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A History of the Policy Landscape

STRATEGIES IMPLEMENTED TO COMBAT THE OPIOID EPIDEMIC

This chapter provides a comprehensive, though not exhaustive, overview of the changing landscape around clinical guidelines and policies related to opioid prescribing since the mid-1990s. In addition to national efforts, this overview demonstrates early guidelines set forth by the Veterans Health Administration (VHA) in 2003 to support clinical decision making around pain management and opioid treatment. VHA clinical guidelines continued to evolve and were subsequently updated (2010, 2017, 2022) along with the agency-wide Department of Veterans Affairs (VA) Opioid Safety Initiative initiated in 2013, which, among many efforts, increased education and monitoring and promoted safe and effective prescribing. These efforts were complemented by other federal agency and state efforts, such as additional clinical guidelines from the Centers for Disease Control and Prevention (CDC) in 2016 and 2022 and the Department of Health and Human Services (HHS) in 2019. In addition, federal legislation was enacted during this time frame, such as the Veterans Access, Choice, and Accountability Act (2014), the Comprehensive Addiction and Recovery Act (2016), and the VA Mission Act (2018), to help support veterans and/or fight the opioid epidemic. The committee recognizes that understanding the policy landscape and how the implementation of new policies changed practices over time is crucial. This chapter describes the context for what individuals faced seeking relief from pain and support from providers and the health care system. Additional policy details are in Appendix D.

Early Attitudes Toward Prescribing Opioids and Pain Management

Attitudes toward managing pain in the mid-1990s and 2000s helped contribute to increased trends in opioid prescription. In 1995, the American Pain Society coined the phrase “pain as the fifth vital sign” (Campbell, 1995). Furthermore, in 1999, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)¹ approved standardized pain assessment and management of all patients, which was required to be incorporated into policies of health care organizations and providers to obtain JCAHO-accreditation (Baker, 2017; Ahmedani et al., 2014).

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¹ A U.S, based nonprofit organization that accredits more than 22,000 health care organizations and programs in the country. (https://www.jointcommission.org/).

These new standards² went into effect in 2012. In 1999, the VHA followed the American Pain Society recommendations, integrating the Pain as the 5^th Vital Sign Initiative into the VHA National Pain Management Strategy, whereby routine screening, a published comprehensive pain assessment and management toolkit, and educational campaigns were launched (VA, 2000, 2018b; Mularski et al., 2006; Cleeland et al., 2003; Kerns et al., 2000). In addition, given efforts to improve pain management in patients and the pharmaceutical industry’s push of the use of opioid pharmacotherapy, several organizations, such as the Federation of State Medical Boards and Drug Enforcement Administration, reduced oversight and scrutiny to encourage providers to prescribe opioids to address the unmet needs of chronic pain patients (Tompkins et al., 2017; Van Zee, 2009).

Relevant Clinical Guidelines, Policies, Legislation

Guidelines, policies, and legislation have affected opioid prescribing practices within the context of changing attitudes toward pain management. To provide context, the committee reviewed several VA policies, VA clinical guidelines, and federal legislation that had an impact on opioid prescribing, including by VHA providers, and support for veterans during the study period (2007–2019). In addition, guidelines from other agencies, such as CDC and HHS, were also reviewed (Dowell et al., 2016, 2022; HHS, 2019). Table 2-1 outlines these efforts and includes a summary of VA clinical practice guidelines (CPGs) (inform clinical decision making within the VHA), VHA directives (outline mandatory department policies), federal legislation, and other relevant guidelines or efforts within the VA or of other agencies. Figure 2-1 depicts a timeline of key policies implemented by the VA, various federal agencies, and the federal government between 2001 and 2024.

This chapter is a brief summary of dynamic changes in the attitudes, policies, and CPGs that occurred during the study period of interest. Appendix D provides further detail of the policies and legislation outlined in Table 2-1 as well as other efforts, such as FDA’s Opioids Analgesic Risk Evaluation and Mitigation Strategies and state Prescription Drug Monitoring Programs. Given the dynamic aspects of opioid and benzodiazepine prescribing during the study period, the committee adjusted for these factors in the analytic models (see chapter 3 for more details, section on Accounting for Secular Trends and Variation by Facility).

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² In 2009, assessment of pain in all patients, except for those receiving behavioral health care, was eliminated as a standard, given concerns that the standards encouraged opioid use (Baker, 2017).

TABLE 2-1 Opioid Policy Landscape

¹ California became the first state to implement a PDMP program in 1939.

² Public Law 113-146, Veterans Access, Choice and Accountability Act of 2014, 113th Congress, August 7, 2014.

³ Public Law 114-198, Comprehensive Addiction and Recovery Act of 2016. 114th Congress, July 22, 2016.

⁴ Public Law 115-182, VA Mission Act of 2018, 115th Congress, June 6, 2018.

⁵ Public Law 115-271, Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT), 115th Congress, October 24, 2018.

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