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BMJ Open. 2018 Jun 27;8(6):e020097. doi: 10.1136/bmjopen-2017-020097.

Effectiveness of policy and risk targeting for opioid-related risk mitigation: a randomised programme evaluation with stepped-wedge design.

Author information

Partnered Evidence-based Policy Resource Center, VA Boston Healthcare System, Boston, Massachusetts, USA.
Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts, USA.
Geriatrics Research, Education, and Clinical Center, James J. Peters VA Medical Center, Bronx, New York, USA.
Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York City, New York, USA.
Department of Health Law, Policy and Management, Boston University of Public Health, Boston, Massachusetts, USA.
Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Cambridge, Massachusetts, USA.



There is an epidemic of opioid use related to adverse events and deaths in the USA. The rates of chronic pain, mental illness and substance use disorder are higher at the Veterans Health Administration (VHA) compared with the general US population. The 2016 Comprehensive Addiction and Recovery Act requires the VHA to improve opioid therapy strategies in treating patients and to ensure responsible prescribing practices. The Stratification Tool for Opioid Risk Mitigation (STORM) is a web-based dashboard that prioritises review of VHA patients receiving opioids based on their risk. The VHA Partnered Evidence-based Policy Resource Center is coordinating a multiyear evaluation of STORM and aspects of the VHA policy that mandate case review of patients identified by STORM as very high risk.


This stepped-wedge cluster randomised controlled trial will test two hypotheses: (1) VHA medical centres randomised to facilitation for not meeting the targeted case review rate will achieve lower opioid-related serious adverse events (SAEs), relative to facilities not randomised to facilitation and (2) Patients whose cases are required to be reviewed will have a lower rate of opioid-related SAEs compared with comparable risk patients whose cases are not required to be reviewed. Patients who receive an opioid prescription at VHA medical centres will be followed for a minimum of 3 months after their first opioid prescription. Follow-up will continue until the last day of the project or death. The data will be analysed using an intention-to-treat approach with patient-month-level Cox proportional hazards models for both interventions.


Evaluation of the randomised roll-out was approved by the VA Boston Healthcare System Institutional Review Board (IRB) and Research & Development Committees (Protocol # 3069). Findings will be published in peer-reviewed journals and presentations at national conference meetings.




opioids; randomised programme evaluation; united states veterans administration

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