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

Objective: To describe processes and outcomes of a health system quality improvement initiative designed to reduce opioid-related harms. Design: 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. Setting: A VA health care system comprising one large, urban teaching hospital and 11 outpatient clinics in surrounding suburban and rural locations. Subjects: 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. Methods: 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. Results: 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). Conclusion: 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.