GAO Report on VA Health Care: Progress Made Toward Improving Opioid Safety, But Further Efforts to Assess Progress and Reduce Risk Are Needed

June 7, 2018

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GA-18-380: This report examines the progress the progress the Veterans Health Administration (VHA) has made improving opioid safety through its Opioid Safety Initiative (OSI).

decrease in prescriptions graphic 

Since the OSI began, VHA has seen reduction in opioid prescribing rates.


percentage decrease in patients prescribed opioids, 16.7% to 9.7% 

Percentage of patients dispensed an opioid by VHA

 A decrease of about
267000 veterans

 6 out of 9 OSI goals completed
GAO found several factors that may have contributed to inconsistent adherence to key opioid risk mitigation strategies at the selected VHA facilities.
 4 out of 5 facilities
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).

 one on one 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.
Three of the five facilities did not consistently review veterans’ medical records to ensure provider adherence to these strategies.  
3 out of 5 medical records


For more information on this GAO report and other healthcare news, read our Washington Healthcare Update.