd, Bedford, MA 01730. Email: guneet.jasuja@va.gov.
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