Report Summary

Title: Healthcare Inspection – Alleged Improper Opioid Prescription Renewal Practices, San Francisco VA Medical Center, San Francisco, California
Report Number: 13-00133-12
Issue Date: 11/7/2013
City/State: San Francisco, CA
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspections
Release Type: Unrestricted
Summary: The OIG conducted an inspection concerning improper opioid prescription renewal practices in the Medical Practice Clinic (clinic) at the San Francisco VA Medical Center (facility). The complainant alleged that attending physicians on-duty are tasked with evaluating numerous opioid renewal requests for patients with whom they are unfamiliar; providers do not routinely document patients’ opioid prescription renewal problems in the electronic health record; and there have been patient hospitalizations and deaths related to opioid misuse.
We substantiated that attending physicians on-duty are tasked with evaluating numerous opioid renewal requests for patients with whom they are unfamiliar; however, VHA regulations and local policy do not prohibit such practice. We partially substantiated that providers do not routinely document patients’ opioid prescription renewal problems in the electronic health record. The providers did not consistently document an assessment for adherence with appropriate use of opioids and monitor patients for misuse. The primary care providers did not consistently complete the templated Narcotic Instructions Note. We partially substantiated that there have been patient hospitalizations and deaths related to opioid misuse. Seven clinic patients were hospitalized for opioid overdose; however, the primary care provider, Psychiatry Service, and/or the facility’s Substance Abuse Program appropriately assessed and monitored the patients. There were no deaths related to opioid overdose. We recommended that the Facility Director ensure that providers comply with all elements of the management of opioid therapy for chronic pain, as required by Veterans Health Administration and the VA/DoD Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain, and ensure that the Narcotic Instructions Note is reevaluated for appropriate use and that providers comply with established protocol.