Patience Moyo, PhD; Xinhua Zhao, PhD; Carolyn T. Thorpe, PhD, MPH; Joshua M. Thorpe, PhD, MPH; Florentina E. Sileanu, MS; John P. Cashy, PhD; Jennifer A. Hale, BA; Maria K. Mor, PhD; Thomas R. Radomski, MD, MS; Julie M. Donohue, PhD; Leslie R.M. Hausmann, PhD; Joseph T. Hanlon, PharmD, MS; Chester B. Good, MD, MPH; Michael J. Fine, MD, MSc; Walid F. Gellad, MD, MPH
Disclaimer: This work represents the opinions of the authors and does not necessarily represent the views of the VA or the U.S. government.
Financial Support: By grant I01 HX001765-01 from VA Health Services Research & Development. Support for VA–Centers for Medicare & Medicaid Services data is provided by VA, Veterans Health Administration, Office of Research and Development, Health Services Research and Development, VA Information Resource Center (project numbers SDR 02-237 and 98-004).
Disclosures: Dr. C. Thorpe reports grants from VA during the conduct of the study and grants from VA, the Donaghue Foundation, the National Institute on Aging, and the Vasculitis Foundation outside the submitted work. Dr. J. Thorpe reports VA Health Services Research & Development Merit Awards during the conduct of the study and outside the submitted work. Dr. Mor reports grants from VA Health Services Research & Development during the conduct of the study. Dr. Hausmann reports grants from VA during the conduct of the study and grants from VA and the National Institutes of Health outside the submitted work. Dr. Gellad reports grants from VA during the conduct of the study. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M18-2574.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer, Johnson & Johnson, and Colgate-Palmolive. Christina C. Wee, MD, MPH, Deputy Editor, reports employment with Beth Israel Deaconess Medical Center. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Yu-Xiao Yang, MD, MSCE, Deputy Editor, reports that he has no financial relationships or interest to disclose.
Reproducible Research Statement: Study protocol and statistical code: Available from Dr. Gellad (e-mail, firstname.lastname@example.org). Data set: Not available because of data use agreements.
Corresponding Author: Walid F. Gellad, MD, MPH, VA Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA 15240; e-mail, email@example.com.
Current Author Addresses: Dr. Moyo: Brown University School of Public Health, 121 South Main Street, Box G-S121-6, Providence, RI 02912.
Drs. Zhao, Cashy, Mor, Hausmann, Fine, and Gellad; Ms. Sileanu; and Ms. Hale: Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive (151C), Building 30, Pittsburgh, PA 15240-1001.
Drs. C. Thorpe and J. Thorpe: Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, 301 Pharmacy Lane, Chapel Hill, NC 27599.
Dr. Radomski: Division of General Internal Medicine, University of Pittsburgh School of Medicine, 200 Lothrop Street, Pittsburgh, PA 15213.
Dr. Donohue: Department of Health Policy & Management, Graduate School of Public Health, Public Health Building, 130 De Soto Street, Pittsburgh, PA 15261.
Dr. Hanlon: Center for Pharmaceutical Policy and Prescribing, University of Pittsburgh Health Policy Institute, 311 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15261.
Dr. Good: Center for Value Based Pharmaceutical Initiatives, UPMC Health Plan, 600 Grant Street, Pittsburgh, PA 15219.
Author Contributions: Conception and design: P. Moyo, C.T. Thorpe, J.M. Thorpe, F.E. Sileanu, M.K. Mor, J.M. Donohue, L.R.M. Hausmann, C.B. Good, W.F. Gellad.
Analysis and interpretation of the data: P. Moyo, X. Zhao, C.T. Thorpe, J.M. Thorpe, F.E. Sileanu, J.P. Cashy, M.K. Mor, T.R. Radomski, L.R.M. Hausmann, J.T. Hanlon, C.B. Good, W.F. Gellad.
Drafting of the article: P. Moyo, T.R. Radomski, L.R.M. Hausmann.
Critical revision of the article for important intellectual content: P. Moyo, C.T. Thorpe, J.M. Thorpe, F.E. Sileanu, M.K. Mor, T.R. Radomski, J.M. Donohue, L.R.M. Hausmann, J.T. Hanlon, M.J. Fine, W.F. Gellad.
Final approval of the article: P. Moyo, X. Zhao, C.T. Thorpe, J.M. Thorpe, F.E. Sileanu, J.P. Cashy, J.A. Hale, M.K. Mor, T.R. Radomski, J.M. Donohue, L.R.M. Hausmann, J.T. Hanlon, C.B. Good, M.J. Fine, W.F. Gellad.
Provision of study materials or patients: L.R.M. Hausmann.
Statistical expertise: X. Zhao, J.M. Thorpe, F.E. Sileanu, M.K. Mor.
Obtaining of funding: C.T. Thorpe, L.R.M. Hausmann, W.F. Gellad.
Administrative, technical, or logistic support: J.A. Hale, L.R.M. Hausmann, W.F. Gellad.
Collection and assembly of data: C.T. Thorpe, F.E. Sileanu, J.P. Cashy, W.F. Gellad.
More than half of enrollees in the U.S. Department of Veterans Affairs (VA) are also covered by Medicare and can choose to receive their prescriptions from VA or from Medicare-participating providers. Such dual-system care may lead to unsafe opioid use if providers in these 2 systems do not coordinate care or if prescription use is not tracked between systems.
To evaluate the association between dual-system opioid prescribing and death from prescription opioid overdose.
Nested case–control study.
VA and Medicare Part D.
Case and control patients were identified from all veterans enrolled in both VA and Part D who filled at least 1 opioid prescription from either system. The 215 case patients who died of a prescription opioid overdose in 2012 or 2013 were matched (up to 1:4) with 833 living control patients on the basis of date of death (that is, index date), using age, sex, race/ethnicity, disability, enrollment in Medicaid or low-income subsidies, managed care enrollment, region and rurality of residence, and a medication-based measure of comorbid conditions.
The exposure was the source of opioid prescriptions within 6 months of the index date, categorized as VA only, Part D only, or VA and Part D (that is, dual use). The outcome was unintentional or undetermined-intent death from prescription opioid overdose, identified from the National Death Index. The association between this outcome and source of opioid prescriptions was estimated using conditional logistic regression with adjustment for age, marital status, prescription drug monitoring programs, and use of other medications.
Among case patients, the mean age was 57.3 years (SD, 9.1), 194 (90%) were male, and 181 (84%) were non-Hispanic white. Overall, 60 case patients (28%) and 117 control patients (14%) received dual opioid prescriptions. Dual users had significantly higher odds of death from prescription opioid overdose than those who received opioids from VA only (odds ratio [OR], 3.53 [95% CI, 2.17 to 5.75]; P < 0.001) or Part D only (OR, 1.83 [CI, 1.20 to 2.77]; P = 0.005).
Data are from 2012 to 2013 and cannot capture prescriptions obtained outside the VA or Medicare Part D systems.
Among veterans enrolled in VA and Part D, dual use of opioid prescriptions was independently associated with death from prescription opioid overdose. This risk factor for fatal overdose among veterans underscores the importance of care coordination across health care systems to improve opioid prescribing safety.
U.S. Department of Veterans Affairs.
Moyo P, Zhao X, Thorpe CT, Thorpe JM, Sileanu FE, Cashy JP, et al. Dual Receipt of Prescription Opioids From the Department of Veterans Affairs and Medicare Part D and Prescription Opioid Overdose Death Among Veterans: A Nested Case–Control Study. Ann Intern Med. [Epub ahead of print 12 March 2019]170:433–442. doi: 10.7326/M18-2574
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Published: Ann Intern Med. 2019;170(7):433-442.
Published at www.annals.org on 12 March 2019
Emergency Medicine, Healthcare Delivery and Policy, Tobacco, Alcohol, and Other Substance Abuse.
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Print ISSN: 0003-4819 | Online ISSN: 1539-3704
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