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Inside Oversight is an official podcast of the Department of Veteran Affairs, Office of Inspector General. Each episode examines in detail some of our more nuanced oversight reporting. To understand the complexities of the topics, we talk with the report authors to gain insight into how the team conducted its work, what it found, and the impact on veterans and the public. Visit the VA OIG website for recently published reports.
Adam Roy:
Hello and welcome back to another episode of Inside Oversight, an official podcast of the Veterans Affairs Office of the Inspector General.
This is your host, Adam Roy.
Today, we’re talking about opioid use disorder, specifically the transition of clinical care for veterans with the disorder from the Department of Defense to the Veterans Health Administration. The VA OIG evaluated this transition and published its results in a June 2023 national review. According to the report, opioids were responsible for approximately 75 percent of overdose related deaths in 2020 and veterans were twice as likely to die from accidental overdose compared to non-veterans.
Also, failure to identify and document a patient’s known opioid use disorder history may place patients at risk for adverse outcomes, such as overdose.
Helping me understand opioid use disorder, or OUD, among veterans and the findings and ultimately the recommendations from this report is Nicole Maxey, a nurse consultant with our Office of Healthcare Inspections.
Welcome, Nicole. Thanks for being here. How are you doing today?
Nicole Maxey:
Hi, Adam. I’m great, thank you. I’m excited to be talking to you.
Adam Roy:
Excellent. So, before we talk about the report. tell me a little bit about yourself. What led you to the VA OIG? And what experiences in your past helped you prepare for a topic like opioid use disorder?
Nicole Maxey:
Well, Adam, you know a lot of individuals within the VA OIG have connections within the military, which is true for me as well. I have numerous family members on both my side of the family and my husband’s family that have served in all branches of the military from World War II, and most recently my brother just retired from the Coast Guard in 2022.
When I was in high school, I met my husband. His mother worked at the Sheridan VA, and his stepfather had recently retired from the US Army. I remember going with my husband to the VA to stop by and see his mom and seeing the sign at the entrance that states “The Price of freedom is visible here.” That phrase has really stuck with me throughout the years, and I have seen this ring true in not only my family and my husband’s family, but also in veterans and their families that I have had the honor of working with. All that connection with veterans and the VA really had an impact on me, and I knew I really wanted a career to somehow help people. So, I made the decision to go to nursing school to be able to fulfill that need and have been practicing as a nurse for over 20 years, primarily serving in mental health. I started my career in mental health nursing, working in the private sector where I served as a mental health nursing supervisor for community mental health in 4 counties in northern Wyoming, I worked with patients struggling with mental health issues, including substance use issues, and was honored to have assisted with opening one of the first suboxone clinics in Sheridan for patients with opioid use disorder. Suboxone is a medication that’s used to treat opioid use disorder.
Eventually, I took a nursing job at a VA medical center where I served in a variety of roles, including the acute psychiatric unit nurse manager, health quality specialist, and mental health nursing triage supervisor. and I served in some other roles like data analysis and performance improvement. While working on the acute inpatient unit, we assisted veterans with tapering off of opioids also, such as battlefield acupuncture and alpha stimulation. Through this, we also identified a need for Suboxone treatment locally, and I was able to work with the supervisory psychiatrist with opening up a suboxone clinic at that VA. The continued experience that I gained from working in the VA set me up to further my career as a nurse consultant at VA OIG. The OIG has really provided me with those new opportunities to conduct inspections of VA programs and services with the continued goal of improving veterans’ lives.
Adam Roy:
That’s perfect. It’s great to hear those connections. Now as we kind of transition into the report, let’s first talk about OUD. What is opioid use disorder?
Nicole Maxey:
Well, Adam, in order to understand opioid use disorder, also known as OUD, I would also like to provide some context into what constitutes an opioid is. The National Institute on Drug Abuse identifies opioids include the illegal drug heroin, synthetic opioids such as fentanyl, and pain relievers that are legally by prescribed, such as oxycodone, hydrocodone, codeine, morphine, and others. As mentioned, opioids relieve pain, and they can also make the user feel relaxed or “high” which makes the opioids highly addictive.
According to the Substance Abuse and Mental Health Services Administration, OUD is a substance use disorder characterized by a loss of control of opioid use, risky opioid use, impaired social functioning, tolerance, and withdrawal. Withdrawing from opioids can be extremely unpleasant and make it difficult for someone to discontinue. It’s a lifelong chronic disorder that can lead to relapse, accidental overdose, and death. In fact, opioids are one of the most common drugs found in overdose deaths. And a diagnosis of OUD diagnosis makes one 13 times more likely to die by suicide, but this risk is even higher in the veteran population.
Adam Roy:
The transition from military service to civilian life can be challenging. Having a preexisting mental health condition or problems with substance abuse must make the transition even harder. Can you talk a little bit about this?
Nicole Maxey:
I sure came. VHA has identified that in the first 12 months after discharging from the Department of Defense, it presents challenges with transitioning to the civilian life. That can be a stressful time, and it is known that service members experience a difficulty with a sense of identity, financial strains, housing stressors, mental and emotional wellness, employment and education barriers, relationship changes, and physical limitations as a result of their time in the military. For veterans who have an identified mental health condition, as you can see, additional concerns are warranted. These conditions may place a veteran at increased risk for difficulty coping and managing in stressful situations, which makes this transition period potentially even harder for them. Of particular concern, the known issues of substance mismanagement and suicide risk that may present during this transition period. It is important to identify this vulnerable population in order to ensure the appropriate support and resources are available including clinical intervention when appropriate.
Adam Roy:
Now focusing on the report. What brought about this national review?
Nicole Maxey:
The biostatisticians in the Office of Healthcare Inspections developed a database that provided detailed administrative information for veterans who engaged in VHA healthcare following discharge from their service in the Department of Defense, also known as DoD. As we discussed a couple of minutes ago, this transition period from military to civilian life is a period of high risk for veterans, especially for those with a history of substance abuse. Our team was concerned to see many service members had OUD identified in the DoD medical record, but this diagnosis was not visible in VHA data after transitioning their care to VA. This raised concerns for us as this diagnosis was available in the DoD medical record, which VA providers have access to. After additional research, we realized the absence of this diagnosis in VA’s medical record could not only prevent proper treatment but could also limit use of VA initiatives that were developed to decrease the risk of harmful outcomes associated with OUD.
Adam Roy:
Okay. So, you and your team received and reviewed this information and data. Then from there, you identified a sample size to study, which according to the report consisted of 1,783 discharged service members who had an active OUD diagnosis within one year prior to discharge from DoD between the timeframe of October 1, 2016 and September 30, 2019. From there you developed two patient groups. Can you describe these groups?
Nicole Maxey:
I sure can. I just want to make a note for our listeners that even though both groups were from the same study population, a patient could be found in both groups. For patient group 1, we looked at veterans who had no OUD diagnosis identified in VHA data, even though they had the diagnosis while in DoD.
Adam Roy:
And patient group 2?
Nicole Maxey:
Well, in patient group 2 we looked at all the patients in the study population who unfortunately had died since discharge from DoD up to July 2021.
Adam Roy:
I’ll add, Nicole, that the report includes an infographic that really illustrates the two patient groups clearly. I encourage those listening to check it out. Now that you had these groups organized, teams reviewed patient electronic health records for documented evidence that showed that providers were aware of a patient’s previous diagnosis and treatment of OUD. Per VHA policy, providers are expected—and I’m quoting from the report here—to evaluate and document substance use history when completing a comprehensive intake evaluation for service members transitioning their care to VHA. When information regarding OUD is identified, providers should document this information in an encounter note, a progress note, and the problem list.” Could you describe what a comprehensive intake evaluation is as well as those notes and the problem list? How are these things used and what did find related to the patients in two groups?
Nicole Maxey:
Yes, I’ll go ahead and start with what a comprehensive intake is. It’s an initial evaluation conducted by a provider to document social and military history, health history, and health risk factors of the veteran. A provider would take that information and create the veteran’s problem list, which is used in a medical record to assist with listing the active and inactive problems relevant to that veteran’s health, including their diagnoses. This information is used by future providers to make clinical determinations on appropriate treatment. So, if important information is missing a provider may unknowingly prescribe a treatment that needs additional consideration for OUD. Additionally, the veteran may benefit from medications or counseling for OUD, but if that provider is not aware of that diagnosis of OUD these treatments may not occur.
Getting back to group 1, which were the veterans who had the diagnosis of OUD identified in the DoD records, when we looked at those veteran’s first comprehensive VHA intake evaluation we found that only 19% included documentation of OUD or acknowledged a history of opioid misuse.
And then in patients group 2 of our review, which included veterans who had an opioid related death, we looked at any VHA provider notes at any point in time of the veteran’s care and found that 90% had a note indicating an OUD diagnosis or a history of opioid misuse.
As I stated earlier about the problem list being critical for provider recognition of veteran’s diagnoses and problems, we looked at problem lists for patient group 1 and patient group 2. We found that none of the veterans in Group 1 had OUD identified in the VHA problem list; while in patient group 2, which again were those patients who had an opioid-related death, we found that just over half had OUD identified on the VHA problem list.
As you can see our review really shows how critical it is for providers to have information about all the veteran’s health issues.
Adam Roy:
I know that when I change doctors, I need to ensure or confirm my new doctor gets my records from my previous doctor. The DOD manages the medical records of active duty service members. How are VHA providers supposed to get access to their patients’ DOD medical records? What are some of the challenges or barriers to getting this access?
Nicole Maxey:
That’s a great question, Adam. VA providers can access DoD medical records through a web-based platform called Joint Longitudinal Viewer or JLV. When our team was using JLV for our research on DoD data, we found it very time consuming to navigate. We decided to send VA providers a questionnaire regarding their perspectives on using JLV to access DoD medical records. The responses we received frequently described providers difficulties using the JLV platform. We found that more than half of the respondents identified barriers accessing and navigating DoD treatment records. They identified issues such as problems with navigating JLV, delays in information availability, inadequate search functions, missing information, and connection issues.
We also found that 55% of the respondents reported receiving no training on the use of JLV. The VA leaders informed us that they expected providers to review the veteran’s past medical history through JLV, but we found that there really is no national training requirement for JLV training. There are on-demand trainings available, but with the lack of requirements for JLV training it could result in inconsistent use by providers, which could in turn, affect continuity of care for newly transitioned service members.
Adam Roy:
What can happen to a patient if their history of OUD is not communicated to their current doctors? Can this affect the treatment VHA providers offer to their patients and their patients’ health? Your report specifically mentions the risk of opioid overdose death and suicide, sadly.
Nicole Maxey:
Yes, overdose and death risk can be increased when a provider doesn’t have access to this medically relevant information for clinical decision-making. If a provider has the knowledge of an OUD diagnosis readily available, they can offer OUD treatment and resources to the veteran. Also, they can ensure that opioid overdose reversal medications are prescribed. So, for example, if a veteran intentionally or unintentionally takes too many opioids, this medication would reverse the effects of the opioid and therefore potentially save the veteran's life. Additionally, having this medical information can inform prescribing choices for opioids for this high-risk population.
Adam Roy:
VHA has clinical practice guidelines for treating patients with substance use disorders. Your report found that 44 percent of patients in group two (those that died) with an identified OUD diagnosis by DOD died by an opioid-related overdose. And then further, since February 2021, VHA requires naloxone to be offered to patients with OUD. Can you explain what this medication is and why that is helpful for patients with OUD? Additionally, your team learned that VHA has a tool to support its distribution, but unfortunately, your team learned there was concern with the tool. Could you talk about that, too?
Nicole Maxey:
As you mentioned, offering naloxone to all veterans with OUD is a requirement. Naloxone is a medication that can be given to a person who is at risk for opioid overdose. It works to temporarily reverse the effects of the opiate, so it can prevent an intentional or unintentional overdose death. This means that naloxone can be lifesaving. Through our review we learned that VHA uses a tool to support supplying naloxone. The tool is called the Stratification Tool for Opioid Risk Mitigation, also known as STORM. The concern with this tool is that it only includes veterans who have an OUD diagnosis documented in the last year. So, if OUD is not documented in the last year by VHA providers, this tool could miss identifying some veterans with OUD who need naloxone.
Adam Roy:
So, to summarize, the VA OIG identified some opportunities where VHA could improve prescribing practices for OUD-related medicine and how OUD is treated. What were the reports overall recommendations do you want to highlight a few of them?
Nicole Maxey:
Adam, our team made five recommendations to the under secretary for health. These included identifying provider barriers when documenting OUD in the medical record including problem lists. Other recommendations were specific to provider training on the use, navigation, and retrieval of DoD treatment record information. We also recommended an evaluation of provider barriers to access and use of DoD medical records and evaluating and updating processes for identifying veterans with OUD.
We really felt that all five recommendations are critical for not missing this important diagnosis. Missing identification of a veteran’s OUD diagnosis can have adverse outcomes, even including death. Each of our recommendations speak to a certain element to ensure this diagnosis is not missed. We really encourage listeners to read the full report for more details.
Adam Roy:
What was VHA’s response to the recommendations?
Nicole Maxey:
VA did concur with all our recommendations and developed action plans to resolve those recommendations within the next nine months. I'd like to speak about a couple of those action plans. One of the action plans focuses on a technical solution that would identify when a VA provider does not document OUD in the problem list despite that diagnosis being found in the DoD medical record. Another action plan includes VA developing JLV user guides that include step-by-step provider instructions. Again, the full report has further details surrounding the action plan.
Adam Roy:
That’s excellent. Thanks, Nicole. Before we wrap up, is there anything else you want to add?
Nicole Maxey:
Thank you, Adam, I would like to add that veterans face many challenges after leaving military service, and there is an increased risk for veteran suicide within that first year after discharge from DoD. This really put a spotlight on the importance of identifying and documenting OUD to ensure a safe transition of care and linkage to treatment options within VA. Something from our report you and I haven’t talked about today is that we found that 20% of the veteran deaths in Group 2 were suicides. While we couldn’t identify if opioids were a contributing factor in these suicide deaths, it is concerning because OUD is a risk factor for suicide. I think the actions that VHA is implementing will help to ensure this diagnosis is identified and will save veteran lives.
Adam Roy:
That’s great. For those listening today, what do you want them to remember? What’s the big takeaway here they can walk away with?
Nicole Maxey:
We want to make sure that all providers are aware of OUD to ensure that this vulnerable veteran population get the care they need. Even if we prevent one death, this report will have reached the people we really wanted it to.
Adam Roy:
Thank you again, Nicole. Appreciate you being here today.
For those listening, check out this report on our website—the title: Review of Clinical Care Transition from the Department of Defense to the Veterans Health Administration for Service Members with Opioid Use Disorder. We published this report on June 21, 2023.
That’s it for this episode of Inside Oversight. Find more episodes wherever you listen to podcasts. Also check out Veteran Oversight Now, another official VA OIG podcast. Thanks for tuning in.
This has been an official podcast of the VA Office of Inspector General. Inside Oversight is produced by the Office of Communications and Public Affairs and is available at va.gov/oig. Please subscribe and tune in monthly to hear how our work is helping to improve the lives of veterans. Visit the website to learn more about how the VA OIG conducts meaningful independent oversight.
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