Professional Documents
Culture Documents
2008 2009
Policy required access to medication for opioid use disorder VA Pain Directive - established Stepped Care Model for Pain
2010
VA-DoD Clinical Practice Guideline (CPG) Opioid Therapy in Chronic Pain (FIRST)
2011
Created standardized metrics for pain management therapies to pilot opioid safety initiative in 2012
2013
Launched the Opioid and Psychotropic Drug Safety Initiatives (OSI & PDSI)
2014
Targeted interventions for opioid reduction and opioid overdose education and naloxone distribution (OEND)
2016
VA-DoD CPG on Management of Substance Use Disorders Comprehensive Addiction and Recovery Act (CARA)
2017
VA-DoD CPG Opioid Therapy for Chronic Pain Launched Academic Detailing OUD Campaign Launched PDSI Phase 3
S.T.O.P. P.A.I.N. HIGHLIGHTS 8 VA BEST PRACTICES
(PRE-SUMMIT WORKSHOP)
Gellad, Good CB, and Shulkin. JAMA Intern Med. 2017 May 1;177(5):611-612
#Rx Summit www.NationalRxDrugAbuseSummit.org
Clinical Considerations in Addressing Overdose
and Suicide Among Patients Prescribed Opioids
Moving beyond Morphine Equivalent Daily Dose
(MEDD) and opioids
- Based on observational research, we tend to assume that
overdose in Rx-receiving patients is dose-driven
- Re-examining data from these studies suggests that:
• Most patients who die are below recommended MEDD thresholds
• MH/SUD diagnoses and other comorbidities play just as critical a
role, and in some cases an even more critical role than dose in
overdose and/or suicide outcomes
79%
81%
85%
#Rx Summit www.NationalRxDrugAbuseSummit.org
Most Overdose/Serious Opioid-Induced Respiratory
Depression In Patients with No or Lower Dose Opioids
(Zedler et al., Pain Med 2015)
67%
Controls:
47.7 MEDD (SD 65.2)
Median dosage for patients with opioid overdose was 60 MEDD; i.e.,
vast majority below 100 MEDD
• MH/SUD-related
factors 29% of index
• Model ORs:
Opioid dep=4.5
Bipolar/SZ=1.9
Benzo=1.5
Antidep=2.0
• Opioid-related
factors 32% of index
• Model ORs:
ER/LA=2.5
Methadone=2.4
≥100 MEDD=5.0
• MH/SUD-
related factors
36% of index
• Model ORs:
SUD=12.7
Bipolar/SZ=2.8
Benzo=2.3
Antidep=2.2
• Opioid-related
factors 36% of
index
• Model ORs:
Fentanyl=3.7
Methadone=2.8
ER/LA=1.7
≥100 MED=2.0
• MH/SUD diagnoses
27% of max points;
69% of non-age
related points
• Opioid-related factor
7% of max points;
19% of non-age
related points
Age (M, SD) 59.2 (14.2) 51.5 (11.6) 58.2 (14.5) 59.6 (14.2) 52.9 (11.8) 58.2 (15.7)
Currently 48.4% 24.6% 37.1% 49.2% 22.7% 36.8%
married
Female 7.7% 7.9% 3.8% 8.3% 6.7% 3.3%
OEF/OIF 5.5% 7.0% 6.0% 7.7% 10.5% 10.2%
Race/Ethnicity
White 72.1% 78.6% 80.0% 70.6% 76.9% 83.8%
Black 18.0% 9.8% 4.1% 18.4% 16.1% 5.8%
Hispanic 5.4% 4.2% 3.0% 5.9% 3.6% 2.5%
Asian 1.3% 1.0% .6% 1.3% .9% 1.2%
Native Am .7% 1.0% .8% .5 .2% .5%
Urban 61.0% 70.2% 57.9% 62.1% 69.4% 59.3%
Rural 37.4% 28.3% 40.7% 36.4% 28.9% 37.8%
Highly Rural 1.6% 1.5% 1.4% #Rx Summit
1.5%www.NationalRxDrugAbuseSummit.org
1.7% 2.9%
Study 2: Descriptive Information cont.
FY2010- FY2011 Mortality FY2013- FY2014 Mortality
2011 2014
Cohort Cohort
Overall Overdose Suicide Overall Overdose Suicide
N=1,263,660 (n=1,035) (n=661) N=1,352,579 (n=1,014) (n=668)
Medical
Hypertension 60.1% 54.7% 56.9% 59.6% 57.0% 57.6%
Diabetes 28.2% 17.3% 22.2% 29.6% 21.5% 24.4%
COPD 19.1% 24.8% 22.7% 19.3% 24.4% 20.5%
MEDD (M, 34.5 61.2 47.7 33.1 65.7 53.6
SD) (81.7) (76.9) (69.4) (49.3) (107.4) (130.5)
Sedative co- 23.1% 50.4% 45.1% 23.0% 46.6% 39.4%
prescription
Sedating
medications
SNRI 5.1% 10.9% 12.7% 6.1% 15.4% 12.9%
TCAs 11.3% 22.6% 15.4% 11.3% 25.5% 18.9%
Anticonv 22.5% 35.5% 30.0% 27.7% 47.8% 31.7%
Tier
LA 10.1% 28.0% 19.1% 9.2% 27.3% 18.9%
Chronic SA 24.5% 31.5% 32.7% 28.8% 33.5% 34.1%
Acute SA 42.2% 28.5% 32.7% 39.4% 26.1% 32.5%
Tramadol 20.2% 12.0% 15.5% 22.7% 13.1% 14.5%
difference
80
70
Opioids In the Prior Year
60
50
40
30
20
10
0
FY2011 FY2014 FY2011 FY2014
Overdose Mortality Suicide Mortality
16 16
14 14
12 12
10 10
8 8
6 6
4
4
2
2
0
0
1 2 3 4 5 6 7 8 9 10 11 12
1 2 3 4 5 6 7 8 9 10 11 12
Fiscal Year Month
Fiscal Year Month
Opioids Year 2 No Opioids Year 2
Opioids Year 2 No Opioids Year 2
14
12
10
8
6
4
2
0
1 2 3 4 5 6 7 8 9 10 11 12
Fiscal Year Month
Pain
Opioid need
Mental and
illness dependence
SUD,
Physical
Medication
illness
dependence
Other
Psychological
factors
#Rx Summit www.NationalRxDrugAbuseSummit.org
Random Sample of Discontinuations from 2012 (N=600)
Sleep
disorders
Changes
in
cognition Decreased
libido,
disinterest,
isolation,
Depression social
Dysphoria withdrawal
Anhedonia
Pain
Lethargy
Anorexia
Immobilization
Irritability
Anger
Anxiety
Pain Negative
intensity affect Relief
reduced reduction
Nociceptive
Mediated
phenomenon Mediated
through
mediated through
Emotional
through Reward
(limbic)
pain pathways
pathways
pathways
CDC:
0.7% in
opioids
low dose
6% in very
high dose
We don’t talk much about
the grey areas
Birmingham VAMC:
- Director, Homeless PACT at Birmingham VAMC
- Founder, Opiate Advice Team
- Member, Opioid Safety Initiative
University of Alabama at Birmingham School of Medicine
- Professor & Researcher
Findings Limitations
Voluntary + well-run programs No studies of mandatory,
Dose reduction can be involuntary opioid
achieved for some patients discontinuation
Some do feel better
Insufficient evidence on
Rated as “low quality adverse events such as
evidence” “overdose, switch to illicit
opioids, onset of suicidality”
Lovejoy et al., Pain 2017 Darnall et al., JAMA Int Med 2018
Pain
Opioid need
Mental and
illness dependence
SUD,
Physical
Medication
illness
dependence
Other
Psychological
factors
#Rx Summit www.NationalRxDrugAbuseSummit.org
VA Data about Prescription Opioids
and Overdose and Suicide:
Clinical Implications
Stefan Kertesz, MD, MSc
Professor, University of Alabama at Birmingham,
Director of Homeless Patient-Aligned Care Team, Birmingham VA Medical Center
Ajay Manhapra, MD
Physician, Research Scientist, Lecturer, Hampton VA Medical Center, New England
Mental Illness Research, Education and Clinical Center, Yale School of Medicine
Elizabeth Oliva, PhD
VA National Opioid Overdose Education and Naloxone Distribution Coordinator,
Department of Veterans Affairs, Veterans Health Administration
Friedhelm Sandbrink, MD
VA Acting National Director for Pain Management, Department of Veterans Affairs,
Veterans Health Administration
Original Title: Surprising VA Data About Opioid Discontinuation*, Overdose and Suicide: Clinical Implications
*Methodological concerns in defining this group were brought to our attention and we are working on re-
classifying patients and using more appropriate analyses. These concerns will be discussed during the
presentation and we hope will be informative for people doing work in this area.
Moderator: John Eadie, Coordinator, Public Health and
Prescription Drug Monitoring Program Project, National
Emerging Threat Initiative, A National HIDTA Initiative
#Rx Summit www.NationalRxDrugAbuseSummit.org
,
THANK YOU
#RxSummit
www.NationalRxDrugAbuseSummit.org