Half of Veterans Prescribed Medical Opioids Continue to Use Them Chronically, Study Finds

“Of nearly 1 million veterans who receive opioids to treat painful conditions, more than half continue to consume opioids chronically or beyond 90 days, new research says. Results presented at the 30th Annual Meeting of the American Academy of Pain Medicine reported on a number of factors associated with opioid discontinuation with the goal of understanding how abuse problems take hold in returning veterans.

Of 959,226 veterans who received an opioid prescription, 502,634 (representing 52.4% of the total sample) used opioids chronically.

The preliminary analysis showed that certain factors were more likely to be present in veterans who continued to use opioids chronically. They include post-traumatic stress disorder, tobacco use, being married, having multiple chronic pain conditions, the use of multiple opioids and opioid dose above 100 mg per day.

Some findings did not align with previous research in the fields of pain and addiction.

The press release is available at: http://www.newswise.com/articles/half-of-veterans-prescribed-medical-opioids-continue-to-use-them-chronically-study-finds

Source: American Academy of Pain Medicine (AAPM) – March 7, 2014

APA Calls for Better Training to Treat Chronic Pain, Addiction Among Vets

military“Pain management, addiction detection, and effective treatment are significant priorities for the nation’s veterans, and these objectives require better coordination of opioid and benzodiazepine prescribing inside and outside the Veterans Health Administration (VHA).

That’s what the American Psychiatric Association (APA) CEO and Medical Director Saul Levin, M.D., M.P.A., told the House Veterans Affairs Committee in a written statement about management of chronic pain and addiction to painkillers among veterans. The statement was in response to a House hearing titled “Between Peril and Promise: Facing the Dangers of VA’s Skyrocketing Use of Prescription Painkillers to Treat Veterans.”

Levin focused on veterans and the returning military population, but noted that issues such as medication diversion, medication seeking, improper prescribing, inadequate informatics on prescription utilization, and the need for better pain management and utilization of medical options to assist with substance use disorders are prevalent for the United States population as a whole.

He outlined four overarching recommendations: the use of prescription drug management plans (PDMPs) and the need for coordination between the (VHA’s PDMP and state-based plans, the need to recruit and retain more psychiatrists within the VHA, training the VHA workforce in evidence-based pain management and addiction treatment, and the need for new research on pain medications.”

http://psychnews.psychiatryonline.org/newsarticle.aspx?articleid=1793814

Source: PsychiatryOnline.org – September 19, 2013

Blog: Opioid Use in the Veteran’s Administration System

“Recent news reports have denounced rates of opioid prescribing for war veterans. According to the Center for Investigative Reporting, rates of opioid prescribing by VA doctors have increased two hundred and seventy percent over the last twelve years. The VA is now prescribing more than one opioid prescription for each patient it treats.

The dramatically different opioid prescribing rates between different VA systems are concerning. For example, doctors at a VA hospital in Oklahoma prescribed 160.7 opioid prescriptions for every one hundred patients, compared to doctors at a VA hospital in Manhattan, who prescribed 19.8 opioid prescriptions for every one hundred VA patients treated. That’s more than an eight-fold difference.”

http://janaburson.wordpress.com/2013/10/19/opioid-use-in-the-veterans-administration-system/

Source: JanaBurson.com – October 19, 2013

How Would the Candidates Debate Drugs?

In round 2 of the Obama vs. Romney debates there were no questions about drugs. The Fix surveyed their columnists and contributing writers for the top five drug questions they would ask Obama and Romney.

What follows is what they told us, along with an at-a-glance comparison of the two candidates’ positions, based on what they have said or done.

  • As president, would you support the disease model of addiction and, if so, would you reallocate funding so that these medical matters have a bigger share of the pie?
  • As president, how would you address this growing epidemic among our soldiers and veterans?
  • As president, what policies would you support to insure that the benefits of our current drug laws outweigh the costs?
  • As president, how would you prosecute a more effective effort to reduce drug trafficking and drug use?
  • As president, what would your policy be regarding the legalization or decriminalization of marijuana?

http://www.thefix.com/content/drugs-drug-war-presidential-debate8997

Source: TheFix.com – October 15, 2012

New Report Recommends Expanding Access to Medication-Assisted Treatment in Armed Forces

In order to better understand current substance use problems within the U.S. military, the Department of Defense (DoD) asked the Institute of Medicine (IOM) to analyze policies and programs that pertain to prevention, screening, diagnosis, and treatment of substance use disorders (SUDs) for active duty service members in all branches, members of the National Guard and Reserve, and military families.

Service members’ rising rate of prescription drug addiction and their difficulty in accessing adequate treatment for alcohol and drug-related disorders were among the concerns that prompted members of Congress to request this review.

The IOM committee presented its findings and recommendations in a report Substance Use Disorders in the U.S. Armed Forces.

While rates of both illicit and prescription drug abuse are low, the rate of medication misuse is rising.  Just 2 percent of active duty personnel reported misusing prescription drugs in 2002 compared with 11 percent in 2008.  The armed forces’ programs and policies have not evolved to effectively address medication misuse and abuse, the committee noted.

TRICARE, which provides health insurance to service members and their dependents, does not cover several evidence-based therapies that are now standard practice, the committee found.  It also does not permit long-term use of certain medications for the treatment of addiction and covers treatment delivered only in specialized rehabilitation facilities.

The report recommended that TRICARE’s benefits should be revised to cover maintenance medications and treatment in office-based outpatient settings delivered by a range of providers, which would enable ongoing care for patients struggling to avoid relapses.

Data from fiscal year 2010 shows that only 6 active duty service members received methadone treatment for opioid addiction averaging a 42-day supply. A total of 405 active duty service members received buprenorphine treatment averaging an 89 day supply.

Medications for Addiction Treatment Given to Active Duty Service Member and Active Duty Family Member Adult Dependent Beneficiaries (Aged 18 and Over),
All Systems of Care (FY 2010)

Active Duty Service Members Active Duty Family Members
Medication Sum of Days Supply # Users Sum of Days Supply # Users
Antabuse 35,560 605 14,127 214
Buprenorphine 35,966 405 60,718 668
Campral 30,024 619 21,736 343
Methadone 250 6 1,405 20
Naltrexone 54,057 1,034 26,518 371
Vivitrol 956 14 270 3

Source: Personal communication, Greg Woskow, TRICARE Management Activity, May 7, 2012.

The press release can be accessed at: http://www.iom.edu/Reports/2012/Substance-Use-Disorders-in-the-US-Armed-Forces/Press-Release.aspx

The report brief can be accessed at: http://www.iom.edu/Reports/2012/Substance-Use-Disorders-in-the-US-Armed-Forces/Report-Brief.aspx

The full report can be accessed at: http://www.nap.edu/catalog.php?record_id=13441

Sources: Institute of Medicine and National Academy Press – September 17, 2012

150 Soldiers Have Died of Drug Overdose in the Last Two Years, Says Congressman

Congressman Hal Rogers from Kentucky gave a speech on August 1 in the House of Representatives about the issue of prescription drug abuse in America, where he mentioned a growing problem – members of the United States military dying from prescription medications.

“Our military soldiers are coming back from Iraq and Afghanistan hooked on these pain pills. In the last 2 years, over 150 of our soldiers have died from overdoses”, Congressman Rogers said.

http://www.examiner.com/article/150-soldiers-have-died-of-drug-overdose-the-last-two-years-says-congressman

Source: Examiner.com – August 3, 2012

Veterans of Iraq, Afghanistan Wars with Mental Health Diagnoses More Likely to Receive Prescription Opioids for Pain

Iraq and Afghanistan war veterans with mental health diagnoses, particularly posttraumatic stress disorder, are more likely to receive prescription opioid medications for pain-related conditions, have higher-risk opioid use patterns and increased adverse clinical outcomes associated with opioid use than veterans with no mental health diagnoses, according to a study in the March 7 issue of the Journal of the American Medical Association (JAMA).

Greater exposure to combat coupled with improvements in battlefield medicine and protective gear have resulted in large numbers of veterans of Iraq and Afghanistan surviving injuries that would have been fatal in prior wars. Veterans are returning home with co-existing mental and physical health problems, and posttraumatic stress disorder (PTSD) is the most prevalent mental health disorder. “Nationwide, the prescription of opioid analgesics has nearly doubled since 1994 because of a greater recognition of the importance of treating pain. At the same time, rates of prescription opioid misuse and overdose have increased sharply, and prescription opioids are now a leading cause of death in the United States. Iraq and Afghanistan veterans with pain- and PTSD-prescribed opioids may be at particularly high risk of prescription opioid misuse given the high co-occurrence of substance use disorders among veterans with PTSD,” according to background information in the article.

Karen H. Seal, MD, MPH, of the San Francisco Veterans Affairs Medical Center, and colleagues examined the association between mental health disorders and patterns of opioid prescription use, related risks, and adverse clinical outcomes, such as accidents and overdose, among a national sample of 141,029 Iraq and Afghanistan veterans. The study included veterans who received at least one non-cancer-related pain diagnosis within one year of entering the Department of Veterans Affairs (VA) health care system from October 2005 through December 2010.

Additional information on the study is available at: http://pubs.ama-assn.org/media/2012j/0306.dtl#1

Journal of the American Medical Association – March 6, 2012

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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