Healthcare Inspection - Opioid Prescribing to High-Risk Veterans Receiving VA Purchased Care

OIG conducted a healthcare inspection to review opioid prescribing to high-risk veterans receiving VA purchased care. VHA developed two initiatives in 2014 to improve the safety and management of chronic pain in veterans: the Opioid Safety Initiative (OSI), and the enabling of VA providers to participate in state prescription drug monitoring programs (PDMP). The OSI includes specific management guidelines including a prescriber’s toolkit and alternative therapeutic approaches to chronic pain. PDMPs are used to track the prescribing and dispensing of controlled substance prescriptions to patients. VA implemented purchased care programs for veterans to access care in the community when necessary, including the Veterans Choice Program. We determined that with the expansion of community partnerships, a significant risk exists for patients prescribed opioid prescriptions outside of VA. Patients with chronic pain and mental health illness who receive opioid prescriptions from non-VA clinical settings where opioid prescribing and monitoring guidelines conflict with VA guidelines may be especially at risk. The risk is exacerbated when information about opioid prescriptions is not shared. Because of challenges related to health information sharing, we noted that non-VA providers do not consistently have access to critical health care information regarding veterans they are treating. We noted that while the ability to query PDMP databases is available, VA providers would not likely access the PDMP when not prescribing controlled substances. Timely notification of veteran patients receiving non-VA opioid prescriptions would allow more immediate VA provider awareness and action, if action were required. If all routine non-VA opioid prescriptions were submitted directly to VA pharmacies, VA pharmacy staff could alert the VA provider that a non-VA opioid prescription was dispensed. This would also allow the same level of pain management committee oversight by VA of opioid prescriptions prescribed by VA and non-VA providers. We recommended the Acting Under Secretary for Health: Require all participating VA purchased care providers receive and review the OSI evidence-based guidelines for prescribing opioids; Implement a process to ensure all purchased care consults for non-VA care include a complete up-to-date list of medications and medical history; Require non-VA providers to submit opioid prescriptions directly to a VA pharmacy for dispensing and recording in the patient’s VA electronic health record; Ensure that if facility leaders determine that a non-VA provider’s opioid prescribing practices are in conflict with OSI guidelines, immediate action is taken to ensure the safety of all veterans receiving care from the non-VA provider.