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Opioid Tapering at the Veterans Health Administration Taeko Minegishi, MS Taeko.Minegishi@va.gov VETERANS HEALTH ADMINISTRATION

Collaborators & Disclaimers Office of Mental Health and Suicide Prevention Office VA Pharmacy Benefits Management Partners Evidence-based Policy Resource Center • Melissa Garrido, PhD • Steven Pizer, PhD • Austin Frakt, PhD The contents of this presentation do not represent the views of the U.S. Department of Veterans Affairs or the United States Government. VETERANS HEALTH ADMINISTRATION 2

Opioid Tapering Assist Primary Care providers in: - determining if an opioid taper is necessary - performing the taper - providing follow-up and support during the taper VETERANS HEALTH ADMINISTRATION 3

Objective How prevalent is long-term high-dose opioid patients in VHA? - >90 days continuous and >90 MEDD Do we see opioid tapering in the VHA? Are there unintended consequences of opioid tapering? - serious adverse events and overdose death VETERANS HEALTH ADMINISTRATION 4

Why VHA? High risk vulnerable population - Mental health - Chronic pain Data advantage - National Healthcare System (128 VHA medical stations) - Long-term prescription data for patients who use any of the VHA medical centers - Match hospital utilization and patient diagnosis VETERANS HEALTH ADMINISTRATION 5

Cohort Definitions FY13 (baseline) : N= 1.4 million patients Any opioid prescription N = 53,799 At least 90 days of prescription and > 90 MEDD N = 43,539 Exclude if any inpatient admission, metastatic cancer, hospice, or palliative care N = 35,138 At least one 90 days continuous prescription Followed their opioid prescriptions through FY16 VETERANS HEALTH ADMINISTRATION 6

Prevalence of Long-term High-dose Opioid Patients VETERANS HEALTH ADMINISTRATION 7

Length of Opioid Prescription VETERANS HEALTH ADMINISTRATION 8

Opioid Prescription Trends • To zero • To zero and back • Always decreasing • Always increasing • Others To zero and Always Always N To zero back decreasing Increasing Others 35,138 8,727 703 6,288 1,386 18,034 25% 2% 18% 4% 51% VETERANS HEALTH ADMINISTRATION 9

Always Decreasing • To zero • To zero and back • Always decreasing • Always increasing • Others To zero and Always Always N To zero back decreasing Increasing Others 35,138 8,727 703 6,288 1,386 18,034 25% 2% 18% 4% 51% VETERANS HEALTH ADMINISTRATION 10

Always Decreasing: Annual MEDD Trend VETERANS HEALTH ADMINISTRATION 11

Always Decreasing: % Decrease per year ~ 22% per year Some evidence that higher MEDD patients reduce faster? VETERANS HEALTH ADMINISTRATION 12

Geographic Variation in Fast Taper Fast tapering could be dangerous for high dose patients Tapering of >22% per year is common VETERANS HEALTH ADMINISTRATION 13

To zero • To zero • To zero and back • Always decreasing • Always increasing • Others To zero and Always Always N To zero back decreasing Increasing Others 35,138 8,727 703 6,288 1,386 18,034 25% 2% 18% 4% 51% VETERANS HEALTH ADMINISTRATION 14

To Zero: Deceased • 47% of patients were reported deceased (cause of death unknown at this point) 30% died within 6 months of their last prescription date VETERANS HEALTH ADMINISTRATION 15

Main Findings How prevalent is long-term high-dose opioid patients in VHA? • On average 2.8% of patients are long-term high-dose opioid patients in each VHA medical centers Do we see opioid tapering in the VHA? • 18% of patients MEDD consistently decreased over 4 years – Some evidence that higher MEDD patients reduce faster – Tapering >22% per year is common Are there unintended consequences of opioid tapering? • 25% of patients tapered to zero and ~50% of patients deceased during/post prescription periods • Causal direction is unknown VETERANS HEALTH ADMINISTRATION 16

Next Steps • Analysis with shorter time intervals: quarterly and monthly • Cause of death • Link with outcomes: overdose death and serious adverse events • Explore the “others” group (>50%) VETERANS HEALTH ADMINISTRATION 17

Opioid Tapering at the Veterans Health Administration Taeko Minegishi, MS Taeko.Minegishi@va.gov VETERANS HEALTH ADMINISTRATION