Medications for opioid use disorder in the Department of Veterans Affairs (VA) health care system: Historical perspective, lessons learned, and next steps

Abstract

The US Department of Veterans Affairs (VA), the largest health care system in the US, has been confronted with the health care consequences of opioid disorder (OUD). Increasing access to quality OUD treatment, including pharmacotherapy, is a priority for the VA. We examine the history of medications (e.g., methadone, buprenorphine, injectable naltrexone) used in the treatment of OUD within VA, document early and ongoing efforts to increase access and build capacity, primarily through the use of buprenorphine, and summarize research examining barriers and facilitators to prescribing and medication receipt. We find that there has been a slow but steady increase in the use of medications for OUD and, despite system-wide mandates and directives, uneven uptake across VA facilities and within patient sub-populations, including some of those most vulnerable. We conclude with recommendations intended to support the greater use of medication for OUD in the future, both within VA as well as other large health care systems.

Key words::

• opioid use disorder
• pharmacotherapy
• buprenorphine
• Veterans

ACKNOWLEDGEMENTS

We would like to thank Ilse Wiechers, MD, MPP, MHS, Melisa Christopher, Pharm.D and Mitchell Nazario, PharmD for sharing expert knowledge in contribution to this paper. We also thank Julia Holloway for excellent research assistance.

Disclaimer:

The views expressed in this article are those of the author and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.

AUTHOR CONTRIBUTIONS

Drs. Wyse, Gordon, Dobscha, Morasco, Tiffany, Drexler, Sandbrink and Lovejoy all contributed to the paper's conceptualization. Dr. Wyse drafted the manuscript. Drs. Drexler, Gordon, Sandbrink and Tiffany contributed key data. All authors contributed to critical revision of the manuscript.

Additional information

Funding

This work was supported by the United States (U.S.) Department of Veterans Affairs Health Services Research & Development Center to Improve Veteran Involvement in Care at the VA Portland Health Care System (CIN 13–404, PI Dobscha). Dr. Lovejoy received additional support from Career Development Award IK2HX001516 from the U.S. Department of Veterans Affairs Health Services Research and Development during preparation of this manuscript. The funding organization had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.