The VISN 22 dashboard allows the user to navigate to an individual HCP-level and patient-level report (Figures 1 and 2). Filter settings allow report users to select only high-risk patients; it serves as a single location for pertinent details to consider for safely prescribing opioids.
To calculate daily morphine equivalents, each patient’s opioid prescriptions were evaluated. The quantity was divided by the day’s supply to calculate an average daily quantity. From there, the drug strength was used to convert to MEDD. Health care providers were informed that these conversion factors were not recommendations for clinical opioid conversions.
Implementation and Design
In 2012, the VA Pharmacy Benefits Management (PBM) in VISN 21 created a dashboard that allowed users to identify patients on high-dose opioid prescriptions. Structured query language code was used to extract data from the regional data warehouse and calculate MEDD for all patients with active opioid prescriptions. In 2013, VISN 22 expanded that dashboard to incorporate factors that could indicate a high risk for overdose or other adverse outcomes, including a history of depression, PTSD, substance abuse or high-risk suicide flag, and concomitant use of CNS depressant medications.
The high-risk opioid dashboard (Figure 3) and accompanying patient-level report were first introduced to VISN 22 HCPs in January 2013. The business intelligence tools were introduced to each facility through the VISN 22 PBM group. Training on the use of the dashboard and the report was provided, with an initial target of decreasing MEDD of > 200 mg to < 5% of all veterans prescribed opioids at each VISN 22 facility. One month later (in February 2013), a second category of veterans (those with > 120 mg but < 199 mg MEDD) was added. Also the initial MEDD > 200 mg target of < 5% was decreased to < 3% to encourage additional progress.
Eight months after the VISN 22 dashboard technology was implemented there was a 17% decrease in patients with total daily morphine equivalents > 200 mg (January 2013; 1,137 patients vs August 2013; 940 patients—a decrease of 197 patients).
From March 2013 to August 2013, VISN 22 also saw a 12% decrease in the number of patients prescribed > 120 mg MEDD but < 199 MEDD (March 2013; 2,295 vs August 2013; 2,018—a decrease of 277 patients).
Figure 4 shows opioid use as of July 2014 for VISN 22 facilities. There were further reductions in the number of patients receiving > 120 mg but < 199 mg MEDD (August 2013; 2,018 patients vs July 2014; 1,189 patients) and patients receiving > 200 mg MEDD (August 2013; 940 patients vs July 2014; 836 patients).
Case Description
In January 2013, VISN 22 implemented dashboard technology to help providers assess and monitor opioid prescription levels in relation to high-risk variables. The benefits of this dashboard technology are illustrated in the case profile that follows.
A 67-year-old male veteran had a long history of chronic pain. Pain diagnoses included osteoarthritis with spine involvement, lumbar radiculopathy, arthralgia, and peripheral neuropathy. For the past 10 years, he was prescribed opioids with modest relief of his chronic pain symptoms despite recent prescriptions totaling 300 mg MEDD. This veteran had several risk factors for overdose, including a history of depression, suicide risk, PTSD, and concomitant use of the CNS depressants alprazolam and cyclobenzaprine.
More recently, in May 2013, the veteran exhibited aberrant behavior and requested early refills for alprazolam. In response, the pharmacist discussed the case with the HCP who prescribed the opioids, noting the concomitant overdose risk factors. As a result of this interaction, the veteran was referred for mental health services, and his prescriptions for opioids were gradually decreased. He is currently stable, now receiving 120 mg MEDD, and his pain is currently described as moderately controlled on the new lower dose.
In summary, this veteran was receiving > 200 mg MEDD with several known overdose risk factors. Once the HCP was made aware of these risk factors, necessary precautions were taken, and the veteran was safely tapered to a lower dose. Dashboard technology makes the list of risk factors readily available to HCPs who are prescribing (and the pharmacists reviewing the prescriptions), thus allowing a proactive discussion of risks and benefits before continuing, renewing, or initiating opioid prescriptions.
Discussion
As reported in 2013 by NIDA, the greater availability of opioid medications and the consequent increase in prescriptions may be contributing directly to their growing misuse by both civilians and military service personnel. A direct consequence has been an increase in both accidental and intentional overdose deaths.3 Several factors are related to the risk of overdose/death, including high-dose opioid medications, a history of psychiatric disorders (specifically depression and PTSD), a history of substance use disorders, concurrent use of opioid medications and prescription sedatives (specifically benzodiazepines) as well as alcohol and nonprescription drugs of abuse, and previous attempts of suicide.