Translational Behavioral Medicine

, Volume 6, Issue 4, pp 605–612 | Cite as

Healthcare system-wide implementation of opioid-safety guideline recommendations: the case of urine drug screening and opioid-patient suicide- and overdose-related events in the Veterans Health Administration

  • Penny L. BrennanEmail author
  • Aaron C. Del Re
  • Patricia T. Henderson
  • Jodie A. Trafton
Original Research


This study provides an example of how healthcare system-wide progress in implementation of opioid-therapy guideline recommendations can be longitudinally assessed and then related to subsequent opioid-prescribed patient health and safety outcomes. Using longitudinal linear mixed effects analyses, we determined that in the Department of Veterans Affairs (VA) healthcare system (n = 141 facilities), over the 4-year interval from 2010 to 2013, a key opioid therapy guideline recommendation, urine drug screening (UDS), increased from 29 to 42 %, with an average within-facility increase rate of 4.5 % per year. Higher levels of UDS implementation from 2010 to 2013 were associated with lower risk of suicide and drug overdose events among VA opioid-prescribed patients in 2013, even after adjusting for patients’ 2012 demographic characteristics and medical and mental health comorbidities. Findings suggest that VA clinicians and healthcare policymakers have been responsive to the 2010 VA/Department of Defense (DOD) UDS treatment guideline recommendation, resulting in improved patient safety for VA opioid-prescribed patients.


Treatment guideline implementation Opioid therapy safety Urine drug screening Suicide Drug overdose 



This work was supported in part by a VA HSR&D QUERI grant RRP 10-106. We thank the VA Opioid Metric Development Team (William Becker, Rollin Gallagher, Francine Goodman, Patricia Henderson, James Im, Robert Kerns, Amanda Midboe, and Jack Rosenberg) for their work developing the measures used in this study, Amanda Midboe for her helpful comments on an earlier version of this manuscript, and Sonya SooHoo for assisting with manuscript preparation. The views expressed here are those of the authors and do not necessarily reflect positions or policies of the Department of Veterans Affairs or of the US government.

Compliance with ethical standards

Research reported here was supported in part by the Department of Veterans Affairs Health Services Research and Development (HSR&D) grant number RRP 10-106. All work performed in this investigation was in accordance with the ethical standards of our institutional research committees and with the 1964 Helsinki Declaration and its later amendments. For this type of study, formal consent is not required. This research was approved by the Stanford University administrative panels for the protection of human subjects.

Conflict of Interest

The authors declare that they have no conflicts of interest.


  1. 1.
    Centers for Disease Control and Prevention. CDC grand rounds: prescription drug overdoses—A U.S. epidemic. MMWR Morb Mortal Wkly Rep. 2012; 61: 10-13.Google Scholar
  2. 2.
    Daubresse M, Chang H-Y, Yu Y, et al. Ambulatory diagnosis and treatment of nonmalignant pain in the United States, 2000–2010. Med Care. 2013; 51: 870-878.CrossRefPubMedGoogle Scholar
  3. 3.
    Substance Abuse and Mental Health Service Administration, Office of Applied Studies. Drug Abuse Warning Network, 2007: National Estimates of Drug-Related Emergency Department Visits. Rockville, MD; 2010.Google Scholar
  4. 4.
    Nuckols TK, Anderson L, Popescu I, et al. Opioid prescribing: a systematic review and critical appraisal of guidelines for chronic pain. Ann Intern Med. 2014; 160: 38-47.PubMedGoogle Scholar
  5. 5.
    Cheatle MD. Depression, chronic pain, and suicide by overdose: on the edge. Pain Med. 2011; 12: S43-S48.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Rudd RA, Paulozzi LJ, Bauer MJ, et al. Increases in heroin overdose deaths—28 states 2010 to 2012. MMWR Morb Mortal Wkly Rep. 2014; 63: 834-849.Google Scholar
  7. 7.
    Midboe AM, Lewis ET, Paik MC, et al. Measurement of adherence to clinical practice guidelines for opioid therapy for chronic pain. Transl Behav Med. 2012; 2: 57-64.CrossRefPubMedGoogle Scholar
  8. 8.
    The Management of Opioid Therapy for Chronic Pain Working Group. VA/DoD clinical practice guideline for management of opioid therapy for chronic pain. Washington, DC: The Office of Quality and Performance, VA and Quality Management Directorate, US Army MEDCOM; 2003. Available at: Accessibility verified June 20, 2016.
  9. 9.
    Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009; 10: 113-130.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    The Management of Opioid Therapy for Chronic Pain Working Group. VA/DoD clinical practice guideline for management of opioid therapy for chronic pain [U.S. Department of Veterans Affairs web site]. May, 2010. Available at: Accessibility verified November 2, 2015.
  11. 11.
    Volkow ND, McLellan AT. Opioid abuse in chronic pain—misconceptions and mitigation strategies. N Engl J Med. 2016; 374: 1253-1263.CrossRefPubMedGoogle Scholar
  12. 12.
    Franklin GM. Opioids for chronic noncancer pain: a position paper of the American Academy of Neurology. Neurology. 2014; 83: 1277-1284.CrossRefPubMedGoogle Scholar
  13. 13.
    Starrels JL, Becker WC, Alford DP, et al. Systematic review: treatment agreements and urine drug testing to reduce opioid misuse in patients with chronic pain. Ann Intern Med. 2010; 152: 712-720.CrossRefPubMedGoogle Scholar
  14. 14.
    Canada RE, DiRocco D, Day S. A better approach to opioid-prescribing in primary care. J Fam Pract. 2014; 63: E1-E8.PubMedGoogle Scholar
  15. 15.
    Fagan MJ, Chen JT, Diaz JA, et al. Do internal medicine residents find pain medication agreements useful? Clin J Pain. 2008; 24: 35-38.CrossRefPubMedGoogle Scholar
  16. 16.
    Touchet BK, Yates WR, Coon KA. Opioid contract use associated with physician training level and practice specialty. J Opioid Manag. 2005; 1: 195-200.PubMedGoogle Scholar
  17. 17.
    Im JJ, Shachter RD, Oliva EM, et al. Association of care practices with suicide attempts in US Veterans prescribed opioid medications for chronic pain management. J Gen Intern Med. 2015; 30: 979-991.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Centers for Disease Control and Prevention. International Classification of Diseases, Ninth Revision, Sixth Edition. 2011.Google Scholar
  19. 19.
    Elixhauser A, Steiner C, Harris D, et al. Comorbidity measures for use with administrative data. Med Care. 1998; 36: 8-27.CrossRefPubMedGoogle Scholar
  20. 20.
    Nock MK, Hwang I, Sampson NA, et al. Mental disorders, comorbidity and suicidal behavior: results from the National Comorbidity Survey Replication. Mol Psychol. 2010; 15: 868-76.CrossRefGoogle Scholar
  21. 21.
    Seal KH, Shi Y, Cohen G, et al. Association of mental health disorders with prescription opioids and high-risk opioid use in US veterans of Iraq and Afghanistan. JAMA. 2012; 7: 940-7.Google Scholar
  22. 22.
    Bates D, Maechler M, Bolker BM et al. (2014). Lme4: Linear mixed-effects models using Eigen and S4. Available at: Accessibility verified November 2, 2015.
  23. 23.
    R Core Team. R: a language and environment for statistical computing. Vienna, Austria: R Foundation for Statistical Computing. Available at: Accessibility verified November 2, 2015.
  24. 24.
    Bryk SW, Raudenbush AS. Hierarchical Linear Models: Applications and Data Analysis Methods. Thousand Oaks, CA: Sage Publications; 2002.Google Scholar
  25. 25.
    Singer JD, Willett JB. Applied Longitudinal Data Analysis: Modeling Change and Event Occurrence. Oxford, UK: Oxford University Press; 2003.CrossRefGoogle Scholar
  26. 26.
    Buscaglia AC, Paik MC, Lewis E, et al. Baseline variation in use of VA/DOD clinical practice guideline recommended opioid prescribing practices across VA health care systems. Clin J Pain. 2015; 31: 803-812.Google Scholar
  27. 27.
    Reisfield GM, Salazar E, Bertholf RL. Rational use and interpretation of urine drug testing in chronic opioid therapy. Ann Clin Lab Sci. 2007; 37: 301-314.PubMedGoogle Scholar
  28. 28.
    Single topic issue: quality and utility of secondary data for VA research. J Rehabil Res Dev. 2010; 47.Google Scholar
  29. 29.
    U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. National Action Plan for Adverse Drug Event Prevention. Washington, DC: USDHHS; 2014.Google Scholar

Copyright information

© Society of Behavioral Medicine (outside the US) 2016

Authors and Affiliations

  • Penny L. Brennan
    • 1
    Email author
  • Aaron C. Del Re
    • 2
  • Patricia T. Henderson
    • 2
  • Jodie A. Trafton
    • 2
  1. 1.Center for Innovation to ImplementationVA Palo Alto Health Care SystemMenlo ParkUSA
  2. 2.Program Evaluation and Resource CenterVA Palo Alto Health Care SystemMenlo ParkUSA

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