Opioid Dose Reduction in a VA Health Care System--Implementation of a Primary Care Population-Level Initiative.

Abstract

To describe processes and outcomes of a health system quality improvement initiative designed to reduce opioid-related harms. The initiative was a primary care population-level intervention to reduce high-dose opioid prescribing, which was locally defined as >200 morphine-equivalent mg (MED) daily. We describe the implementation process and report prescribing rates and primary care provider (PCP) attitudes and beliefs before and after implementation. A VA health care system comprising one large, urban teaching hospital and 11 outpatient clinics in surrounding suburban and rural locations. All patients who received any prescription from the outpatient pharmacy (unique pharmacy patients) were included in the population. PCPs at the main hospital were surveyed. Prescribing outcomes were determined from merged VA databases by examining rates of opioid dispensing within 90-day time windows before and after implementation. PCP beliefs and attitudes were evaluated with preimplementation and postimplementation surveys. Following implementation, the number of patients prescribed >200 MED daily decreased from 342 (0.65% of unique pharmacy patients) to 65 (0.12%). Overall, the number of unique pharmacy patients who received at least one opioid prescription within 90 days decreased from 6,942 (13.7%) on April 1, 2011 to 5,981 (11.0%) on October 1, 2014 (13.8% decrease). Most PCPs agreed it was reasonable for the medical center to set a 200 MED limit (76% at baseline and 87% at follow up). Opioid Safety Initiative implementation was associated with a substantial reduction in high-dose opioid prescribing. Factors that contributed to initiative success included leadership support and active clinical pharmacy engagement.