VA HEALTH CARE

Progress Made 

Towards Improving 

Opioid Safety, but 

Further Efforts to 

Assess Progress and 

Reduce Risk Are 

Needed

Report to Congressional Committees

May 2018

GAO-18-380

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-18-380, a report to 

congressional committees

May 2018

VA HEALTH CARE

Progress Made Towards Improving Opioid Safety, but 

Further Efforts to Assess Progress and Reduce Risk 

Are Needed

What GAO Found

The Veterans Health Administration (VHA) has made progress improving opioid 

safety through its Opioid Safety Initiative (OSI). Launched in 2013, the OSI aims 

to help ensure that veterans are prescribed opioids in a safe and effective 

manner. Since the OSI began, VHA has seen reductions in opioid prescribing 

rates. For example, from the fourth quarter of fiscal year 2013 to the first quarter 

of fiscal year 2018, the percentage of patients dispensed an opioid decreased 

from about 17 percent to about 10 percent, or by about 267,000 veterans. Also, 

available evidence suggests VHA has accomplished six of nine OSI goals

established in 2014; however, it is unclear whether the remaining three goals 

have been fully met. For example, in the case of OSI goal four (establishing safe 

and effective regional tapering programs for patients on opioids and 

benzodiazepines), GAO found that VHA lacked documentation that its regional 

networks established these programs. VHA also did not establish measures of 

safety or effectiveness under this goal. These limitations prevent VHA from fully 

evaluating progress and accurately determining the extent to which its efforts to 

help ensure safe and effective prescribing of opioids have been successful.

In a review of a nongeneralizable sample of 103 veterans’ medical records at five 

selected VHA medical facilities, GAO found that VHA providers did not always 

adhere to key opioid risk mitigation strategies, which are required by VHA policy 

or relevant to OSI goals. For example, among 53 veterans who were prescribed 

long-term opioid therapy (defined as a 90-day supply in the last 6 months), GAO 

found that

• 40 veterans did not have their names queried in a state-run prescription 

drug monitoring program database. The databases are used to identify 

patients who are receiving multiple prescriptions that may place them at 

greater risk for misusing opioids or overdosing;

• 21 veterans did not have a urine drug screening within the year prior to 

having their prescription filled. The screenings are used to determine 

whether veterans are taking their opioid medications as prescribed; and

• 12 veterans did not provide written informed consent. Informed consent 

is a formal acknowledgement that the veteran has been educated on the 

risks and benefits of opioid use prior to initiating long-term opioid 

therapy.

GAO found several factors that may have contributed to inconsistent adherence 

to key opioid risk mitigation strategies at the selected VHA facilities. For 

example, four of the five selected facilities did not have a pain champion (a 

primary care position required by VHA that can help providers adhere to opioid 

risk mitigation strategies), and not all facilities had access to academic detailing,

a program in which trained clinical pharmacists work one-on-one with providers 

to better inform them about evidence-based care related to the appropriate 

treatment of relevant medical conditions. In addition, three of the five facilities did 

not consistently review veterans’ medical records to ensure provider adherence 

to these strategies. To the extent that these factors affect all VHA facilities, VHA

will continue to face challenges ensuring that its providers prescribe opioids in a 

safe and effective manner.

View GAO-18-380. For more information, 

contact A. Nicole Clowers at (202) 512-7114 

or clowersa@gao.gov.

Why GAO Did This Study

The Comprehensive Addiction and 

Recovery Act of 2016 and Senate 

Report 114-57 included provisions for

GAO to report on VHA’s OSI and the 

opioid prescribing practices of its 

health care providers. 

This report examines, among other 

issues, (1) the extent to which VHA 

has met OSI goals established in 2014

and (2) the extent to which VHA 

providers adhere to key opioid risk 

mitigation strategies. To do this work, 

GAO reviewed data and documents 

related to OSI efforts and goals and 

interviewed VHA officials. In addition, 

GAO reviewed a random,

nongeneralizable selection of medical 

records for 103 veterans who were 

prescribed opioids at five selected VHA 

medical facilities from March 2016 

through March 2017. GAO selected the 

facilities to obtain diversity in

geography and rates of opioid 

prescribing. At the selected facilities, 

GAO reviewed facility data and 

documents related to opioid safety and 

interviewed officials. 

What GAO Recommends

GAO is making five recommendations 

to VHA, including that it document 

actions and develop measurable 

outcomes related to its OSI goals,

ensure that providers are adhering to 

opioid risk mitigation strategies, and 

ensure that all its regional networks

have implemented academic detailing

programs and that all VHA medical 

facilities have a designated primary 

care pain champion, as required. The 

Department of Veterans Affairs 

concurred with GAO’s 

recommendations and described steps 

it will take to implement them.
Page i GAO-18-380 Veterans Prescribed Opioids

Letter 1

Background 6

Under Its OSI, VHA Tracks Opioid Prescribing Patterns, Identifies 

Prescribing Outliers, and Educates Prescribers 9

VHA Has Made Progress on OSI Goals, but Performance 

Measurement Limitations Exist for Some Goals and Certain 

CARA Provisions Have Not Been Fully Implemented 13

VHA Providers Do Not Always Adhere to Required Opioid Safety 

Risk Mitigation Strategies and Guideline Recommendations for 

Prescribing Opioids in a Safe Manner 18

Conclusions 25

Recommendations for Executive Action 26

Agency Comments 27

Appendix I Known Efforts and Data Related to the Veterans Health 

Administration’s (VHA) Opioid Safety Initiative (OSI) 2014 Goals, 

July 2013-December 2017 30

Appendix II Comments from the Department of Veterans Affairs 34

Appendix III GAO Contact and Staff Acknowledgments 39

Tables

Table 1: Veterans Health Administration (VHA) Opioid Safety 

Initiative (OSI) goals and required actions, December 

2014 6

Table 2: Changes in Veterans Health Administration (VHA) Opioid 

Safety Initiative (OSI) metrics, Fourth Quarter Fiscal Year 

2014 through First Quarter, Fiscal Year 2018 10

Table 3: Status of Veterans Health Administration (VHA) 2014 

Opioid Safety Initiative (OSI) Goals as of March 2018 14

Contents
Page ii GAO-18-380 Veterans Prescribed Opioids

Abbreviations

CARA Comprehensive Addiction and Recovery Act of 2016

DOD Department of Defense

OSI Opioid Safety Initiative

OTRR Opioid Therapy Risk Report

PDMP prescription drug monitoring program

STORM Stratification Tool for Opioid Risk Mitigation

VA Department of Veterans Affairs

VHA Veterans Health Administration

VISN Veterans Integrated Service Network

This is a work of the U.S. government and is not subject to copyright protection in the 

United States. The published product may be reproduced and distributed in its entirety 

without further permission from GAO. However, because this work may contain 

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Page 1 GAO-18-380 Veterans Prescribed Opioids

441 G St. N.W.

Washington, DC 20548

May 29, 2018

Congressional Committees

The United States is in the midst of an unprecedented opioid epidemic. 

According to 2016 data from the Substance and Mental Health Services 

Administration, nearly 12 million people age 12 or older misused opioids 

in the previous year. In addition, Centers for Disease Control data show 

that over 42,000 people died as a result of an opioid overdose in 2016—

either from prescription opioids or illicit opioids such as heroin—a fivefold 

increase since 1999. According to the Department of Veterans Affairs’ 

(VA) Veterans Health Administration (VHA), veterans are twice as likely to 

die from an accidental overdose when compared to the non-veteran 

population.

VHA has found that in its primary care settings, more than 50 percent of 

male veterans report having chronic pain, and the incidence among 

female veterans may be higher.1 To help ensure that veterans are 

prescribed and use opioid pain medications in a safe and effective 

manner, VHA launched its national Opioid Safety Initiative (OSI) in 2013.2

In 2014, VHA established a number of goals and requirements under the 

OSI aimed at improving the safety and care of veterans who are 

prescribed opioids for pain. In addition, in 2017, VA, along with the 

Department of Defense (DOD), updated its clinical practice guidelines 

related to opioid therapy for chronic pain to increase providers’ 

awareness of evidence-based pain management practices.3

 1

Veterans Affairs Academic Detailing Service, Pain Management Opioid Safety VA 

Education Guide (Washington, D.C.: 2014).

2

According to VHA officials, the OSI rolled out nationwide during the 4th quarter of fiscal 

year 2013. Prior to the national roll out, according to officials, an OSI pilot task force was 

chartered in August 2012 and pilot programs were ongoing at various VHA facilities. 

3

Veterans Health Administration/Department of Defense, The Management of Opioid 

Therapy for Chronic Pain Working Group, VA/DOD Clinical Practice Guideline for 

Management of Opioid Therapy for Chronic Pain (Washington, D.C.: February 2017). 

Clinical practice guidelines are summaries of potential health care interventions designed 

to assist providers in their decision-making when creating a plan of care for a patient. 

Clinical practice guidelines typically describe the level of evidence associated with each 

intervention and provide recommendations based on that evidence.

Letter
Page 2 GAO-18-380 Veterans Prescribed Opioids

The Comprehensive Addiction and Recovery Act (CARA) of 2016 

requires VA to implement a number of efforts aimed at improving opioid 

safety for veterans. CARA also includes a provision for GAO to assess 

VHA’s recent efforts under the OSI as well as the opioid prescribing 

practices of VHA health care providers.4 In addition, a Senate Report 

accompanying H.R. 2029, enacted as the 2016 Consolidated 

Appropriations Act, included a provision for GAO to review the 

effectiveness of the OSI and overall opioid prescribing patterns 

throughout VHA.5 In this report, we

1. describe key efforts VHA has undertaken since 2013 as a part of the 

OSI;

2. examine the extent to which VHA has met its OSI goals established in 

2014 and implemented certain provisions of CARA related to 

monitoring veterans who are prescribed opioids; and

3. examine the extent to which VHA providers adhere to selected opioid 

risk mitigation strategies and clinical practice guideline 

recommendations related to prescribing opioids.

To describe key efforts VHA has undertaken since 2013 as a part of the 

OSI, we reviewed VHA documents and interviewed VHA Central Office 

officials regarding OSI efforts, including VHA efforts to monitor and 

address opioid prescribing patterns. We also analyzed data VHA collects 

under the OSI on four metrics related to rates of opioid prescribing and 

urine drug screening among certain veterans from the fourth quarter of 

fiscal year 2013 (roughly when the national OSI began at VHA) to the first 

quarter of fiscal year 2018, the most current quarter of data available at 

the time of our review. We also analyzed VHA data from its academic 

detailing programs on the frequency with which program representatives 

consulted with VHA providers on issues related to opioid safety.6 We 

assessed the reliability of the data sources by reviewing relevant 

documentation, interviewing knowledgeable agency officials, and 

reviewing the data for missing values and outliers. Through these steps, 

 4

Comprehensive Addiction and Recovery Act of 2016, Pub. L. No. 114-198, § 913, 130 

Stat. 695, 762. 

5

See Pub. L. No. 114-31,129 Stat. 2242 (2015); S. Rep. 114-57, at 47 (2015).

6

Academic detailing is a program in which trained clinical pharmacists work one-on-one 

with providers to better inform them about evidence-based care related to the appropriate 

treatment of relevant medical conditions.
Page 3 GAO-18-380 Veterans Prescribed Opioids

we determined that the data were sufficiently reliable for the purposes of 

this reporting objective.

To examine VHA’s progress on its 2014 OSI goals, we reviewed VHA 

documents and data relevant to OSI goals, including VHA opioid safety 

training data and OSI metric data. We also interviewed VHA Central 

Office officials, selected Veteran Integrated Service Network (VISN) 

officials, and VHA medical facility officials from 5 of 170 VHA medical 

facilities that we selected for our review.7 We selected the 5 VHA medical 

facilities based on variation in geography and to reflect the full range of 

variation in the rate of change over time in the percentage of veterans 

who have been prescribed an opioid.8 Our findings from the selected 

facilities are not generalizable to all VHA medical facilities. We examined 

VHA’s progress on its OSI goals in the context of federal internal control 

standards for documentation requirements and the establishment and 

review of performance measures and indicators.9 We assessed the 

reliability of the data sources by reviewing relevant documentation, 

interviewing knowledgeable agency officials, and reviewing the data for 

missing values and outliers. Through these steps, for the purposes of this 

reporting objective, we determined that the VISN-level opioid safety 

training assignment data were not reliable; however, all other data 

sources we analyzed were sufficiently reliable. To assess whether VHA is 

meeting certain provisions of CARA related to monitoring veterans who 

 7

VISNs are regional networks that manage the VHA medical facilities located in their 

region. In October 2015, VHA began to implement a realignment of its VISN boundaries 

which will result in the number of its VISNs decreasing from 21 to 18. For the purposes of 

this report, “VHA medical facilities” refers to medical centers, health care systems, or 

outpatient centers, including any affiliated community-based clinics.

8

Based on the OSI metric represented by the percentage of patients dispensed an opioid, 

we calculated the change over time from quarter 4, fiscal year 2012 through quarter 1, 

fiscal year 2017 for all VHA facilities, including the average change over time of all 

facilities. We selected one facility that exhibited the average change, two facilities above 

the average change, and two facilities below the average change. All facilities experienced 

a decrease in this metric over this time period except one, which experienced no change, 

while one facility in Manila, Philippines experienced an increase. Our selection process 

resulted in one facility that had among the greatest decreases and one facility that had 

among the lowest decreases. The VHA medical facilities we included in our review are 

based in Roseburg, OR (VISN 20); Hampton, VA (VISN 6); Columbus, OH (VISN 10); 

Tuscaloosa, AL (VISN 7); and Minneapolis, MN (VISN 23).

9

GAO, Standards for Internal Control in the Federal Government, GAO-14-704G 

(Washington, D.C.: Sept. 10, 2014) and Standards for Internal Control in the Federal 

Government, GAO/AIMD-00-21.3.1 (Washington, D.C.: Nov. 1, 1999). Internal control is a 

process effected by an entity’s management, oversight body, and other personnel that 

provides reasonable assurance that the objectives of an entity will be achieved. 
Page 4 GAO-18-380 Veterans Prescribed Opioids

are prescribed opioids, we interviewed VHA Central Office officials and 

reviewed documents related to these provisions.10

To examine the extent to which VHA providers adhere to selected opioid 

risk mitigation strategies and clinical practice guideline recommendations 

related to prescription opioid therapy, we focused on three key VHA 

opioid risk mitigation strategies and three VA/DOD clinical practice 

guideline recommendations—all of which, generally speaking, are strong 

evidence-based strategies for reducing the potential health risks 

associated with opioid use.11 The three opioid risk mitigation strategies 

are the following:

• an annual urine drug screening for patients on long-term opioid 

therapy (defined by VHA as having had a 90-day supply in the last 6 

months; increasing these screenings is an explicit goal of the OSI;

• a VHA-required annual query of a prescription database maintained 

by a state prescription drug monitoring program when prescribing 

controlled substances, including opioids, to check for whether patients 

are receiving multiple prescriptions;12 and

• obtaining written informed consent from patients on the use of opioids 

so that they have an informed understanding of the medications’ risks 

and benefits, as required by VHA policy.13

 10CARA requires VHA to ensure that the Opioid Therapy Risk Report (OTRR), an opioid 

safety monitoring tool, has the ability to track whether a provider prescribed opioids to a 

veteran without first checking the information in the tool and to include in the OTRR 

information on the most recent time the tool was accessed by a provider. In addition, 

CARA requires VHA to modify its electronic medical record system to notify providers if a 

veteran is receiving opioid therapy and has a history of substance use disorder or prior 

overdose; has a history of opioid abuse; or is at risk of developing an opioid use disorder. 

11VA/DOD Clinical Practice Guideline for Management of Opioid Therapy for Chronic 

Pain. The guideline contains 18 recommendations. 

12Veterans Health Administration, Querying State Prescription Drug Monitoring Programs, 

VHA Directive 1306 (Washington, D.C.: Oct.19, 2016). This requirement is subject to 

limitations imposed by states on VA’s access to state prescription drug monitoring 

databases.

13Veterans Health Administration, Informed Consent for Long-Term Opioid Therapy for 

Pain, VHA Directive 1005 (Washington, D.C.: May 6, 2014). This requirement does not 

apply to patients enrolled in hospice or patients receiving long-term opioids for cancer 

pain.
Page 5 GAO-18-380 Veterans Prescribed Opioids

The three clinical practice guideline recommendations are the following:

• the use of non-pharmacological treatments (such as cognitive 

behavioral therapy and yoga) in addition to or in lieu of opioid therapy;

• the prescribing of naloxone to help reverse opioid overdoses; and

• appropriate follow-up visits with a provider after an opioid is 

prescribed and after an opioid prescription is changed.14

To assess adherence to these opioid risk mitigation strategies and 

guideline recommendations, we reviewed a random, nongeneralizable 

sample of medical records for 103 veterans who had received long-term 

opioid therapy between March 1, 2016 and March 31, 2017. The 103 

records we reviewed included a minimum of 20 records each from our 

five selected facilities. The sample of records also included records for 50 

veterans at a greater risk of adverse events due to opioid use, including 

25 veterans who received benzodiazepines concurrently with an opioid 

and another 25 veterans who were categorized as “very high” risk in 

VHA’s opioid safety monitoring tool, the Stratification Tool for Opioid Risk 

Mitigation (STORM), during the summer and fall of 2017 when the 

medical record review was conducted.15 As part of our work, we also 

reviewed relevant documents and interviewed officials from the five 

selected VHA medical facilities, the VISNs associated with the facilities, 

and VHA Central Office.

 14Guidance on the appropriate timing of pain management follow-up visits is provided in 

both the 2017 and 2010 VA/DOD clinical practice guidelines. Under the 2017 

recommendation, follow-up pain management visits should be scheduled at least every 1-

4 weeks after any change in medication regimen and at least once every 1-3 months for 

the duration of the therapy. This was a change from the 2010 recommendation, which we 

used for our analysis. The 2010 recommendation states that follow-up visits should be 

scheduled at least every 2-4 weeks after any change in medication regimen and at least 

once every 1-6 months for the duration of the therapy. 

15Benzodiazepines are a type of depressant that, among other things, produces sedation 

and relieves anxiety (e.g., Valium and Xanax). According to the 2017 VA/DOD clinical 

practice guideline for chronic pain, there is evidence that using opioids and 

benzodiazepines concurrently increases the risk of overdose and overdose death and 

therefore is not recommended. STORM is a clinical tool that provides 1-year and 3-year 

risk categories (i.e., low, medium, high, and very high) reflecting a patient’s risk of an 

adverse event if opioids are prescribed, based on the veteran’s individual medical history 

and characteristics. The 25 veterans we reviewed had “very high” risk categories for both 

the 1-year and 3-year estimates. For example, a patient with an 18 percent risk of a 

suicide- or overdose-related health care event or death in the next year would be 

categorized as “very high” risk by the tool. 
Page 6 GAO-18-380 Veterans Prescribed Opioids

We conducted this performance audit from November 2016 to May 2018 

in accordance with generally accepted government auditing standards. 

Those standards require that we plan and perform the audit to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions based on our audit objectives. We believe that 

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives.

To help ensure that veterans are prescribed and use opioid pain 

medications in a safe and effective manner, VHA launched its OSI 

nationally in 2013. VHA established nine OSI goals in a December 2014 

memorandum. For each of the goals, VHA directed its VISNs and their 

associated VHA medical facilities to take specified actions to meet the 

goals. (See table 1.)

Table 1: Veterans Health Administration (VHA) Opioid Safety Initiative (OSI) goals and required actions, December 2014

OSI goal VHA-required action 

(1) Educate opioid prescribers regarding the effective 

use of urine drug screening

Veteran Integrated Service Networks (VISN) will establish a network-wide 

standardized education program by December 31, 2014

(2) Increase the use of urine drug screening Urine drug screening targets based on previous urine drug screening rates 

for all VHA facilities by quarter 2, fiscal year 2015

(3) Facilitate the use of prescription drug monitoring 

program databases containing patient-level information 

on prescriptions for controlled substances

VISNs must certify by quarter 2, fiscal year 2015 that facilities have an 

education program that consists of training and/or education materials for 

providers

(4) Establish safe and effective VISN tapering 

programs for veterans using opioids and 

benzodiazepines

VISNs must develop local tapering protocols and plans to resource the 

implementation of those tapering protocols

(5) Develop tools to identify veterans at a higher risk 

for adverse events while using opioids

Develop an opioid risk stratification toolkit; opioid safety education guides 

must be updated annually

(6) Improve prescribing practices around long-acting 

opioid formulations

VISNs need to develop local tapering protocols and plans to resource the 

implementation of those tapering protocols

(7) Review treatment plans for veterans on high doses 

of opioids

VISN certification that patients with greater than a 200 morphine milligram 

equivalent dose per day have been reviewed by quarter 2, fiscal year 2015

(8) Offer complementary and alternative medicine 

modalities for chronic pain at all medical facilities

Each facility must provide evidence that at least two evidence-based 

behavioral/psychological treatments or approved complementary or 

alternative modalities can be provided by quarter 2, fiscal year 2015a

Background

OSI goals and related 

requirements
Page 7 GAO-18-380 Veterans Prescribed Opioids

OSI goal VHA-required action 

(9) Develop new models of mental health and primary 

care collaboration to manage the prescribing of opioids 

and benzodiazepines in patients with chronic pain

Identify strong practices that can be operationalized across VHA by quarter 3, 

fiscal year 2015; a request for proposal to be released to the field to establish 

model interdisciplinary teams and strategies for management and tapering of 

medications at three VHA medical facilities

Source: VHA. | GAO-18-380

a

According to VHA, evidence-based behavioral/psychological treatments include cognitive behavioral 

therapy for pain and relaxation practices, and approved complementary and alternative modalities 

include acupuncture, acupressure, yoga and progressive relaxation.

VHA has also developed opioid risk mitigation strategies for its providers 

to follow when prescribing opioid pain medications to veterans. These key 

strategies include one whose increased use is an explicit goal for the OSI 

and two that are requirements in VHA policy.

1. Annual urine drug screening for veterans on long-term opioid therapy. 

Providers should generally ensure that a urine drug screening has 

been conducted for veterans who are on long-term opioid therapy at 

least once in the 365 days prior to initiating or renewing an opioid 

prescription.16 Urine drug screening allows providers to monitor the 

types of drugs that are in a veteran’s system, including controlled and 

illicit substances. Increasing the use of urine drug screening is OSI 

goal two.

2. Annual prescription drug monitoring program (PDMP) query. PDMPs 

are state-run electronic databases used to track the prescribing and 

dispensing of prescriptions for controlled substances, identify 

suspected misuse or diversion (i.e., channeling drugs into illegal use), 

and identify trends in drug utilization. In 2016, VHA began requiring in 

policy that providers query state PDMPs at least once annually when 

prescribing opioids to determine whether their patients have received 

prescriptions for opioid medications or other controlled substances 

from non-VA providers.17

3. Informed consent for long-term opioid therapy. In 2014, VHA began 

requiring in policy that providers educate their patients on the risks 

 16VHA defines long-term opioid therapy as having had a 90-day supply or more of opioids 

in the last 6 months.

17Veterans Health Administration, Querying State Prescription Drug Monitoring Programs, 

VHA Directive 1306 (Washington, D.C.: Oct.19, 2016). This requirement is subject to 

limitations imposed by states, which can impact VHA providers’ access to PDMP 

databases. According to VHA policy, providers should follow state regulations for PDMP 

queries if these regulations are more stringent than VHA’s policy. 
Page 8 GAO-18-380 Veterans Prescribed Opioids

associated with the use of prescription opioids and to obtain veterans’ 

formal acknowledgment of these risks in writing prior to initiating longterm opioid therapy.18

In 2010, in coordination with DOD, VA developed clinical practice 

guidelines for its providers to use when prescribing opioids for chronic 

pain. These guidelines were updated in 2017.19 While clinical practice 

guidelines contain evidence-based recommendations, they are not 

required to be followed in all clinical situations; therefore, variations in 

practice may occur based on individual patient needs subject to the 

discretion of the provider.

The 2017 VA/DOD clinical practice guidelines related to opioid therapy for 

chronic pain generally complement VHA’s OSI goals. For example, the 

guidelines recommend a conservative use of opioids for chronic pain and 

emphasize strategies to mitigate the risk of using opioids. The evidencebased clinical practice guideline recommendations include the following:

1. Use of non-pharmacological treatments. The guidelines advise not 

initiating opioid therapy for chronic pain. They also recommend 

alternatives to opioid therapy, such as non-opioid medications and 

non-pharmacological treatments. Non-pharmacological treatments for 

chronic pain include, for example, cognitive behavioral therapy and 

yoga.

2. Naloxone prescribing. Naloxone is a highly effective, potentially lifesaving intervention for reversing opioid overdoses, and it can be 

prescribed to veterans as a preventive measure. Veterans who are 

prescribed naloxone can use it when experiencing an overdose or a 

family member can administer it on their behalf. According to the 

clinical practice guidelines, naloxone should be offered as an antidote 

 18Veterans Health Administration, Informed Consent for Long-Term Opioid Therapy for 

Pain, VHA Directive 1005 (Washington, D.C.: May 6, 2014). This requirement does not 

apply to patients enrolled in hospice or patients receiving long-term opioids for cancer 

pain.

19A Senate report directed VA, in consultation with DOD, to update its clinical practice 

guideline for chronic pain no later than December 31, 2016. See S. Rep. No. 114-57, at 46 

(2015). According to a VHA official, generally speaking, the recommendations contained 

in the VA/DOD clinical practice guideline for opioid therapy for chronic pain are largely 

consistent with the Centers for Disease Control’s 2016 Guideline for Prescribing Opioids 

for Chronic Pain. See Centers for Disease Control, CDC Guideline for Prescribing Opioids 

for Chronic Pain – United States, 2016 (Atlanta: March 18, 2016). 

Clinical Practice 

Guidelines for the 

Treatment of Chronic Pain
Page 9 GAO-18-380 Veterans Prescribed Opioids

to all patients at risk for an opioid overdose, including those who are 

in the process of tapering from opioids.20 The guidelines describe 

several significant risk factors which can indicate the prescribing of 

naloxone, including the duration and dose of opioids, current or 

history of depression or substance use disorder, and suicidality.

3. Appropriate follow-up visits with a provider. According to the 

guidelines, follow-up pain management visits should be scheduled at 

least every 1-4 weeks after any change in medication regimen and at 

least once every 1-3 months for the duration of the therapy to help 

ensure that the treatment plan is optimized.21

VHA officials told us that the main focus of the OSI is changing the 

prescribing patterns of providers to better align with evidence-based 

practices. We found that this has been carried out by VHA through three 

key efforts: tracking opioid prescribing rates and other trends, identifying 

irregular prescribing patterns, and educating providers on best practices 

through academic detailing.

Tracking Opioid Prescribing Patterns. Under the OSI, VHA uses quarterly 

data derived from VHA’s electronic medical record system to monitor 

prescription opioid use among veterans, the related prescribing patterns 

of VHA providers, and the rates of urine drug screening for veterans 

receiving long-term opioid therapy.22 Specifically, VHA tracks the 

following four clinical indicators, known as the OSI metrics, for each of its 

medical facilities:

1. the percentage of patients dispensed an opioid,

2. the percentage of patients dispensed an opioid and a benzodiazepine,

 20CARA directs VHA to maximize the availability of naloxone to veterans and to ensure 

that veterans who are considered at risk for opioid overdose have access to naloxone and 

training on its proper administration. Comprehensive Addiction and Recovery Act of 2016, 

Pub. L. No. 114-198, § 911(e)(1), 130 Stat. 695, 759. 

21This 2017 recommendation represents a change from the 2010 clinical practice 

guideline, which states that follow-up visits should be scheduled at least every 1-4 weeks 

after any change in medication regimen and at least once every 1-6 months for the 

duration of the therapy.

22VHA defines long-term opioid therapy as having had a 90-day supply or more of opioids 

in the last 6 months. VHA began making the quarterly opioid prescribing data it tracks 

publicly available in January 2018. See 

https://www.data.va.gov/story/department-veterans-affairs-opioid-prescribing-data (last 

access date: March 14, 2018). 

Under Its OSI, VHA 

Tracks Opioid 

Prescribing Patterns, 

Identifies Prescribing 

Outliers, and 

Educates Prescribers
Page 10 GAO-18-380 Veterans Prescribed Opioids

3. the percentage of patients on long-term opioid therapy who received a 

urine drug screen within the previous year of having their prescription 

filled, and

4. the percentage of patients dispensed greater than or equal to 100 

morphine milligram equivalents per day.23

Our analysis of quarterly OSI metric data shows that since the beginning 

of the OSI in the fourth quarter of fiscal year 2013 to the first quarter of 

fiscal year 2018 (the most recent data available at the time of our review), 

the percentage of veterans dispensed an opioid has decreased by 7 

percentage points, or roughly 267,000 veterans, while the rate of urine 

drug screening for veterans on long-term opioid therapy increased 

significantly—by over 47 percentage points. The increase in the 

percentage of patients receiving a urine drug screening was driven more 

by a reduction in the total number of patients on long-term opioid therapy 

(about 197,000 veterans) than an increase in the number of patients 

receiving the screening (about 27,000 veterans). (See table 2.)

Table 2: Changes in Veterans Health Administration (VHA) Opioid Safety Initiative (OSI) metrics, Fourth Quarter Fiscal Year 

2014 through First Quarter, Fiscal Year 2018

OSI metric

Fiscal year 2013

(4th quarter)

Fiscal year 2018

(1st quarter)

Percentage point change

Percentage of patients 

dispensed an opioida 16.7(665,786 of 3,984,165 patients)

9.7

(398,899 of 4,130,536 patients)

- 7.1

(- 266,887 patients)

Percentage of patients 

dispensed an opioid and a 

benzodiazepineb

13.2

(116,739 / 885,142)

6.6

(36,938 / 558,199)

- 6.6

(- 79,801)

Percentage of patients on longterm opioid therapy having 

received a urine drug screen 

within the previous year of 

having their prescription filledc

42.2

(182,194 / 431,694)

89.2

(209,102 / 234,392)

+ 47.0e

(+ 26,908)

Percentage of patients 

dispensed greater than or equal 

to a 100 morphine milligram 

equivalents per dayd

6.5

(56,831 / 869,956)

4.4

(23,968 / 543,782)

- 2.1

(- 32,863)

Source: VHA. | GAO-18-380

Notes: 4th quarter, fiscal year 2013=July to September 2013. 1st quarter, fiscal year 2018=October to 

December 2017.

 23The 2017 VA/DOD clinical practice guideline for chronic pain does not recommend 

opioid doses of greater than 90 morphine milligram equivalents per day.
Page 11 GAO-18-380 Veterans Prescribed Opioids

a

Denominator=patients who were dispensed at least one outpatient prescription during the reporting 

timeframe.

b

Denominator=patients who were dispensed opioids, including tramadol, in the reporting timeframe.

c

Denominator=patients who were dispensed at least one opioid medication in the reporting timeframe 

and had a total supply of opioids greater than or equal to 90 days for the selected quarter and the 

prior quarter. Increasing the use of urine drug screening is an explicit goal of the OSI.

d

Denominator=patients who were dispensed opioids, including tramadol, in the reporting timeframe. 

The 2017 VA/DOD clinical practice guideline for chronic pain does not recommend opioid doses of 

greater than 90 morphine milligram equivalents per day.

e

The increase in the rate of urine drug screening was driven more by a reduction in the number of 

veterans on long-term opioid therapy than an increase in the number of veterans receiving screening 

over time.

Identifying Irregular Prescribing Patterns. As part of its monitoring of the 

OSI metrics, VHA Central Office has periodically identified VHA medical 

facilities and VHA providers who deviate from average prescribing rates 

across VHA. For example:

• Facilities. In 2014, VHA Central Office identified 39 of 140 medical 

facilities across 12 VISNs with relatively higher rates of opioid 

dispensing as outliers based on the OSI metric percentage of 

veterans dispensed an opioid.24 VHA Central Office notified the VISNs 

of these facilities and required each facility to submit a corrective 

action plan to VHA Central Office outlining the actions they would take 

to reduce opioid prescribing. Based on our analysis of VHA 

documents, we found that the identified facilities in the five VISNs 

selected for our review submitted information in response to VHA 

Central Office’s request.25

• Providers. In February 2017, VHA Central Office identified 320 

outliers out of 8,351 providers at 94 VHA medical facilities based on 

the relatively high proportion of their patients who were prescribed 

opioids.26 VHA Central Office directed the VHA medical facilities 

 24Outlier VHA medical facilities were flagged if the facility’s rate of decrease in opioid 

dispensing between fiscal year 2012 to fiscal year 2014 was less than the national rate of 

decrease, or if opioid dispensing increased during this time period.

25We did not review the extent to which these VHA medical facilities completed the steps 

identified in their action plan or the extent to which VISNs or VHA Central Office monitored 

the completion of the action plans.

26Providers were identified as outliers if (1) the provider wrote at least one opioid 

prescription; (2) prescribed at least one medication of any type to a minimum of 150 

veterans from October 2016 through December 2016; and (3) the provider’s percentage of 

opioid prescriptions was greater than two standard deviations from the national mean for 

the same time period.
Page 12 GAO-18-380 Veterans Prescribed Opioids

associated with these outlier providers to review their prescribing 

rates in the context of their clinical practice, and to report back with 

any feedback given or actions taken. According to officials from the 

five facilities in our review, outlier providers tended to be surgeons, 

pain management specialists, or physical rehabilitation providers who 

might be expected to prescribe opioids at a higher-than-average rate 

due to the nature of their specialty and the types of patients they treat. 

According to a VHA Central Office progress report, the facilities 

provided feedback and follow-up actions for 319 out of 320 outlier 

providers.27 In May 2017, VHA identified a second round of 303 

outliers out of 8,505 providers; 187 of these providers were previously 

identified as outliers in February 2017.28 According to one VHA 

Central Office official, as of September 2017, VHA was reviewing 

these outlier data and will evaluate whether VHA facilities will be 

asked to conduct further reviews of these prescribers.

Educating Providers through Academic Detailing. To help change the 

prescribing patterns of providers, VHA has also implemented a systemwide academic detailing program to educate providers and improve the 

delivery of evidence-based health care at facilities. In 2015, VHA required 

each VISN to establish such a program to improve performance on all 

OSI metrics.29 According to VHA Central Office officials, academic 

detailers are responsible for reviewing facility-level data on the 

prescribing patterns of providers and identifying potential areas of 

improvement. Detailers can educate providers with higher-than-average 

prescribing rates—such as those outliers identified in February and May 

2017 by VHA Central Office—to help ensure providers are delivering safe 

and effective care for pain.

According to VHA, as of January 2018, academic detailers have 

conducted over 20,000 opioid-related visits to VHA providers. According 

to VHA officials, their data also show that academic detailing results in 

greater patient safety for veterans taking opioids. For example, compared 

 27While we discussed these responses with facility officials in our review, we did not verify 

or evaluate any actions taken in response to outlier prescribers. 

28Providers were identified as outliers if (1) the provider wrote at least one opioid 

prescription; (2) prescribed at least one medication of any type to a minimum of 150 

veterans from January 2017 through March 2017; and (3) the provider’s percentage of 

opioid prescriptions was greater than two standard deviations from the national mean for 

the same time period.

29VHA Central Office requires a minimum of three full-time equivalent detailers for each 

VISN. 
Page 13 GAO-18-380 Veterans Prescribed Opioids

with those who did not receive academic detailing visits, providers who 

did receive such visits experienced (1) greater reductions in the 

proportion of their patients on high-dose opioids, (2) reductions in their 

patients’ average morphine milligram equivalent daily dosage, and (3) 

increases in their naloxone prescribing rates.30

 30For example, according to VHA, their data show that from October 2013 to September 

2016, the proportion of patients on high-dose opioids decreased by 58 percent among 

providers who had received an academic detailing visit, compared to a 34 percent 

decrease among providers who did not receive an academic detailing visit. From October 

2015 to September 2016, the average morphine milligram equivalent daily dosage 

decreased 59 percent among providers who met with a detailer, compared to 31 percent 

for those who did not. Finally, 1 year after visiting with a detailer, the average number of 

naloxone prescriptions per month was three times greater among providers who received 

an academic detailing visit compared with those who did not. See M Bounthavong et al. 

“Trends in naloxone prescriptions prescribed after implementation of a National Academic 

Detailing Service in the Veterans Health Administration: A preliminary analysis.” Journal of 

the American Pharmacists Association (2017) S68-S72.

VHA Has Made 

Progress on OSI 

Goals, but

Performance 

Measurement 

Limitations Exist for 

Some Goals and 

Certain CARA 

Provisions Have Not 

Been Fully 

Implemented
Page 14 GAO-18-380 Veterans Prescribed Opioids

Based on our analysis of VHA information, we found evidence suggesting 

that the agency has accomplished six of the nine 2014 OSI goals. For 

example, the agency has seen increases in the use of urine drug 

screening for veterans on long-term opioid therapy, and it has developed 

provider tools to identify veterans at a higher risk for adverse events while 

using opioids. For several goals, although VHA did not implement the 

actions required in all those instances, the agency provided us with 

information or data demonstrating that the goals had effectively been met. 

However, for three OSI goals, it is unclear if the goal has been fully met 

because VHA lacks documentation showing that it has implemented the 

required action under the goal or the required action is still in progress. 

(See table 3.)

Table 3: Status of Veterans Health Administration (VHA) 2014 Opioid Safety Initiative (OSI) Goals as of March 2018

Goals VHA required action(s)

Were these required 

action(s) completed?

Did VHA provide 

documentation that other 

actions met the goal?

(1) Educate opioid prescribers 

regarding the effective use of 

urine drug screening

Each VISN must establish a 

network-wide standardized 

education program by December 

31, 2014

No Yes

(2) Increase the use of urine drug 

screening

Urine drug screening targets 

based on previous urine drug 

screening rates for all VHA 

facilities must be reached by 

quarter 2, fiscal year 2015 (March 

31, 2015)

No Yes

(3) Facilitate the use of 

prescription drug monitoring 

program (PDMP) databases, 

which contain patient-level 

information on prescriptions 

received for controlled 

substances

Each VISN must certify by quarter 

2, fiscal year 2015 (March 31, 

2015), that all facilities have a 

program consisting of PDMP 

training and/or education materials 

for providers

No Yes

(4) Establish safe and effective 

Veteran Integrated Service 

Network (VISN) tapering 

programs for veterans using 

opioids and benzodiazepines

VISNs must develop local tapering 

protocols and plans to resource 

the implementation of those 

tapering protocols

No No. VHA lacks documentation 

related to the required action 

and could not provide 

evidence to indicate the goal 

was accomplished.

(5) Develop tools to identify 

veterans at a higher risk for 

adverse events while using 

opioids

An opioid risk stratification toolkit 

must be developed; opioid safety 

education guides must be updated 

annually

Yes Yes

VHA Has Made Progress 

on Many 2014 OSI Goals, 

but for Some Goals, 

Performance 

Measurement Limitations 

Prevent an Accurate 

Determination of their 

Completion
Page 15 GAO-18-380 Veterans Prescribed Opioids

Goals VHA required action(s)

Were these required 

action(s) completed?

Did VHA provide 

documentation that other 

actions met the goal?

(6) Improve prescribing practices 

around long-acting opioid 

formulations

VISNs must develop local tapering 

protocols and plans to resource 

the implementation of those 

tapering protocols

No Yes

(7) Review treatment plans for 

veterans on high doses of 

opioids

Each VISN must certify that the 

treatment of all patients with 

greater than a 200 morphine 

milligram equivalent dose per day 

has been reviewed by quarter 2, 

fiscal year 2015 (March 31, 2015)

No No. VHA lacks documentation 

related to the required action 

and could not provide 

evidence to indicate the goal 

was accomplished.

(8) Offer complementary and 

alternative medicine modalities 

for chronic pain at all medical 

facilities

Each facility must provide 

evidence that at least one 

evidence-based psychosocial 

service and one approved 

complementary and integrative 

service is available by quarter 2, 

fiscal year 2015 (March 31, 2015)

Yes Yes

(9) Develop new models of 

mental health and primary care 

collaboration to manage the 

prescribing of opioids and 

benzodiazepines in patients with 

chronic pain

Identify strong practices that can 

be operationalized across VHA by 

quarter 3, fiscal year 2015 (June 

30, 2015); a request for proposal 

to be released to the field to 

establish model interdisciplinary 

teams and strategies for 

management and tapering of 

medications at three VHA medical 

facilities

No To be determined. VHA 

reported other actions are 

underway to address this goal.

Source: GAO analysis of VHA information. | GAO-18-380

(See appendix I for a more detailed description of VHA’s known efforts 

and data related to each goal).

When asked about the lack of documentation for two of its OSI goals 

(goals four and seven), VHA officials told us that relevant documentation 

could not be produced. This lack of documentation is inconsistent with 

federal internal control standards. Specifically, according to federal 

internal control standards, management should evaluate and document 

the results of monitoring.31 By not documenting the actions it is taking 

under each of its OSI goals, VHA lacks assurance that these actions have 

been implemented by the VISNs or VHA medical facilities. As a result, 

VHA does not know whether it has fully met these OSI goals.

 31GAO-14-704G and GAO/AIMD-00-21.3.1.
Page 16 GAO-18-380 Veterans Prescribed Opioids

Moreover, for the OSI goal related to establishing safe and effective VISN 

tapering programs for veterans using opioids and benzodiazepines (goal 

four), VHA officials told us that they addressed this goal by issuing 

national tapering guidance, including a provider reference guide in 2014, 

an opioid taper decision tool in 2016, and the VA/DOD clinical practice 

guidelines in 2017. However, these actions do not appear to be sufficient 

for meeting the goal as it is currently written, because issuing national 

guidance alone does not ensure that safe and effective tapering programs 

are established.32 Furthermore, VHA did not specify how safety and 

effectiveness within a tapering program would be measured, nor did the 

agency specify a deadline for the required action as described in 

December 2014. According to federal internal control standards relating 

to the establishment and review of performance measures and indicators, 

government agencies should use appropriate information to adequately 

assess performance, including establishing milestones or numerical 

targets, as appropriate.33 Without clearly defined and measurable 

outcomes, VHA cannot fully assess its progress towards meeting this OSI 

goal.

We also found that VHA has not implemented two CARA requirements 

intended to improve opioid safety for veterans. First, CARA requires that 

VHA’s Opioid Therapy Risk Report (OTRR) have the ability to determine 

whether a provider has prescribed opioids to a veteran without checking 

that veteran’s information in the OTRR.34 Available to providers through 

VHA’s electronic medical record system, OTRR is a clinical tool that 

provides information on any opioid and concurrent benzodiazepine 

 32VHA officials told us they have not updated the 2014 OSI goals since the December 

2014 memo was issued. According to one VHA official, CARA requirements and the 

issuance of the VA/DOD clinical practice guideline for chronic pain superseded the 2014 

OSI goals and made any follow-up of the 2014 OSI goals obsolete. However, VHA did not 

provide any documentation during our review indicating that VHA Central Office 

determined that the 2014 OSI goals became obsolete given new priorities or that this 

determination was communicated to the medical facilities.

33GAO-14-704G and GAO/AIMD-00-21.3.1.

34CARA requires the Secretary to include in the OTRR tool information on the most recent 

time the tool was accessed by a provider with respect to each veteran as well as 

information on the results of the most recent urine drug test for each veteran. See Pub. L. 

No. 114-198, § 911(f), 130 Stat. 695, 759. CARA also states that the Secretary shall 

establish guidance that each provider, before initiating opioid therapy to treat a patient as 

part of the comprehensive assessment conducted by the health care provider, use the 

OTRR tool (or any subsequent tool). Pub. L. No. 114-198, § 911(a)(2), 130 Stat. 695, 756.

VHA Has Not 

Implemented Certain 

CARA Requirements 

Related to Monitoring 

Veterans Prescribed 

Opioids
Page 17 GAO-18-380 Veterans Prescribed Opioids

prescriptions a veteran is receiving, the veteran’s current and prior health 

conditions, recent and upcoming appointments, and whether any opioid 

risk mitigation strategies have been employed (such as urine drug 

screening or PDMP query).35 However, we found that VHA Central Office 

cannot track the extent to which VHA providers use OTRR because this 

tool does not have this tracking capability.36 VHA officials said that adding 

tracking capabilities to OTRR is not a high priority for the agency due to 

limited resources and competing priorities. Instead, according to a draft 

memorandum, VHA Central Office is planning to address this CARA 

provision by requiring VHA providers to document the use of OTRR in a 

standardized way that VHA can monitor. However, as of March 2018, 

VHA has not established this requirement or outlined the process for 

monitoring providers’ use of OTRR. Without the ability to track the use of 

OTRR, VHA cannot sufficiently monitor whether providers are using the 

tool to help reduce the likelihood of opioid-related adverse events 

occurring among veterans receiving care through VHA.

CARA also requires that VHA modify its electronic medical record system 

so that any provider who accesses the record of a veteran will be notified 

whether that veteran is receiving opioid therapy and has a history of 

substance abuse disorder or prior instances of overdose; has a history of 

opioid abuse; or is at risk of developing an opioid use disorder. However, 

we found that VHA does not plan to modify its electronic medical record 

system to implement this capability. When asked about this provision in 

CARA, VHA officials said that VHA’s medical record currently has realtime alerts to inform providers about veterans’ existing opioid 

prescriptions and that any patient exposed to an opioid could be at risk of 

developing an opioid use disorder. Additionally, they said that an alert 

regarding current or past history of opioid use disorder could have an 

 35VHA has another tool, STORM, available to providers to help monitor patients 

prescribed opioids. It provides risk scores based on veterans’ individual medical histories 

and characteristics indicating the risk of an adverse event if opioids are prescribed. To 

help providers determine the level of risk if an opioid prescription is started, increased, or 

reduced, hypothetical risk scores are available to providers through STORM. According to 

VHA officials, the agency plans to meet some CARA requirements with STORM rather 

than OTRR. 

36VHA is able to track generally how many times providers have accessed OTRR, but 

OTRR cannot provide any more specific details, such as which providers accessed the 

tool and whether they did so prior to initiating opioid therapy for a particular veteran. In the 

case of STORM, officials said that they can tell whether providers have accessed 

STORM, but they cannot track which particular veterans were reviewed. 
Page 18 GAO-18-380 Veterans Prescribed Opioids

unintended consequence of discouraging veterans from reporting their 

medical history due to the stigma surrounding drug use disorders.

Our review of selected VHA medical facilities shows that providers do not 

always follow three key opioid risk mitigation strategies, two of which are 

required under VHA policy. Specifically, increasing the use of urine drug 

screening is an explicit goal of the OSI, and providers should generally 

ensure that an annual urine drug screening has been conducted. VHA 

policy requires providers to 1) query state PDMPs at least annually when 

prescribing opioids to determine if the veteran has obtained opioid 

medications or other controlled substances from a non-VA provider and 

2) obtain written informed consent from patients about the risks of 

initiating long-term opioid therapy. These strategies are intended to help 

ensure that patients at VHA medical facilities are safely prescribed opioid 

medications. Overall, based on our review of 103 veterans at five 

selected facilities, we found that 75 percent of the veterans in our sample 

VHA Providers Do 

Not Always Adhere to 

Required Opioid 

Safety Risk Mitigation 

Strategies and 

Guideline 

Recommendations for 

Prescribing Opioids in 

a Safe Manner

VHA Providers at Selected 

Medical Facilities Do Not 

Consistently Follow Opioid 

Risk Mitigation Strategies
Page 19 GAO-18-380 Veterans Prescribed Opioids

had an annual urine screening, 26 percent had their names queried in a 

PDMP, and 70 percent provided informed consent.37

Provider Adherence to Three Veterans Health Administration (VHA) Opioid Risk Mitigation Strategies at Five Selected 

Medical Facilities, March 2016 through March 2017

Increasing the use of urine drug screening is an explicit goal of VHA’s Opioid Safety Initiative (OSI), and providers should generally 

ensure that an annual urine drug screening has been conducted. VHA policy requires providers to (1) query state prescription drug 

monitoring programs (PDMP) at least annually when prescribing opioids to determine if the veteran has obtained opioid medications 

or other controlled substances from a non-VA provider, and (2) obtain written informed consent from patients about the risks of 

initiating long-term opioid therapy. However, our review of medical records for a random nongeneralizable selection of 103 veterans 

subject to these risk mitigation strategies found that 

Of the 53 veterans who received long-term opioid therapy:a

• 32 veterans received an annual urine drug screening, which allows providers to monitor the types of medications in a 

veteran’s system, including controlled and illicit substances;

• 13 veterans had their names queried annually in a state PDMP to see if they had received prescriptions for controlled 

substances, including opioids from non-VHA prescribers; and

• 41 veterans had provided informed consent indicating that they had been educated on the risks and benefits of opioid use.

Of the 25 veterans prescribed an opioid and benzodiazepine concurrently:

• 17 veterans received an annual urine drug screening;

• 8 veterans had an annual PDMP query; and

• 22 veterans had provided informed consent.

Of the 25 veterans with the highest risk of an adverse event, such as a suicide, overdose, fall, or accident, based on their Stratified 

Tool for Opioid Risk Mitigation (STORM) risk score:b

• 24 veterans received an annual urine drug screening; 

• 5 veterans had an annual PDMP query; and

• 11 veterans had provided informed consent.

Source: GAO analysis of veterans’ medical records. | GAO-18-380

 37Our findings related to urine drug screening and informed consent at the five selected 

VHA medical facilities are consistent with VHA data for all of its medical facilities. For the 

period April 1, 2017 through June 31, 2017, VHA data show that nationwide about 87 

percent of veterans on long-term opioid therapy received an annual urine drug screening. 

For the period January 1, 2017 through March 31, 2017, about 83 percent of veterans who 

were prescribed long-acting or chronic short-acting (excluding schedule IV and V) opioids 

provided informed consent. However, our results are not consistent with nationwide VHA 

data for the period April 1, 2017 through June 31, 2017 showing that about 63 percent of 

veterans for whom long-acting or chronic short-acting opioids were prescribed had their 

names queried in a PDMP. This inconsistency is partly due to the fact that VHA did not 

require providers to query the PDMP until October 2016, 7 months into our review of 

patients from March 2016 to March 2017.
Page 20 GAO-18-380 Veterans Prescribed Opioids

a

VHA defines long-term opioid therapy as a 90-day supply of opioid medication prescribed in a 6-

month period.

b

The Stratified Tool for Opioid Risk Management (STORM) is designed to help providers estimate 

veteran risk for an overdose or suicide-related event and provide suggested interventions to mitigate 

that risk. It provides 1-year and 3-year risk categories (i.e., low, medium, high, and very high) 

reflecting a patient’s risk of an adverse event if opioids are prescribed, based on the veteran’s 

individual medical history and characteristics. The 25 veterans we reviewed had “very high” risk 

categories for both the 1-year and 3-year estimates. For example, a patient with an 18 percent risk of 

a suicide- or overdose-related health care event or death in the next year would be categorized as 

“very high” risk by the tool.

We identified a number of factors that may have contributed to the 

inconsistent adherence to the three key opioid risk mitigation strategies at 

our selected VHA medical facilities. These factors may impede providers’ 

ability to consistently follow these strategies for all applicable patients at 

these facilities. To the extent that these factors are present across other 

facilities, VHA’s ability to ensure that all veterans are prescribed opioids in 

a safe and effective manner may be limited.

PDMP access issues. Officials at four of the five selected medical 

facilities faced PDMP access issues. Officials at two facilities told us that 

not all facility staff can access state PDMPs due to state laws and 

regulations that do not allow access to all types of providers, such as 

nurses and pharmacists.38 Officials at one of these selected facilities 

explained that nurse practitioners in that state cannot access the state’s 

PDMP, so they must rely on other providers to obtain information from the 

PDMP about their patients. In addition, in some states, only providers 

licensed in the state may access the state’s PDMP. Because providers at 

VHA facilities may not be licensed in the state where the VHA facility is 

located but licensed in another state, these providers may be unable to 

access the state’s PDMP. Officials at two selected facilities also 

described difficulties accessing PDMPs in neighboring states that are part 

of the catchment area for the facility and where the veteran may reside.

The low rates of adherence we identified may also be attributed to the 

fact that VHA did not require providers to query the PDMP until October 

2016, 7 months into our review of patients from March 2016 to March 

2017.

CARA directed VA to ensure access by VHA providers to information on 

controlled substances prescribing through state PDMPs, including by 

 38The VHA directive requiring that providers query PDMPs notes that the requirement is 

subject to limitations imposed by states, which can impact VHA providers’ access to 

PDMP databases.
Page 21 GAO-18-380 Veterans Prescribed Opioids

seeking to enter into memoranda of understanding with states to allow 

shared access of such information between states and the VA. According 

to VHA officials, VHA Central Office has not taken steps to develop 

memoranda of understanding with states, nor has it developed any 

related guidance. Officials said this issue is likely being addressed by 

individual VISNs and medical facilities. In addition, VHA officials told us 

they have communicated with Members of Congress and the National

Governors Association to address issues related to VHA provider access 

to the state PDMPs.39

Lack of required staff to support providers. We also found that not all of 

the selected medical facilities and their respective VISNs had filled 

required staff positions that can help ensure provider adherence to opioid 

risk mitigation strategies—specifically, academic detailers and pain 

champions.

• At the time of our review, not all facilities had access to VISN 

academic detailing services, which, according to VHA, can help 

ensure that providers follow opioid risk mitigation strategies. While 

VHA officials said that most VISNs across VHA had implemented an 

academic detailing program as required by VHA policy, two of the five 

VISNs for the selected facilities in our review had not.40 Nationally, as 

of March 2018, four VISNs had not implemented an academic 

detailing program. Additionally, 11 facilities across VHA had not 

received a visit from a detailer.

• At the time of our review, four of five selected facilities did not have a 

Pain Champion as required by VHA policy beginning in March 2015.41

Pain champions are generally primary care providers knowledgeable 

about pain care who can serve as a resource for other primary care 

 39An assessment of legal challenges affecting VHA providers’ access to state PDMPs was 

outside the scope of our review.

40VHA requires that all VISNs fully implement an academic detailing program by 

September 30, 2015, defined as having at least three full time equivalent detailers. 

According to VHA Central Office officials, some VISNs have not met this requirement due 

to limits on the number of full time equivalent positions at the VISN. See VHA 

Memorandum, System-wide Implementation of Academic Detailing and Pain Program 

Champions (Washington, D.C.: March 27, 2015).

41VHA policy requires each medical facility to maintain a 0.25-0.50 full-time equivalent 

pain champion serving in primary care. See VHA Memorandum, System-wide 

Implementation of Academic Detailing and Pain Program Champions (Washington, D.C.: 

March 27, 2015). 
Page 22 GAO-18-380 Veterans Prescribed Opioids

providers by promoting safe and effective pain care. According to 

VHA officials, pain champions play a critical role in opioid safety and 

can help providers remedy gaps in pain care management for 

individual patients, such as incomplete opioid risk mitigation 

strategies.

Lack of clinical opioid safety alerts. Another factor that may limit 

adherence to the opioid risk mitigation strategies is the fact that none of 

the selected facilities employ electronic reminders to help remind primary 

care nurses of strategies that have not been completed. Primary care 

nurses are typically responsible for ensuring adherence to these 

strategies, and VHA facilities often employ electronic alerts to notify 

providers when certain tasks need to be completed, such as regular 

screenings for depression and traumatic brain injury. Although VHA 

facilities are not required to develop these alerts, according to some 

primary care nurses we interviewed, it would be helpful to receive a 

reminder when a veteran is due for a PDMP query, urine drug screening, 

or has not given long-term opioid use informed consent. According to the 

nurses, such an alert could be issued through the electronic medical 

record system.42

Limited facility monitoring. We found that facilities’ monitoring of provider 

adherence to the opioid risk mitigation strategies was limited across the 

five selected facilities in our review, which could hinder identification of 

non-adherence to these strategies. Specifically, while we found that all 

five medical facilities and VISNs in our review have an active pain 

management committee, facility officials told us that three of five facility 

committees do not conduct regular medical record reviews, which VHA 

encourages under its pain management directive to improve pain 

management.43 The directive states that facility pain management 

committees should monitor the pain management practices at their 

facility. For example, the pain management committee could monitor 

providers’ care plans for individual veterans, which are to be documented 

in the veterans’ medical records. These types of medical record reviews 

 42According to facility officials, one facility in our review has alerts to remind prescribers to 

order a urine drug screening or query the PDMP when ordering an opioid. However, these 

alerts are not visible to primary care nurses.

43VHA’s Pain Management Directive provides policy and implementation procedures for 

the improvement of pain management consistent with the VHA National Pain 

Management Strategy and compliance with generally accepted pain management 

standards of care. See VHA Directive 2009-053, Pain Management, (Washington, D.C.; 

October 28, 2009). 
Page 23 GAO-18-380 Veterans Prescribed Opioids

could help identify providers who are not adhering to VHA’s opioid safety 

requirements.

We also found that some VHA providers at selected facilities do not 

consistently follow selected clinical practice guideline recommendations 

related to opioid safety. Our findings are based on our review of a random 

selection of medical records for 103 veterans prescribed opioids between 

March 2016 and March 2017. These guidelines recommend, for example, 

that providers consider using non-pharmacological treatments, such as 

acupuncture and yoga, for chronic pain and prescribe naloxone, a 

potentially lifesaving drug, as warranted. The guidelines provide 

evidence-based recommendations designed to assist in provider 

decision-making; however, they are not VHA requirements and variations 

in practice will occur based on provider discretion and the needs of 

individual patients. Overall, we found that, 20 percent of veterans in our 

sample were prescribed a non-pharmacological therapy, 23 percent of the 

veterans were prescribed naloxone, 54 percent had appropriate 

maintenance follow-up visits with a provider while prescribed opioids, and 

17 percent had appropriate follow-up visits with a provider after a change 

in their opioid prescription.

Some VHA Providers Do 

Not Consistently Follow 

Clinical Practice Guideline 

Recommendations 

Related to Opioid Safety
Page 24 GAO-18-380 Veterans Prescribed Opioids

Provider Adherence to Selected Clinical Practice Guideline Recommendations for Management of Opioid Therapy for 

Chronic Pain at Five Selected Veterans Health Administration (VHA) Medical Facilities, March 2016 through March 2017

Clinical practice guidelines provide evidence-based recommendations designed to assist in provider decision-making; however, they 

are not VHA requirements and variations in practice will occur based on provider discretion and the needs of individual patients. Our 

review of medical records for a random, nongeneralizable selection of 103 veterans subject to the recommendations found that 

Of the 53 veterans who had been prescribed long-term opioids:a

• 11 veterans were prescribed a non-pharmacological therapy, such as yoga, or cognitive behavioral therapy;

• 13 veterans were prescribed naloxone, which is a highly effective intervention for reversing an overdose;

• 29 veterans had a maintenance follow-up visit at least once every 30-180 days for the duration of the veteran’s opioid 

therapy; and

• 3 of 21 veterans who had a change in their opioid medication during the time of our review had a follow-up visit between 14 

and 28 days following the change.

Of the 25 veterans prescribed a concurrent opioid and benzodiazepine:

• 6 veterans were prescribed a non-pharmacological therapy;

• 4 veterans were prescribed naloxone;

• 11 veterans had a maintenance follow-up visit; and

• 0 of 9 veterans who had a change in their opioid medication during the time of our review had a follow-up visit between 14 

and 28 days following the medication change.

Of the 25 veterans with the highest risk of an adverse event, such as a suicide, overdose, fall, or opioid-induced respiratory 

depression, based on their Stratified Tool for Opioid Risk Mitigation (STORM) risk score:

b

• 4 veterans were prescribed a non-pharmacological therapy;

• 7 veterans were prescribed naloxone;

• 16 veterans had a maintenance follow-up visit; and

• 5 of 17 veterans who had a change in their opioid medication during the time of our review had a follow-up visit between 14 

and 28 days following the medication change.

Source: GAO analysis of veterans’ medical records. | GAO-18-380

a

VHA defines long-term opioid therapy as a 90-day supply of opioid medication prescribed in a 6-

month period.

b

The Stratified Tool for Opioid Risk Mitigation (STORM) is designed to help providers estimate 

veteran risk for an overdose or suicide-related event and provide suggested interventions to mitigate 

that risk. It provides 1-year and 3-year risk categories (i.e., low, medium, high, and very high) 

reflecting a patient’s risk of an adverse event if opioids are prescribed, based on the veteran’s 

individual medical history and characteristics. The 25 veterans we reviewed had “very high” risk 

categories for both the 1-year and 3-year estimates. For example, a patient with an 18 percent risk of 

a suicide- or overdose-related health care event or death in the next year would be categorized as 

“very high” risk by the tool.
Page 25 GAO-18-380 Veterans Prescribed Opioids

There are a variety of reasons that VHA providers may not always follow 

clinical practice guideline recommendations. For example, the availability 

of these non-pharmacological therapies may be limited, according to 

officials at all five selected VHA medical facilities. Officials at some 

facilities noted that the availability of these therapies can be particularly 

challenging for facilities in rural areas.

VHA officials explained that the biggest barrier to providing naloxone is 

educating providers, so that they consistently consider prescribing 

naloxone for their patients receiving opioid therapy.44 According to 

officials, an education course for providers on naloxone prescribing 

became available in December 2015, and naloxone education efforts are 

a key focus of academic detailing programs. According to VHA data, 

since fiscal year 2014, naloxone distribution has increased. Specifically, 

as of March 2018, the agency has dispensed almost 142,000 naloxone 

kits to veterans, an increase of about 58 percent since June 2017.

VHA is taking important steps under the OSI to help ensure that veterans 

receive safe care. For example, VHA has begun tracking and publicly 

reporting data on four key metrics related to opioid prescriptions, and 

these data show that opioid prescription rates have decreased since 

2013. In addition, our review also found that VHA has made progress on 

most of its 2014 OSI goals. However, for two goals, VHA lacks 

documentation showing whether VISNs and medical facilities have 

completed required relevant actions, and in one case, VHA has not 

specified measurable outcomes, which makes it challenging to determine 

whether these goals have been accomplished. Without sufficient 

documentation and measurable outcomes, VHA cannot determine 

whether these OSI goals to help ensure safe and effective care for 

veterans prescribed opioids have been fully successful.

Our review also shows that VHA needs to do more to ensure that its 

providers are following three key opioid risk mitigation strategies when 

prescribing an opioid medication to a veteran: conducting an annual urine 

drug screening, querying a PDMP, and obtaining written informed 

 44Additionally, primary care nurses at the facilities in our review said they had difficulty 

finding adequate time and clinic space to provide the necessary education on naloxone to 

veterans when it was prescribed. They also described technological challenges, such as 

trying to show veterans education videos with audible sound on computers, and a lack of 

wireless internet access for the devices used.

Conclusions
Page 26 GAO-18-380 Veterans Prescribed Opioids

consent from the veteran on the benefits and risks of using opioid 

medications.

VHA has several means at its disposal for improving adherence to these 

strategies—at a minimum it should ensure that each VISN has a fully 

staffed academic detailing program and that each facility has a 

designated primary care pain champion, as VHA policy requires. In 

addition to enforcing these requirements, VHA should direct its facilities to 

strengthen monitoring efforts to help ensure providers’ adhere to the 

opioid risk mitigation strategies. These efforts include regular reviews of 

veterans’ medical records and creating electronic alerts reminding 

providers when these risk mitigation strategies have not been completed. 

Academic detailers and pain champions would also help educate 

providers further about evidence-based clinical practice guideline 

recommendations, such as non-pharmacological alternatives to opioid 

therapy and prescribing naloxone. Without these efforts to improve 

adherence to key opioid risk mitigation strategies, VHA’s ability to ensure 

that all veterans are prescribed opioids in a safe and effective manner 

may be limited.

We are making the following five recommendations to VA:

• The Undersecretary for Health should ensure that Central Office, 

VISNs, and medical facilities document the actions they take towards 

achieving OSI goals. (Recommendation 1)

• The Undersecretary for Health should ensure that any OSI goals that 

have not been met have clearly defined, measurable outcomes, 

including milestones or numerical targets, as appropriate, and 

timeframes. (Recommendation 2)

• The Undersecretary for Health should track the use of the OTRR (or 

any subsequent tool) by providers prior to initiating opioid therapy. 

(Recommendation 3)

• The Undersecretary for Health should ensure that all VISNs have 

implemented an academic detailing program that supports all medical 

facilities in the VISN and that all VHA medical facilities have a 

designated primary care pain champion as required. 

(Recommendation 4)

Recommendations for 

Executive Action
Page 27 GAO-18-380 Veterans Prescribed Opioids

• The Undersecretary for Health should require VHA medical facilities to 

take steps to ensure provider adherence to opioid risk mitigation 

strategies, including querying PDMPs, obtaining written informed 

consent, and conducting urine drug screening. For example, these 

steps could include creating alerts in the electronic medical record 

system to remind primary care teams when these actions should be 

completed or strengthening facility monitoring of providers. 

(Recommendation 5)

We provided a draft of this report to VA for comment. While VA was 

reviewing a draft of this report, it requested further specificity in 

recommendation two; as a result, we revised the recommendation to be 

clearer. In its written comments, which are reproduced in appendix II, VA 

concurred with our recommendations and provided technical comments,

which we have incorporated as appropriate. 

In its comments, VA agreed that clarifying ongoing priorities and plans 

and filling in gaps in implementation will help facilitate progress in its 

opioid safety efforts. VA stated that it will establish a workgroup to review 

all OSI goals and ensure that the goals have clearly defined measurable 

outcomes and timelines, and that documentation requirements are 

established. VA also informed us that in March 2018 it published a notice

requiring VHA clinicians to conduct and document a data-based risk 

review using one of VHA’s clinical decision support tools for opioid 

management, such as STORM, prior to initiating opioid therapy. VA also 

stated that it will take actions to ensure that academic detailing programs 

are fully implemented and primary care pain champions are in place 

across the system. To improve its clinicians’ adherence to opioid risk 

mitigation strategies, VA stated that it will establish a workgroup to review 

and develop methods for increasing adherence. VA expects to complete 

all these actions by April 2019 or earlier.

We are sending copies of this report to the appropriate congressional 

committees, the Secretary of Veterans Affairs, the Undersecretary for 

Health, and other interested parties. In addition, the report is available at 

no charge on the GAO website at http://www.gao.gov.

Agency Comments
Page 28 GAO-18-380 Veterans Prescribed Opioids

If you or your staff have any questions about this report, please contact 

me at (202) 512-7114 or clowersa@gao.gov. Contact points for our 

Offices of Congressional Relations and Public Affairs may be found on 

the last page of this report. GAO staff who made key contributions to this 

report are listed in appendix III.

A. Nicole Clowers

Managing Director, Health Care
Page 29 GAO-18-380 Veterans Prescribed Opioids

List of Committees

The Honorable Johnny Isakson

Chairman

The Honorable Jon Tester

Ranking Member

Committee on Veterans’ Affairs

United States Senate 

The Honorable John Boozman

Chairman

The Honorable Brian Schatz

Ranking Member

Subcommittee on Military Construction, Veterans’ Affairs, and Related 

Agencies

Committee on Appropriations

United States Senate

The Honorable Phil Roe

Chairman

The Honorable Tim Walz

Ranking Member

Committee on Veterans’ Affairs

House of Representatives

The Honorable John Carter

Chairman

The Honorable Debbie Wasserman Schultz

Ranking Member

Subcommittee on Military Construction, Veterans’ Affairs, and Related 

Agencies

Committee on Appropriations

House of Representatives
Appendix I: Known Efforts and Data Related to 

the Veterans Health Administration’s (VHA) 

Opioid Safety Initiative (OSI) 2014 Goals, July 

2013-December 2017

Page 30 GAO-18-380 Veterans Prescribed Opioids

OSI goals VHA-required action(s) Description of known related efforts and data

(1) Educate opioid prescribers 

regarding the effective use of 

urine drug screening

Each Veteran Integrated Service 

Network (VISN) must establish a 

network-wide standardized education 

program by December 31, 2014

According to VHA training system data, 13 of 21 VISNs 

developed at least one education course addressing the 

use of urine drug screening from January 1, 2015 through 

April 29, 2017. Ten of the 13 VISNs developed at least 

one course by the deadline (December 31, 2014) as 

required. Further, 6 of the 13 VISNs had at least one 

course with 30 or fewer providers completing it. Because 

we found the VISN course assignment data unreliable, we 

could not determine the completion rates for these 

courses. However, we found that, in response to a 2015 

White House memorandum that required all federal 

employee opioid prescribers to complete training on the 

appropriate prescribing of opioids (which included 

discussion of urine drug screening) by April 15, 2017, of 

20,231 prescribers who were identified and assigned the 

course, 19,242 completed it, for a completion rate of 

about 95 percent, according to VHA data from January 1, 

2015 through April 29, 2017.

(2) Increase the use of urine 

drug screening

Urine drug screening targets based on 

previous urine drug screening rates for 

all VHA facilities must be reached by 

2nd quarter, fiscal year 2015 (March 31, 

2015)

According to VHA data, 151 of 157 facilities met or 

exceeded their urine drug screening target by the 

deadline (March 31, 2015) as required.

In addition, VHA OSI metric data also show that there has 

been a 47 percentage point increase nationally in the 

percentage of patients on long-term opioid therapy who 

received a urine drug screen from the 4th quarter of fiscal 

year 2013 to the 1st quarter of fiscal year 2018. The 

increase in the percentage of patients receiving a urine 

drug screening was driven more by a reduction in the total 

number of patients on long-term opioid therapy rather 

than an increase in the number of patients receiving the 

screening.

(3) Facilitate the use of 

prescription drug monitoring 

program (PDMP) databases, 

which contain patient-level 

information on prescriptions 

received for controlled 

substances

Each VISN must certify by 2nd quarter, 

fiscal year 2015 (March 31, 2015), that 

all facilities have a program consisting of 

PDMP training and/or education 

materials for providers 

VHA Central Office lacks certifications from all VISNs that 

programs were established. Although officials at the five 

VISNs in our review told us they had supported training 

efforts on the use of PDMPs, only one VISN in our review 

provided documentation that it had established a program 

by the deadline (March 31, 2015) as required.

However, in October 2016, VHA issued a directive 

requiring providers to query state PDMPs for patients 

prescribed opioids and also issued guidance on how 

PDMPs should be accessed and how these efforts should 

be documented in VA’s electronic health record system. 

In addition, according to VHA officials, querying the 

PDMP was added to the 2015 White House-required 

opioid safety training, as described earlier. According to 

VHA data, there has been a 22 percent increase in the 

querying of PDMPs by providers from 4th quarter, fiscal 

year 2016 to 3rd quarter, fiscal year 2017. 

Appendix I: Known Efforts and Data Related 

to the Veterans Health Administration’s 

(VHA) Opioid Safety Initiative (OSI) 2014 

Goals, July 2013-December 2017 
Appendix I: Known Efforts and Data Related to 

the Veterans Health Administration’s (VHA) 

Opioid Safety Initiative (OSI) 2014 Goals, July 

2013-December 2017

Page 31 GAO-18-380 Veterans Prescribed Opioids

OSI goals VHA-required action(s) Description of known related efforts and data

(4) Establish safe and effective 

VISN tapering programs for 

veterans using opioids and 

benzodiazepines

VISNs must develop local tapering 

protocols and plans to resource the 

implementation of those tapering 

protocols

VHA Central Office lacks documentation from all VISNs 

regarding VISN-specific protocols and implementation 

plans. Only one of the five VISNs in our review provided 

documentation regarding a VISN-specific protocol relating 

to patients on opioids and benzodiazepines, which was 

developed in 2013. Four of the five VISNs did not provide 

documentation of a VISN-specific protocol or 

implementation plans.a

However, VHA officials told us that they addressed this 

goal by issuing national tapering guidance including a 

provider reference guide in 2014, an opioid taper decision 

tool in 2016, and the VA/DOD clinical practice guideline in 

2017. VHA officials said that the issuance of this guidance 

made the VISN-required action irrelevant. In addition, 

VHA OSI metric data show that there has been a 6.6 

percentage point decrease nationally in the percentage of 

patients dispensed an opioid and benzodiazepine from 

the fourth quarter of fiscal year 2013 to the first quarter of 

fiscal year 2018.

(5) Develop tools to identify 

patients at a higher risk for 

adverse events while using 

opioids

An opioid risk stratification toolkit must 

be developed; opioid safety education 

guides must be updated annually

In 2016, VHA released its opioid risk stratification toolkit in 

the form of an opioid safety monitoring tool called the 

Stratification Tool for Opioid Risk Mitigation.b In addition, 

VHA updated its pain management opioid safety 

education guide and quick reference guide for providers 

in July 2017. 

(6) Improve prescribing 

practices around long-acting 

opioid formulations

VISNs must develop local tapering 

protocols and plans to resource the 

implementation of those tapering 

protocols

VHA Central Office lacks documentation from all VISNs 

regarding VISN-specific protocols and implementation 

plans. Only one of the five VISNs in our review provided 

documentation regarding a VISN-specific protocol relating 

to patients on opioids and benzodiazepines, which was 

developed in 2013. Four of the five VISNs did not provide 

documentation of a VISN-specific protocol or 

implementation plans.a

As earlier described, VHA officials said that issuance of 

guidance nationally made the VISN-required action 

irrelevant. In addition, according to VHA data, the 

percentage of patients who were prescribed long-acting 

opioids by providers nationally has decreased by about 1 

percentage point from quarter 3, fiscal year 2014 to 

quarter 3, fiscal year 2017, representing a decrease of 

about 44,000 patients prescribed long-acting opioids and 

an accompanying increase of about 223,000 patients who 

used VHA care in the last four quarters.
Appendix I: Known Efforts and Data Related to 

the Veterans Health Administration’s (VHA) 

Opioid Safety Initiative (OSI) 2014 Goals, July 

2013-December 2017

Page 32 GAO-18-380 Veterans Prescribed Opioids

OSI goals VHA-required action(s) Description of known related efforts and data

(7) Review treatment plans for 

veterans on high doses of 

opioidsc

Each VISN must certify that the 

treatment of all patients with a daily dose 

of greater than 200 morphine milligram 

equivalents has been reviewed by 2nd 

quarter, fiscal year 2015 (March 31, 

2015)

VHA Central Office lacks certifications from all VISNs that 

reviews were conducted. Although officials at the five 

VISNs in our review told us they had completed these 

reviews, only one VISN provided us with documentation 

to conclude that its facilities completed their review.

However, VHA OSI metric data show that there has been 

a 2.1 percentage point decrease nationally in the 

percentage of patients dispensed greater than or equal to 

100 morphine milligram equivalents per day from the 

fourth quarter of fiscal year 2013 to the first quarter of 

fiscal year 2018.

(8) Offer complementary and 

alternative medicine modalities 

for chronic pain at all medical 

facilities

Each facility must provide evidence that 

at least two evidence-based 

behavioral/psychological treatments or 

approved complementary or alternative

modalities can be provided by 2nd 

quarter, fiscal year 2015 (March 31, 

2015)

According to VHA 2nd quarter, fiscal year 2015 data, all 

VHA medical facilities located in the United States 

provided at least one psychosocial service and at least 

one complementary and integrative health service.d

However, VHA officials indicated that due to the nature of 

the data, they cannot verify that all psychosocial services 

provided at that time were evidence-based and that not all 

complementary and integrative health services provided 

had a strong evidence base. 

(9) Develop new models of 

mental health and primary care 

collaboration to manage the 

prescribing of opioids and 

benzodiazepines in patients 

with chronic pain 

Identification of strong practices that can 

be operationalized across VHA by 3rd 

quarter, fiscal year 2015 (June 30, 

2015); a request for proposal to be 

released to the field to establish model 

interdisciplinary teams and strategies for 

management and tapering of 

medications at three VHA medical 

facilities

In February 2016, VHA began a pilot to implement a 

model of care known as the Collaborative Chronic Care 

Model into existing Behavioral Health Interdisciplinary 

Program teams at nine VHA medical facilities. According 

to a VHA document, the pilot will provide facilitation 

support to enhance existing Behavioral Health 

Interdisciplinary Program teams by incorporating 

evidence-based Collaborative Care Model elements, 

which can include a care manager to proactively monitor 

care and progress as well as other tools intended to 

improve communication between primary care and 

specialty care. In fiscal year 2017, efforts were expanded 

to 30 additional VHA medical facilities. According to one 

VHA official, the pilot is expected to be completed no 

earlier than August 2019. 

Source: VHA, GAO. | GAO-18-380

Notes: OSI goals and required actions were issued via memorandum by VHA Central Office in 

December 2014. This table is not intended to be an exhaustive description of all of VHA’s efforts 

related to its OSI goals.

VISNs are regional networks that manage the VHA medical facilities located in their area. In October 

2015, VHA began to implement a realignment of its VISN boundaries which resulted in the number of 

its VISNs decreasing from 21 to 18.

a

One VISN provided evidence of one VHA medical facility’s tapering recommendations for patients on 

opioids and benzodiazepines.

b

This tool helps providers identify patients who are at a higher risk of adverse events when using 

opioids depending on their clinical profile.

c

Patients on high doses of opioids are at greater risk for adverse events. According to the Centers for 

Disease Control, providers should avoid or carefully justify opioid prescriptions delivering a daily dose 

of greater than or equal to 90 morphine milligram equivalents.

d

Based on information we obtained from VHA relative to this goal, “psychosocial” services refer to 

“behavioral/psychological” treatments, and “integrated health” is a term that may be used to refer to 
Appendix I: Known Efforts and Data Related to 

the Veterans Health Administration’s (VHA) 

Opioid Safety Initiative (OSI) 2014 Goals, July 

2013-December 2017

Page 33 GAO-18-380 Veterans Prescribed Opioids

“complementary and alternative” modalities. According to a VHA official, the VHA facility in Manila, 

the Philippines did not offer at least one psychosocial service and at least one integrative health 

service for this time period.
Appendix II: Comments from the Department 

of Veterans Affairs

Page 34 GAO-18-380 Veterans Prescribed Opioids

Appendix II: Comments from the Department 

of Veterans Affairs
Appendix II: Comments from the Department 

of Veterans Affairs

Page 35 GAO-18-380 Veterans Prescribed Opioids
Appendix II: Comments from the Department 

of Veterans Affairs

Page 36 GAO-18-380 Veterans Prescribed Opioids
Appendix II: Comments from the Department 

of Veterans Affairs

Page 37 GAO-18-380 Veterans Prescribed Opioids
Appendix II: Comments from the Department 

of Veterans Affairs

Page 38 GAO-18-380 Veterans Prescribed Opioids
Appendix III: GAO Contact and Staff 

Acknowledgments

Page 39 GAO-18-380 Veterans Prescribed Opioids

Angela N. Clowers, (202) 512-7114 or clowersa@gao.gov

In addition to the contact named above, Marcia A. Mann, Assistant 

Director; Stella Chiang, Analyst-in-Charge; Emily Binek, Krister Friday, 

Diona Martyn, and Michael Rose made key contributions to this report. 

Also contributing were Zhi Boon and Emily Wilson.

Appendix III: GAO Contact and Staff 

Acknowledgments

GAO Contact

Staff 

Acknowledgments

(101257)
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