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Vets More at Risk of Opioid Abuse in Private Care: Inspector General

In this June 21, 2013, file photo, the seal affixed to the front of the Department of Veterans Affairs building in Washington. (AP Photo/Charles Dharapak)
In this June 21, 2013, file photo, the seal affixed to the front of the Department of Veterans Affairs building in Washington. (AP Photo/Charles Dharapak)

Veterans using the VA's Choice program allowing private-sector health care face a "significant risk" of opioid abuse in the treatment of chronic pain, according to the VA's Inspector general.

Policies in place at the Department of Veterans Affairs to reduce the number of opioid prescriptions do not necessarily apply to private-sector doctors, the IG said.

In a report titled "Opioid Prescribing to High-Risk Veterans Receiving VA Purchased Care," the IG said there is an overall lack of communication between the VA and private-sector doctors on what drugs should be prescribed.

"Veterans receiving opioid prescriptions from VA-referred clinical settings may be at greater risk for overdose and other harm because medication information is not being consistently shared," VA Inspector General Michael Missal in a statement.

"That has to change," he said. "Health-care providers serving veterans should be following consistent guidelines for prescribing opioids and sharing information that ensures quality care for high-risk veterans."

The report highlighted the main problem: "Under Choice, prescriptions for veterans who are authorized care through Choice are required to be filled at a VA pharmacy," but "a veteran can choose to fill the prescription outside the VA and pay for the prescriptions with his or her own funds."

The report said, "With the expansion of community partnerships, a significant risk exists for patients who are prescribed opioid prescriptions outside of VA.

"Patients suffering from chronic pain and mental health illness who receive opioid prescriptions from non-VA clinical settings where opioid prescribing and monitoring guidelines conflict with the guidelines in place within VA may be especially at risk," the report said.

The report noted that "access to an up-to-date list of medications and a relevant past medical history is important for any provider when caring for a patient, but particularly with high-risk veterans such as those with chronic pain and mental health illness."

"However, this information is not consistently included in the authorization and consult documentation for VA purchased care" through the Choice program, the IG's report said.

The report recommended the VA make sure all referrals to private care include a list of the medications and medical history of the patient until an electronic record-sharing system can be implemented.

The VA should also require private doctors to submit opioid prescriptions directly to VA pharmacies for dispensing and also for the purpose of making a record of what was prescribed, the report said.

The IG's report reflects the growing concerns over the nationwide opioid epidemic that has hit the veterans community particularly hard.

Overdose deaths involving prescription opioids have quadrupled since 1999. In 2014, more than 14,000 people died from overdoses involving prescription opioids and "overdose deaths among veterans remain elevated when compared to the civilian population," the report said.

According to a 2011 study by the VA, veterans are twice as likely to die from overdoses as civilians.

"Considering the unique experience of veterans, it is not surprising that so many veterans suffer from some form of chronic pain," the report said. In 2013, the VA told Congress that "more than 50 percent of veterans receiving care at Veterans Health Administration (VHA) facilities were affected by chronic pain."

The problems for the veteran with chronic pain can also be complicated by PTSD (post-traumatic stress disorder), depression, traumatic brain injury, and substance use disorder, the report said.

The report also included case summaries, including that of a veteran described only as "Patient 1," a male in his forties with a past medical history of PTSD, chronic low back pain, obstructive sleep apnea, obesity, and depression.

"During the 4 years prior to his death, he had been hospitalized twice for suicidal ideation and a reported suicide attempt," the report said.

Patient 1 was referred from the VA to a private pain management doctor who offered him spinal injections to alleviate pain and also prescribed oral opioids.

During the course of his treatment, the non-VA provider prescribed a 30-day supply of morphine tablets, 30 milligrams each, to be taken twice daily as needed for pain. The prescription was filled at a VA pharmacy and the patient was found dead several days later.

"The cause of death listed on the death certificate is suicide caused by toxic levels of sertraline, morphine, and gabapentin," the report said. "There is no evidence in the medical record that any of his VA providers were aware of the new opioid prescriptions."

In 2015, more than 33,000 people died of opioid overdose, with an additional 20,000 dying from other drugs, according to Centers for Disease Control and Prevention figures.

Deaths from drug overdoses rose sharply in the first nine months of 2016, according to an interim report of the President's Commission on Combating Drug Addiction and the Opioid Crisis.

The rate of overdose deaths increased every three months last year, reaching a record 19.9 per 100,000 people in the third quarter, up from 16.7 for the same three months in 2015, the interim report said.

The Veterans Choice Program was enacted by Congress in 2014 in response to the wait-times scandals at the Phoenix VA. The program was due to run out of funds this month, but last month President Donald Trump signed a bill extending Choice for six months while Congress and the VA work to reform and expand the program.

At a VA Innovation Day program at Georgetown University on Tuesday, VA Secretary Dr. David Shulkin said that expanded Choice is vital to reforming the VA, despite the fears of veterans service organizations that too much Choice would lead to privatizing the VA.

Shulkin said, "A fundamental way to fix our system is to give veterans more choice."

The goal is to make veterans health-care consumers who would have to be shown that the VA has a product they want, he said.

"As tough as that is, we're going to have to open up our system to be more competitive with the private sector," he said. "That will fundamentally raise our level of performance."

-- Richard Sisk can be reached at Richard.Sisk@Military.com.

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