Report Summary

Title: Pharmacists’ Practices Delayed Buprenorphine Refills for Patients with Opioid Use Disorder at the New Mexico VA Health Care System in Albuquerque
Report Number: 21-03195-189 Download
Issue Date: 6/30/2022
City/State: Albuquerque, NM
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Hotline Healthcare Inspection
Release Type: Unrestricted

The VA Office of Inspector General (OIG) assessed allegations at the New Mexico VA Health Care System (facility) regarding the policy and practices related to the provision of buprenorphine treatment for patients with opioid use disorder.

The OIG substantiated that pharmacists declined early refills of buprenorphine despite prescribing providers’ documented clinical rationales, which increased patients’ risk for adverse clinical outcomes associated with interruption of buprenorphine treatment. The OIG substantiated that justification for declining early refills was incorrectly based on a facility policy that was not applicable to the use of buprenorphine for treatment of opioid use disorder.

The OIG substantiated that the Opioid Safety Committee pharmacist placed standing orders for urine drug screening without coordinating with patients’ prescribing providers. However, the pharmacist acted within the scope of practice.

The OIG did not substantiate that the facility’s Opioid Safety Committee Chairperson interfered with prescribing providers’ practices regarding buprenorphine orders for patients with opioid use disorder, the facility’s standing operating procedure (SOP) on buprenorphine treatment for patients with opioid use disorder was inconsistent with VHA guidance or that facility practices varied from VHA guidance on increasing access to buprenorphine.

The OIG did not substantiate that facility leaders failed to respond to a provider’s report of patient safety concerns. However, actions taken by leaders did not fully address the reported concerns.

The OIG identified a related concern regarding staffing challenges that affected the Substance Use Disorder program and plans for expanding buprenorphine treatment.

The OIG made five recommendations to the Facility Director to align facility practices with policy applicable to early refills for buprenorphine; ensure communication between providers, pharmacists, and patients for early medication refills; clarify and educate staff on the Opioid Safety Committee’s role in buprenorphine treatment; revise the facility’s buprenorphine SOP; and review Substance Use Disorder provider staffing.