Publicly Released: January 14, 2020
Objective
The objective of this audit was to determine whether selected DoD military treatment facilities (MTFs) overprescribed opioids for DoD beneficiaries. DoD beneficiaries are active duty service members, retirees, and eligible family members who receive health care at MTFs, which the Defense Health Agency (DHA) and the Surgeons General of the Military Departments oversee.
In this audit, we focused on specific examples of beneficiaries who received opioids from 2015 to 2017 at Madigan Army Medical Center (MAMC) in Joint Base Lewis–McChord, Washington; Naval Medical Center Portsmouth (NMCP) in Portsmouth, Virginia; and Joint Base Elmendorf-Richardson (JBER) Hospital in Anchorage, Alaska.
Background
Opioids are a class of drugs that includes the illegal drug heroin; synthetic opioids, such as fentanyl; and legally prescribed pain relievers, such as oxycodone, hydrocodone, and morphine. Opioid pain relievers are generally safe when taken for a short time and as prescribed by a doctor; however, because they produce euphoria in addition to pain relief, they are more likely to be misused (taken in higher doses than prescribed or without a doctor’s prescription). Regular use—even as prescribed by a doctor—can lead to dependence and, when misused, opioid pain relievers can lead to addiction, overdose incidents, and death. Prescriptions for controlled substances, like opioids, must be issued for a legitimate medical purpose by health care providers acting in the usual course of their professional practice.
The Centers for Disease Control and Prevention (CDC) published a guideline for prescribing opioids to beneficiaries with chronic pain. The guideline is intended to improve communication between providers and patients about the risks and benefits of opioid therapy for chronic pain, improve safety and effectiveness of pain treatment, and reduce the risks associated with long-term opioid therapy, including opioid use disorder and overdose. According to the CDC, opioid use disorder is a “problematic pattern of opioid use that causes significant impairment or distress.” The CDC guideline states that to prevent this disorder, providers prescribing opioids should: (1) prescribe the lowest effective dosage; (2) carefully reassess evidence of individual benefits and risks when considering increasing dosage to more than 50 morphine milligram equivalents (MME) per day; and (3) avoid increasing dosage to more than 90 MME per day or carefully justify a decision to adjust the dosage to greater than 90 MME per day.
In addition, the Department of Veterans Affairs (VA)/DoD “Clinical Practice Guideline for Opioid Therapy for Chronic Pain” recommends against prescribing opioid doses over 90 MME per day to treat chronic pain. Beneficiaries who are prescribed higher doses of opioids are at higher risk for opioid overdose and overdose death. The VA/DoD guideline recommends that, for beneficiaries prescribed doses equal to or over 90 MME per day, the provider evaluate the beneficiary for tapering to a reduced dose or to discontinue use of the opioid.
DoD guidance states that 90 days of continuous opioid therapy with no greater than a 30‑day break in use is considered long-term opioid therapy. Beneficiaries prescribed long-term opioid therapy are also at a higher risk for opioid-related complications, such as overdose or addiction.
Finding
By examining patient records, we identified examples of beneficiaries at the three MTFs we reviewed who may have been overprescribed opioids from 2015 through 2017. For example, a beneficiary received an average of 450 MME per day for 16 months, which is five times the CDC’s recommended maximum dose of 90 MME that chronic pain beneficiaries should avoid.
We concluded that MTFs potentially overprescribed opioids from 2015 through 2017 because the DHA and Military Departments did not have policies and processes in place to identify and monitor beneficiaries who were prescribed over 90 MME per day. In December 2017, the DoD began implementing tools that are expected to help the DoD to identify and monitor beneficiaries who receive prescriptions that deviate from VA/DoD and CDC opioid clinical practice guidance, such as beneficiaries who receive opioids for more than 90 days or are prescribed opioids at or above 90 MME per day. In June 2018, the DHA issued a procedural instruction that requires the DoD to monitor the percentage of beneficiaries who are prescribed more than 90 MME per day and the beneficiaries receiving long-term opioid therapy.
However, the staff at the MTFs we visited did not prevent providers from prescribing unusually high doses of opioids. For example, at one MTF we visited, a pharmacist stated that many of the beneficiaries received an unusual amount of opioids, but the pharmacist would not acknowledge that providers overprescribed opioids to their beneficiaries. At another MTF we visited, a pharmacist stated that “there is not a will” to stop some beneficiaries from receiving their opioid medications, and a physician stated that it was a professional courtesy among physicians not to criticize how other physicians provided services and prescriptions to their beneficiaries. Additionally, MTF officials did not intervene to prevent providers from prescribing unusually high doses of opioids.
We attempted to determine how many beneficiaries received an opioid prescription written by MTF providers with a dose greater than the CDC guideline of 90 MME per day for calendar years 2015 through 2018. However, we did not use the analysis in the report because we identified numerous errors and limitations in the DoD Medical Health System Data Repository when we compared the data to the beneficiaries’ medical records. As a result, we determined that the data was unreliable for calculating the number of beneficiaries that received opioid prescriptions solely from MTF providers.
The DoD needs to monitor opioid prescriptions and hold providers accountable for not following clinical practice guidance. The DoD should also carefully justify why the provider did not follow the guidance so that beneficiaries identified in this report, and potentially other beneficiaries receiving opioids from MTFs, will not be at increased risk of being overprescribed opioids; developing opioid use disorder; progressing to the use of heroin; and possibly dying of an opioid overdose. Furthermore, overprescribing opioids increases the risk that people other than the prescribed beneficiary will have access to and use the opioids for nonmedical use.
Recommendations
We recommend that the DHA Director continue to monitor MME doses per day by beneficiary, examine data for unusually high opioid prescriptions, and if appropriate, hold providers accountable for overprescribing opioids. Also, we recommend that the DHA Director implement controls to ensure that the prescriptions in the Military Health System Data Repository exist and that the dispense date and the metric quantity field for opioid prescriptions in liquid form are accurate and consistent among all systems.
Management Comments and Our Response
The DHA Director agreed with the recommendation to continue to monitor MME doses per day by beneficiary, examine data for unusually high opioid prescriptions, and if appropriate, hold providers accountable for overprescribing opioids. The DHA stated that it has already implemented solutions to the findings in the report. Additionally, the DHA and Military Departments will continue to strengthen efforts to identify, monitor, and intervene in patients with increased health risks from any appropriate use of opioids while working to develop increased capacity to provide non‑pharmacologic pain treatments at MTFs.
Comments from the Director addressed all specifics of the recommendation; therefore, the recommendation is resolved but will remain open. We will close the recommendation once the DHA provides documentation to support that the DHA is able to identify unusually high opioid prescriptions, and holds providers accountable for those prescriptions, if appropriate.
The DHA Director partially agreed with the recommendation to implement controls to ensure that the prescriptions in the Military Health System Data Repository (MDR) exist and that the dispense date and metric quantity field for opioid prescriptions in liquid form are accurate and consistent among all systems. The Director stated that the DHA has internal controls to ensure that data on prescriptions in the MDR exist and are accurate. The Director also stated that a method exists to identify and separate prescription data from MTF and TRICARE providers, and is not an error in the validity of the MDR system. The future use of the new Military Health System (MHS) GENESIS Electronic Health Record system will significantly improve the data quality for prescriptions and the standardization of the metric quantity field for liquid opioid prescriptions.
Comments from the Director addressed all specifics of the recommendation; therefore, the recommendation is resolved but will remain open. We will close the recommendation once the Director provides documentation to support that the MHS GENESIS system has improved the data quality for prescriptions and the standardization of the metrics quantity field for liquid opioid prescriptions.
This report is the result of Proj. No D2018-D000AW-0102.000