	Background

To help ensure that veterans are prescribed and use opioid pain  medications in a safe and effective manner, VHA launched its OSI  nationally in 2013. Our analysis of quarterly OSI metric data shows that since the beginning  of the OSI in the fourth quarter of fiscal year 2013 to the first quarter of  fiscal year 2018 (the most recent data available at the time of our review),  the percentage of veterans dispensed an opioid has decreased by 7  percentage points, or roughly 267,000 veterans, while the rate of urine  drug screening for veterans on long-term opioid therapy increased  significantly—by over 47 percentage points. For example:
Facilities. VHA Has Made Progress on OSI Goals, but Performance Measurement Limitations Exist for Some Goals and Certain CARA Provisions Have Not Been Fully Implemented

		VHA Has Made Progress on Many 2014 OSI Goals, but for Some Goals, Performance Measurement Limitations Prevent an Accurate Determination of their Completion

Based on our analysis of VHA information, we found evidence suggesting  that the agency has accomplished six of the nine 2014 OSI goals. Moreover, for the OSI goal related to establishing safe and effective VISN  tapering programs for veterans using opioids and benzodiazepines (goal  four), VHA officials told us that they addressed this goal by issuing  national tapering guidance, including a provider reference guide in 2014,  an opioid taper decision tool in 2016, and the VA/DOD clinical practice  guidelines in 2017. However, we found that VHA Central Office  cannot track the extent to which VHA providers use OTRR because this  tool does not have this tracking capability. VHA Providers Do Not Always Adhere to Required Opioid Safety Risk Mitigation Strategies and Guideline Recommendations for Prescribing Opioids in a Safe Manner

		VHA Providers at Selected Medical Facilities Do Not Consistently Follow Opioid Risk Mitigation Strategies

Our review of selected VHA medical facilities shows that providers do not  always follow three key opioid risk mitigation strategies, two of which are  required under VHA policy. Provider Adherence to Three Veterans Health Administration (VHA) Opioid Risk Mitigation Strategies at Five Selected  Medical Facilities, March 2016 through March 2017 Increasing the use of urine drug screening is an explicit goal of VHA’s Opioid Safety Initiative (OSI), and providers should generally  ensure that an annual urine drug screening has been conducted. VHA policy requires providers to (1) query state prescription drug  monitoring programs (PDMP) at least annually when prescribing opioids to determine if the veteran has obtained opioid medications  or other controlled substances from a non-VA provider, and (2) obtain written informed consent from patients about the risks of  initiating long-term opioid therapy. However, our review of medical records for a random nongeneralizable selection of 103 veterans  subject to these risk mitigation strategies found that  Of the 53 veterans who received long-term opioid therapy:  32 veterans received an annual urine drug screening, which allows providers to monitor the types of medications in a  veteran’s system, including controlled and illicit substances;  13 veterans had their names queried annually in a state PDMP to see if they had received prescriptions for controlled  substances, including opioids from non-VHA prescribers; and  41 veterans had provided informed consent indicating that they had been educated on the risks and benefits of opioid use. We identified a number of factors that may have contributed to the  inconsistent adherence to the three key opioid risk mitigation strategies at  our selected VHA medical facilities. To the extent that these factors are present across other  facilities, VHA’s ability to ensure that all veterans are prescribed opioids in  a safe and effective manner may be limited. We also found that not all of  the selected medical facilities and their respective VISNs had filled  required staff positions that can help ensure provider adherence to opioid  risk mitigation strategies—specifically, academic detailers and pain  champions. At the time of our review, four of five selected facilities did not have a  Pain Champion as required by VHA policy beginning in March 2015. However, for two goals, VHA lacks  documentation showing whether VISNs and medical facilities have  completed required relevant actions, and in one case, VHA has not  specified measurable outcomes, which makes it challenging to determine  whether these goals have been accomplished. Without sufficient  documentation and measurable outcomes, VHA cannot determine  whether these OSI goals to help ensure safe and effective care for  veterans prescribed opioids have been fully successful. (Recommendation 3)
The Undersecretary for Health should ensure that all VISNs have  implemented an academic detailing program that supports all medical  facilities in the VISN and that all VHA medical facilities have a  designated primary care pain champion as required. VA also  stated that it will take actions to ensure that academic detailing programs  are fully implemented and primary care pain champions are in place  across the system. To improve its clinicians’ adherence to opioid risk  mitigation strategies, VA stated that it will establish a workgroup to review  and develop methods for increasing adherence.
Why GAO Did This Study

The Comprehensive Addiction and Recovery Act of 2016 and Senate Report 114-57 included provisions for GAO to report on VHA's OSI and the opioid prescribing practices of its health care providers.
This report examines, among other issues, (1) the extent to which VHA has met OSI goals established in 2014 and (2) the extent to which VHA providers adhere to key opioid risk mitigation strategies. To do this work, GAO reviewed data and documents related to OSI efforts and goals and interviewed VHA officials. In addition, GAO reviewed a random, nongeneralizable selection of medical records for 103 veterans who were prescribed opioids at five selected VHA medical facilities from March 2016 through March 2017. GAO selected the facilities to obtain diversity in geography and rates of opioid prescribing. At the selected facilities, GAO reviewed facility data and documents related to opioid safety and interviewed officials.

What GAO Found

The Veterans Health Administration (VHA) has made progress improving opioid safety through its Opioid Safety Initiative (OSI). Launched in 2013, the OSI aims to help ensure that veterans are prescribed opioids in a safe and effective manner. Since the OSI began, VHA has seen reductions in opioid prescribing rates. For example, from the fourth quarter of fiscal year 2013 to the first quarter of fiscal year 2018, the percentage of patients dispensed an opioid decreased from about 17 percent to about 10 percent, or by about 267,000 veterans. Also, available evidence suggests VHA has accomplished six of nine OSI goals established in 2014; however, it is unclear whether the remaining three goals have been fully met. For example, in the case of OSI goal four (establishing safe and effective regional tapering programs for patients on opioids and benzodiazepines), GAO found that VHA lacked documentation that its regional networks established these programs. VHA also did not establish measures of safety or effectiveness under this goal. These limitations prevent VHA from fully evaluating progress and accurately determining the extent to which its efforts to help ensure safe and effective prescribing of opioids have been successful.
In a review of a nongeneralizable sample of 103 veterans' medical records at five selected VHA medical facilities, GAO found that VHA providers did not always adhere to key opioid risk mitigation strategies, which are required by VHA policy or relevant to OSI goals. For example, among 53 veterans who were prescribed long-term opioid therapy (defined as a 90-day supply in the last 6 months), GAO found that
40 veterans did not have their names queried in a state-run prescription drug monitoring program database. The databases are used to identify patients who are receiving multiple prescriptions that may place them at greater risk for misusing opioids or overdosing;
21 veterans did not have a urine drug screening within the year prior to having their prescription filled. The screenings are used to determine whether veterans are taking their opioid medications as prescribed; and
12 veterans did not provide written informed consent. Informed consent is a formal acknowledgement that the veteran has been educated on the risks and benefits of opioid use prior to initiating long-term opioid therapy.
GAO found several factors that may have contributed to inconsistent adherence to key opioid risk mitigation strategies at the selected VHA facilities. For example, four of the five selected facilities did not have a pain champion (a primary care position required by VHA that can help providers adhere to opioid risk mitigation strategies), and not all facilities had access to academic detailing, a program in which trained clinical pharmacists work one-on-one with providers to better inform them about evidence-based care related to the appropriate treatment of relevant medical conditions. In addition, three of the five facilities did not consistently review veterans' medical records to ensure provider adherence to these strategies. To the extent that these factors affect all VHA facilities, VHA will continue to face challenges ensuring that its providers prescribe opioids in a safe and effective manner.

What GAO Recommends

GAO is making five recommendations to VHA, including that it document actions and develop measurable outcomes related to its OSI goals, ensure that providers are adhering to opioid risk mitigation strategies, and ensure that all its regional networks have implemented academic detailing programs and that all VHA medical facilities have a designated primary care pain champion, as required. The Department of Veterans Affairs concurred with GAO's recommendations and described steps it will take to implement them.