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Report: VA not following guidelines on pain drugs

May. 14, 2014 - 06:08PM   |  
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The Veterans Affairs Department may not be overprescribing potentially addictive opioid painkillers, but a new report says VA is failing to screen adequately for potential abuse or protect some patients who are given such drugs.

Among those at risk, according to the VA Inspector General, are patients with known substance abuse problems and those taking other medications that can have fatal consequences when mixed with opiates.

In the report released Wednesday, VA Assistant IG Dr. John Daigh said the Veterans Health Administration issued 1.68 million prescriptions for opioids to more than 440,000 outpatients, or 7.7 percent of VA patients, in 2012.

Nearly 88 percent of the prescriptions were for pain and 67 percent were prescribed for 90 days or less.

But while nearly 100 percent of patients received their prescriptions at a single VA medical center and three-quarters had their prescriptions issued by a single physician, the report found that VA is not prescribing these medications according to its own clinical practice guidelines or accepted medical norms.

For example, urine tests are recommended for new patients prescribed opiates, either before beginning treatment or within two to four weeks after starting. But according to the IG, only 6.4 percent of such patients were given urine tests.

And at one VA medical center, just 1.1 percent of patients issued a new prescription for opioids were screened in accordance to the guidelines.

The IG also found that 13.1 percent of those prescribed the medications had an active substance use issue, even though VA’s guidelines say that chronic opioid therapy “is absolutely contraindicated in patients with active substance use disorders who are not in treatment.”

Another issue raised by the extensive prescribing of opioid medications, the IG found, is the potential for problems when such drugs are prescribed with benzodiazepines, which, like opioids, can depress the central nervous system, affecting heart rate and basic body functions.

According to the report, 7.4 percent of patients taking opioids also had a prescription for a benzodiazepine.

The report also found that opioids were prescribed in conjunction with acetaminophen — another potential problem when used in conjunction with opioids, since many opiates contain acetaminophen, which is known to cause liver damage in doses beyond recommended limits.

According to the report, 92 percent of the group also had a prescription for acetaminophen.

Daigh said the large number of patients prescribed these painkillers — nearly half a million — did not necessarily indicate that opiates are overprescribed within the VA system, which has nearly 10 million patients.

“Because the decision to prescribe take-home opiods should reflect individual patients’ clinical needs, higher VAMC prevalence alone does not necessarily indicate overprescribing,” Daigh wrote.

But he made several recommendations to VA health officials, including that they:

■ Follow recommended guidelines for prescribing opiates with acetaminophen.

■ Follow guidelines for routine and random urine drug tests.

■ Monitor patients and follow guidance designed to prevent adverse drug interactions.

The IG report was requested by the Senate Veterans’ Affairs Committee following several high-profile incidents of accidental drug overdoses related to opioid prescriptions among veterans.

In 2012, the Center of Investigative Reporting published an analysis showing that VA prescriptions for opiates such as hydrocodone, oxycodone, methadone and morphine have increased 270 percent over the past 12 years.

The investigation also found that on average, VA has issued more than one opiate prescription per patient for the past two years.

Government witnesses, including Heather McDonald, whose husband Scott, 35, died in 2012 from liver failure, have testified that VA was not doing enough to protect its patients from drug toxicity.

According to McDonald, her husband never was offered or received a test to monitor whether the drugs he was prescribed were harming his kidneys or liver.

The report can be found on the VA IG’s web page at

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