Regional and Rural–Urban Variation in Opioid Prescribing in the Veterans Health Administration

Abstract

Introduction Opioid prescribing is heterogenous across the US, where 3- to 5-fold variation has been observed across states or other geographical units. Residents of rural areas appear to be at greater risk for opioid misuse, mortality, and high-risk prescribing. The Veterans Health Administration (VHA) provides a unique setting for examining regional and rural–urban differences in opioid prescribing, as a complement and contrast to extant literature. The objective of this study was to characterize regional variation in opioid prescribing across Veterans Health Administration (VHA) and examine differences between rural and urban veterans. Materials and Methods Following IRB approval, this retrospective observational study used national administrative VHA data from 2016 to assess regional variation and rural–urban differences in schedule II opioid prescribing. The primary measure of opioid prescribing volume was morphine milligram equivalents (MME) dispensed per capita. Secondary measures included incidence, prevalence of any use, and prevalence of long-term use. Results Among 4,928,195 patients, national VHA per capita opioid utilization in 2016 was 1,038 MME. Utilization was lowest in the Northeast (894 MME), highest in the West (1,368 MME), and higher among rural (1,306 MME) than urban (988 MME) residents (p < 0.001). Most of the difference between rural and urban veterans (318 MME) was attributable to differences in long-term opioid use (312 MME), with similar rates of short-term use. Conclusion There is substantial regional and rural–urban variation in opioid prescribing in VHA. Rural veterans receive over 30% more opioids than their urban counterparts. Further research is needed to identify and address underlying causes of these differences, which could include access barriers for non-pharmacologic treatments for chronic pain.

<p>Regional Differences in Opioid Prescribing in Germany – Results of an Analysis of Health Insurance Data of 57 Million Adult People</p>

“…We used data for all persons insured with an SHI for at least 180 days in 2010 and who were 18 years or older in the respective year. On a state level, the number of all insured persons was provided by age group (18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41)(42)(43)(44)(45)(46)(47)(48)(49), 50-69 and ≥70 years) and sex whereas on the district level only the overall numbers, the mean age and sex ratio per district were available.…”

“…For Europe a more than 10-fold difference was observed between the highest consumption in Western/Northern countries and the lowest in Southern/ Eastern countries. 7 Besides differences between countries, regional variations in opioid utilization are known for example from the United States, the United Kingdom or Australia 8,[16][17][18][19] listing, among others, ruralness and lower social economic status as influencing factors for higher opioid consumption.…”

Community Treatment for Opioid Use Disorders in Urban and Rural Veterans

“…In turn, opioid pain management is a significant risk factor for later opioid and heroin misuse in both veteran and civilian populations . Since 2012, both the Department of Defense and VHA have initiated prescription guidelines to limit long‐term medication pain management, and there is initial evidence based on analysis of VHA administrative data that these measures are reducing long‐term opiate prescription use in VHA . However, opioid misuse among veterans and the rates of substance use disorders (SUDs) remain high, suggesting the need for other measures to address this problem …”

“…[7][8][9][10][11] Since 2012, both the Department of Defense and VHA have initiated prescription guidelines to limit long-term medication pain management, and there is initial evidence based on analysis of VHA administrative data that these measures are reducing longterm opiate prescription use in VHA. [12][13][14][15] However, opioid misuse among veterans and the rates of substance use disorders (SUDs) remain high, suggesting the need for other measures to address this problem. 6,10,[16][17][18] It is a challenge for VHA to develop a comprehensive understanding of the trends in SUDs for veterans, including opioid use disorders, because not all veterans are enrolled in VHA.…”

Variation in Abuse‐Deterrent Formulation Opioid Prescribing in California, Florida, and Kentucky in 2018

“…Opioid analgesic prescribing varies by geographic region. Previous studies have found opioid prescribing rates and high-risk opioid prescribing are higher in rural areas, as compared to urban or metropolitan areas, [11][12][13][14][15] with regional variation and higher prescribing rates in Southern states. 16 Higher adverse event rates, including opioid-involved hospitalization and overdose, follow similar trends for these areas.…”