New research shows that veterans enrolled in dual-system care are two to three times more likely to die from an unintentional opioid overdose when they obtain opioids from both systems.
The study, published in the Annals of Internal Medicine, correlated mortality rates from opioid overdose with veterans who filled prescriptions with multiple healthcare systems in 2012 and 2013.
Previous research funded by the VA has looked at the effect of dual-system opioid prescriptions, particularly in terms of how such prescribing affects patients with high-dose prescriptions or those exposed to harmful combinations of drugs. The current study expands upon that work by establishing a link between dual-system prescribing and increased mortality rates.
The research also raises new questions about why mortality rates among patients who get their opioids through both systems are so much higher than those who stick with one or the other, according to Patience Moyo, Ph.D., the study’s lead author and an assistant professor of health services, policy and practice at Brown University School of Public Health.
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While researchers did find that patients who obtained opioids from both systems on average received higher-dose prescriptions than those who used only a single system, adjusting for that and other likely variables, such as alcohol or substance abuse disorders, leaves a substantial, unexplained relationship.
“There’s more than we could understand in terms of what’s really making these individuals higher-risk,” Moyo said. "I think that’s something that could be unpacked more because there might actually be some other characteristics of those who have dual use that need to be explored further beyond this study.”
The set of issues that have been linked to dual-system use suggest that the root of the problem involves a lack of communication between plans.
“By definition, patients receiving care from two or more systems are at risk for adverse events attributable to suboptimal care coordination,” wrote Laurence J. Meyer, M.D., Ph.D., and Carolyn M. Clancy, M.D., of the U.S. Department of Veterans Affairs in an editorial accompanying the study.
That view gains even more credence in light of evidence that consistent use of state prescription drug monitoring programs (PDMPs) corresponds with decreased numbers of overdoses. Every state now operates such a program, but providers face a number of hurdles when it comes to integrating those systems universally. For starters, Meyer and Clancy call for better data standards, better integration of PDMP checks in provider workflows and data sharing across state lines.
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New legislation signed in 2017 requires VA facilities to submit data to state PDMPs. The study also points out that the VA plans to integrate PDMP results with its electronic health record system, but they aren’t expected to implement that change any time soon.
Figuring out the right way to coordinate care across multiple systems may also depend on developing a deeper understanding of why dual-system patients are so much more prone to overdoses.
“Not only is the health system fragmented, data are fragmented too, so that makes it hard to quantify the extent of dual use,” Moyo points out.
At a fundamental level, she says, day-to-day clinical practices don’t fully appreciate who the patients are who enroll in and obtain medications from more than one system, or why they do so.
“That knowledge could help understand what could be done within individual systems to make sure that whatever people seek out from other places can be more coordinated, and if there’s a way to consolidate their care, for that to be done in a more appropriate way,” she says.