May is National Military Appreciation Month, when Americans are asked to recognize current and former U.S. service members as a symbol of unity. The observation culminates in Memorial Day, when we honor those who died in the pursuit of freedom.
But veterans are suffering on the opioid battlefield at home in far greater numbers than on any battlefield overseas.
According to the U.S. Department of Veterans Affairs, veterans and service members of all ages are disproportionately afflicted with opioid use disorder (OUD). The VA estimates that 68,000 veterans are addicted to opioids, a threefold increase in 15 years. They’re ten times more likely than the general public to abuse opioids and twice as likely to overdose.
Addressing the opioid epidemic as it relates to the active duty and veteran population comes with added complications. This includes the stigma that service members worry about when they seek help within the insular military community.
Improvement through coordination
Having experienced both physical and psychological trauma, two of the leading factors in developing an addiction to opioids, veterans are particularly vulnerable to the perils of painkillers. They're more likely to receive opioids for pain, and they're more likely to develop a use disorder as they try to cope with chronic pain and PTSD. Traumatic brain injuries, more often experienced by veterans than the general population, also predisposes a person to addiction. Between 2001 and 2009, opioid prescriptions written by military physicians quadrupled to close to 3.8 million.
But in recent years, the VA has taken steps to decrease the number of prescriptions and increase access to evidence-based treatment.
Veterans experience greater chronic and severe pain than people in the general population, with up to 75 percent of older veterans experiencing chronic pain. Working with the Substance Abuse and Mental Health Services Administration (SAMHSA) and the U.S. Department of Defense, the VA has seen improvement on all sides of this issue, from prescribing practices to treatment options.
Per the CDC, the research on chronic pain and opioids shows that opioids are not very effective in treating chronic pain, but that taking them dramatically increases risk of addiction, overdose, and death. As a result, the VA is now relying less on medication and more on other approaches, including behavioral therapies, physical therapy and integrative health modalities, and emphasizing physical and mental function. With this approach, veterans are finding relief from the stress of chronic pain and enjoying better health outcomes.
The Opioid Safety Initiative, launched in 2013, is the coordinating center for all of the VA's efforts to promote safe prescribing practices and to address the broader opioid epidemic in the United States. More recently, the VA began posting information publicly on opioids dispensed from VA pharmacies, along with VA’s strategies to prescribe these pain medications appropriately and safely. The goal is to better track overall opioid use by this population.
The initiative also provides guidelines and other support for VA health care providers on treating pain. These include recommendations to decrease doses of opioids and offer fewer in combination with a class of medications prescribed for anxiety known as benzodiazepines, which together increase the risk of opioid overdose.
In an effort to prevent misuse and diversion of prescription medicines, the VA Prescription Data Accountability Act of 2017 directs the VA pharmacies to disclose their drug dispensing information to each state's prescription drug monitoring program, just like all other U.S. retail pharmacies are required to do. Health care providers are obligated to check a patient’s medication history through these programs before prescribing any controlled substances.
Increasing access to treatment
The VA is also actively increasing access to medication-assisted treatment (MAT), after determining that MAT is more effective than other treatments in increasing a patient’s adherence to treatment, reducing illicit drug use, and preventing relapse.
Access to all kinds of treatment is particularly challenging in remote areas. More physicians must be certified so that this effective and efficient form of outpatient treatment is more widely available to all, including veterans.
A pilot project by the DoD, Building Healthy Military Communities, has been addressing the unique needs of service members and their families regardless of where they live, including concerns related to mental health and substance use disorders. This is one of many efforts underway to strengthen veterans communities in far-flung areas and improve access to critical services.
Since 2013, the DoD, VA, and the U.S. Health and Human Services Dept. (HHS) have collaborated in the Interagency Task Force on Military and Veterans Mental Health to improve access to services for veterans, service members, and their families. The combined federal effort allows risks and safety concerns across a wide range of issues to be tightly coordinated.
As part of this effort, SAMHSA provides a number of resources to DoD and VA providers, including:
- Online trainings and webinars, including medication-assisted treatment training, that not only educate prescribing professionals, but also family members who might need to administer medication if overdose occurs.
- SAMHSA review of Management of Substance Use Disorder and Management of Opioid Therapy for Chronic Pain Clinical Practice Guidelines and the subsequent development of new areas.
- The Service Members, Veterans, and their Families Technical Assistance Center (SMVF TA) that provides technical assistance to states and territories and offers policy academies, where all three departments work together to determine ways to strengthen behavioral health supports at the state level.
- Video modules on safe opioid prescribing practices.
- Screening, brief intervention, and referral to treatment (SBIRT) training to recognize and mobilize if someone may be at risk for or have a substance use disorder.
- MAT-X mobile app to support medication assisted treatment of opioid use disorder.
SAMHSA has also eliminated the co-pay on drugs like Naloxone, making these overdose-reversal drugs more accessible to veterans and their families, and is encouraging doctors to be more creative in how they think about overdose prevention, education, and treatment.
"A model for other parts of the healthcare system"
This effort to connect more VA patients with MAT is working. In 2017, 34 percent of VA patients diagnosed with OUD received MAT, up from 25 percent in 2004. Compare this to the only 1 in 9 Americans—11 percent—with substance use disorder who receives any treatment.
According to Captain Mike Colston, Director of Mental Health Policy and Oversight for the Office of the Assistant Secretary of Defense for Health Affairs, military prescriptions for opioids have reduced by 15%.
The rates of deadly opioid overdoses for active duty service members are now a quarter of the national average. Vice Admiral Raquel C. Bono, director of the Defense Health Agency, reported that less than 1% of active duty service members are addicted to opioids.
“These VA practices and systems can serve as models for other parts of the healthcare system,” writes Beth Connelly for Pew.
Rep. Jackie Speier, Ranking Member on the House Armed Services Subcommittee on Military Personnel, recently expressed her belief that “the military has the opportunity to lead the nation to reduce opioid abuse and develop alternate pain management therapies.”
Still, 2 of 3 veterans with OUD are not receiving evidence-based treatment and recovery services.
“By expanding the use of MAT and increasing access to care, the United States and the VA can better serve those who served their country.”
CleanSlate treats patients suffering from opioid or alcohol addiction with medications and a continuum of integrated care to support each individual's journey to recovery. If you or someone you love needs help, contact us at 833-505-HOPE, or visit our website at www.cleanslatecenters.com to find the center nearest you.
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