PRACTICE POINTERS: How to Effectively Treat Veterans Using Medication-Assisted Treatment

At the end of 2011, veterans from Iraq returned home, many of whom will require treatment for their addiction to prescription opioids. Also at year’s end, the federal government issued a proposal to lift the ban on the military paying for medication-assisted treatment (MAT) with methadone and buprenorphine. In order to help opioid treatment programs (OTPs) prepare for more veterans seeking MAT, AT Forum interviewed three top federal officials—one with the Department of Defense (DoD), one with the Veterans Administration (VA), and one with the Substance Abuse and Mental Health Administration (SAMHSA)—on the effective treatment of veterans.

Military History

The first and most important thing OTPs can do for patients who are veterans is to take a complete “military history,” says Andrew J. Saxon, MD, director of the Addiction Treatment Center in the VA Puget Sound Health Care System in Seattle. OTPs should always ask patients at admission: “Were you in the service? What branch? Where did you do your boot camp or basic training? Where were you stationed? What was your job in the military? What kind of discharge did you get? What happened since you’ve been out?”

Taking the military history lets the veteran know that this is an area of interest, and helps to build a relationship of trust. “Although they don’t necessarily want to talk about their military service, most veterans are proud of it, and they want to have someone acknowledge it,” says Dr. Saxon, who is also professor in the Department of Psychiatry and Behavioral Sciences and director of the Addiction Psychiatry Residency Program at the University of Washington.

“Also, they may divulge something that is troublesome, including posttraumatic stress disorder (PTSD).”

Managing Pain Disorders

Many veterans will be coming home from Iraq and Afghanistan with pain from injuries. OTPs can treat pain, as long as the patient also has an addiction, notes Dr. Saxon. “Some OTPs struggle with how to manage pain,” he says. “Methadone maintenance will not handle all pain issues.” Patients might need other medications, and most people with chronic pain need some form of psychotherapy.

Treating chronic pain is a challenge even for VA methadone programs, which have the benefit of being part of a larger health system, says Daniel Kivlahan, PhD, Acting National Mental Health Program Director, Addictive Disorders, Office of Mental Health Services, in the Veterans Health Administration. “For freestanding OTPs, it’s particularly difficult.”

Nicholas Reuter, team leader for the certification and waiver team of the Division of Pharmacologic Therapies at the Center for Substance Abuse Treatment at SAMHSA, noted that for people on active duty, there’s a huge stigma issue with methadone. “Someone might question their suitability for service,” he said. But this would be wrong. “We’ve done what we can to advocate for the ability of a methadone maintenance patient to hold down just about any job.” Mr. Reuter recommends that OTPs emphasize the effectiveness of methadone maintenance treatment when working with veterans. He noted that patients in the Reserves who are called up will need take-home exemptions to allow them to fulfill their Reserve duties, which presents additional difficulty.

Lifting the Ban on MAT

In fact, VA OTPs are in a special—and privileged—position. There are a multitude of services that can be offered, which are paid for without the concerns most non-VA OTPs have about payment or insurance.

Some veterans would prefer to go outside the VA system for substance abuse treatment, Dr. Kivlahan acknowledges. They are fearful that if the VA knows about their addiction, it may hinder their future military career, if they want to be redeployed. Current rules ban people on methadone or buprenorphine from serving in the military.

Finally there is a proposal to change this. The ban on MAT coverage by Tricare, the insurance program run by the DoD for people on active duty, may soon be lifted. The 1986 federal regulation (32 CFR 199.4[e]) applies to methadone and to buprenorphine and allows these drugs to be used only for detoxification or medically supervised withdrawal. Family members and retirees also are banned from accessing Tricare coverage for maintenance treatment with agonist (or partial agonist) opioid medications.

Recently, with troops returning from Iraq and Afghanistan, and the increase in prescription opioid abuse, including among family members of troops in the armed forces, many advocates have urged the DoD to review the evidence and best practice recommendations about OTPs and MAT treatment. The DoD has published a proposed rule in the December 29 Federal Register, citing the “long-term use of pain medications” among troops and the consequent risks of addiction.

The preamble to the proposed rule stated that “in the past, there was not sufficient reliable evidence . . . to establish that the substitution of one addictive drug for another was an effective part of a drug treatment program.” The preamble also says that “medicine is constantly evolving including in the area of drug addiction treatments.” Comments are due by February 27. To read the Federal Register notice, go to http://www.federalregister.gov/articles/2011/12/29/2011-33106/tricare-removal-of-the-prohibition-to-use-addictive-drugs-in-the-maintenance-treatment-of-substance.

About 20 percent of troops return with PTSD, and about 20 percent come back with traumatic brain injury, said Dr. Saxon. The percentage of troops returning with a documented diagnosis of any substance use disorder is 10 percent, said Dr. Kivlahan. However, this is likely the tip of the iceberg, since addiction issues may not surface for weeks or months after troops return home or are discharged from active duty.

Asked whether veterans in OTPs are presenting with prescription opioid addiction or heroin addiction, Dr. Saxon says “We’re seeing both heroin and prescription opioids — I think OTPs need to be prepared for both.”

Additional resources for understanding the special needs of treating veterans:

http://www.va.gov/oaa/pocketcard/
http://www.ptsd.va.gov/
http://www.ptsd.va.gov/professional/ptsd101/course-modules/course-modules.asp
http://www.ptsd.va.gov/professional/ptsd101/course-modules/military_culture.asp
http://www.samhsa.gov/samhsanewsletter/Volume_19_Number_3/fall-2011-volume-19-number-3.pdf
http://www.samhsa.gov/samhsaNewsletter/Volume_19_Number_3/military.aspx
http://www.samhsa.gov/MilitaryFamilies/
(all links accessed February 20, 2012)

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