The number of high-dose opioid painkiller prescriptions written to veterans has declined following the release of a Veterans Health Administration plan to reduce the potentially addictive substance, according to a new study conducted by the University of Michigan and Ann Arbor researchers. 
Published in the scientific journal Pain, the research study found prescriptions written from high-dose opioids decreased by 16 percent and prescriptions written for very high-dose opioids decreased by 24 percent. The journal also noted the prescribed combination of opioids and sedatives, a possibly a deadly one, decreased by 21 percent over the course of two years.
The plan, coined the Opioid Safety Initiative, was introduced in 2013 in an attempt to reduce risky opioid prescribing and other potentially lethal drug combinations.
The OSI is a computer system that oversees prescriptions and provides physicians with additional knowledge for safer prescribing. The initiative was implemented in the national, integrated health care system of the Veterans Association and provided support to physicians monitoring patients using opioids.
According to the Centers for Disease Control and Prevention, patients who take opioids may develop tolerance over time and the effectiveness of the drug may decrease. Overdose related to opioids is associated with the dosage given. The higher the dose of opioids, the increased likelihood of an overdose.
Michael Clay, an assistant professor of internal medicine at University’s Medical School who worked on the study, emphasized that opioids generally have minimal benefit for chronic pain and are traditionally used for acute pain. He highlighted the central responsibilities of a prescriber if opioids are considered for chronic pain relief.
“The prescriber needs try all other options for chronic pain management — physical therapy, injections, psychology, ‘alternative’ therapies like acupuncture — before considering prescribing opioids,” Clay said. “The provider needs to then weigh all of the risks of opioids (addiction, death, depression, constipation, decreased testosterone in men and many others) and make sure that patients understand these risks.”
The Medical School evaluated the effectiveness of the OSI used in Veterans Affairs hospitals nationwide. The Institute for Healthcare Policy and Innovation, the Veterans Affairs Ann Arbor Healthcare System and Yale University also collaborated on the project.
Lewei Lin, the study’s first author and an addiction fellow in the University’s Department of Psychiatry, emphasized how this study is one of the first to look at a health care system’s role in risky opioid prescriptions at a national level.
“What I am hoping is that this would give further support to other health care systems, for example, University of Michigan or other health care systems around the country in thinking about, within the health care system, how to help providers prescribe more safely,” Lin said.
The OSI was designed to be used in different settings, including urban and rural VA hospitals as well as local clinics. Because of this, there was variation in the ways the OSI was implemented.
Clay highlighted the quality and quantity of resources may help explain the distinction between rural and urban hospitals.
“For example, the Ann Arbor VA has many national experts in the field and they were able to help out with our OSI implementation,” Clay said. “We used a variety of professions to help implement OSI: physicians, pharmacists, psychologists, physical therapists. As a primary care physician, I was the lead for our facility. Other facilities used psychologists or pharmacists as the lead and did not have as many resources as VA hospitals with strong university affiliations.”
The study shows an initiative to reduce opioid prescriptions implemented by a large health system may benefit patient outcomes. Changing policies and providing prescribers with the necessary tools may lead to positive changes in opioid prescribing.
Mark Ilgen, an associate professor of psychiatry at the University’s Medical School, described how the findings within the VHA may be helpful to other health care systems.
“A lot of the headlines you see about opioids and the so-called opioid epidemic can make the situation feel somewhat hopeless,” Ilgen said. “In this case, we do see that there is an overall trend in reducing very high-dose prescribing. … (The OSI) likely accelerated that trend … it gives some hints into the types of strategies that might be helpful to make those changes.”
Lin is interested in studying further what went on at the facility level associated with a larger reduction in risky prescribing at some facilities, compared to others.
“I’ve been doing research around opioids for a few years,” Lin said. “As an addiction clinician, I see a lot of the negative consequences. Anything that gives us some insight about the next steps that we can do to try to reduce some of the negative consequences, I think is really exciting and promising.”

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