Healthcare Inspection – Opioid Prescribing Practice Concerns, VA Illiana Health Care System, Danville, Illinois

OIG conducted a healthcare inspection to assess an alleged unsafe opioid prescribing practice of a primary care physician (PCP) at VA Illiana Health Care System, Danville, IL. The specific allegation related to the initiation of a fentanyl patch to treat pain in a patient with a complex mental health history who subsequently died of fentanyl toxicity. We found the PCP considered the use of non-steroidal anti-inflammatory medications for pain but was concerned about an interaction with one of the patient’s other medications. Fentanyl is typically prescribed to alleviate severe pain and not indicated for the management of acute pain or in opioid naïve patients. This patient had received opioid medications in the past for chronic pain issues and would be considered opioid tolerant. The PCP had safety concerns regarding oral opioid analgesics and prescribed a low dose fentanyl patch in a small supply. The autopsy report showed pieces of fentanyl patches in the patient’s gastric contents, indicating that the patient likely ingested one or more patches. The patient also had two patches on his back; one of which he obtained outside the VA as the dose on one of the patches was approximately eight times the dose the VA PCP had ordered. Facility pharmacy staff performed an opioid medications audit and confirmed that each fentanyl patch ordered by the VA PCP had been dispensed to the patient with the prescribed lower dose. We did not substantiate that the PCP engaged in unsafe opioid prescribing practices, specifically regarding initiation of a fentanyl patch to treat pain in a patient with a complex mental health history who subsequently died of fentanyl toxicity. The provider followed the 2010 VA/Department of Defense Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain recommendations when initiating the patient’s pain management. If used appropriately, the low dose fentanyl patches would not likely have resulted in fentanyl toxicity or death. We made no recommendations.