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The Veterans Health Administration (VHA) Stratification Tool for Opioid Risk Mitigation (STORM) decision support system and targeted prevention program were designed to help mitigate risk factors for overdose and suicide among veterans who are prescribed opioids and/or with opioid use disorder (OUD) and are served by the VHA.¹ Veterans, particularly those prescribed opioids, experience overdose and suicide events at roughly twice the rate of the general population.^1,2

The STORM decision support system uses data extracted from VHA electronic medical records and predictive analytics to facilitate the identification of patients at high risk of experiencing overdose and suicide events. The STORM decision support system can also review risk factors for patients who are being considered for prescription opioid therapy. STORM prioritizes patients for monitoring and intervention according to their modeled risk and aids clinicians by displaying a patient’s risk factors and associated evidence-based risk mitigation interventions. Note that the target population does not include patients with OUD in medication-assisted treatment (MAT).

Many patients with OUD and/or in prescription opioid therapy have complex medical and psychosocial needs (e.g., painful conditions, mental health challenges), resulting in interactions with multiple care providers. To address the complexity of a patient’s case, STORM aims to provide a holistic intervention that includes multiple care providers and accounts for multiple parts of the patient’s history and medical profile.³ Under the STORM-based targeted prevention program, an interdisciplinary team of clinicians, including those with expertise in pain and behavioral health, conduct case reviews for patients identified to be at the highest risk of overdose and/or suicide and implement treatment changes or share recommendations with the patients‘ providers.

The VHA completed a three-year randomized program evaluation of the implementation of the national STORM-based targeted prevention program. Preliminary results indicate that mandating that very high-risk patients receive an interdisciplinary review was associated with a decrease in all-cause mortality among identified patients in the 127 days after identification by the decision support system.⁴

The STORM decision support system and targeted prevention program were developed and implemented in the context of relatively high rates of opioid prescribing to veterans and overall rising opioid-involved overdose mortality in the U.S. population. In the last 10 years, overdose deaths have more than doubled in the United States.⁵ As one response to the problem, the 2016 Comprehensive Addiction and Recovery Act requires the VHA to improve opioid therapy strategies and to ensure responsible prescribing practices. STORM is one of several VHA overdose prevention initiatives that include the distribution of naloxone, efforts to reduce opioid prescribing, and introduction of pain management clinical review and support teams.⁵

This case describes multiple emergency department (ED) encounters and hospitalizations experienced by a middle-aged woman with sickle cell crisis and a past history of multiple, long admissions related to her sickle cell disease. The multiple encounters highlight the challenges of opioid prescribing for patients with chronic, non-cancer pain.