How can we ever fully thank our veterans for their service? As a group of health care professionals, we have an obligation to provide outstanding clinical care to this heroic population. Every Veterans Day we celebrate the service of all U.S. Military Veterans. We know that this courageous group has been protecting American’s freedom at home and abroad. As clinicians we can continue to offer our veterans freedom from chronic pain. We know that untreated chronic pain can significantly increase the risk of suicide, but poorly managed opioid regimes can also be fatal. Appropriate clinical management poses a double edge threat. Our veterans are a vulnerable population. Veterans are twice as likely to die from accidental opioid overdoses than non-veterans. We are capable of working more effectively with those who are suffering from significant physical and psychic pain.
Addiction medicine has historically been segregated from the entire medical field. However, we now know that most individuals with opioid use disorders have at least one co-occurring mental health issue that requires evaluation and effective treatment. Recently there has been a focus on employing evidence based therapeutic interventions. We have developed a sophisticated model of Medication Assisted Treatment (MAT) in combination with behavioral intervention (Fiellin, 1917). A weak opioid when carefully administered has reduced opioid rates up to 80 % with both Methadone and Suboxone (buprenorphine).
The Opioid Safety Initiative was created by the VA to provide alternative therapies to military patients for pain management and to prevent opioid misuse (Torres, 2016). The list has included much safer pain management approaches including physical therapy, acupuncture, aquatic therapy, massage therapy, tai chi, yoga therapy and meditation. We desperately need to increase the ease and availability of these therapies for all of our Veterans.
Increased access to the opioid antagonist Naloxone can significantly reduce opioid related morbidity and mortality. The Substance Abuse and Mental Health Services (SAMHSA) has expanded the availability and use of Naloxone. Naloxone Rescue Kits are now available to prescribers, pharmacists and patients. In addition, the national Opioid Overdose Education and Naloxone distribution program has been a game changer (Oliva, 2017). A timely administration of Narcan/Naloxone must occur if lives are to be saved. Naloxone can now be given by intranasal spray, intramuscularly (into the muscle) and subcutaneously (under the skin) for opioid overdoses (Davis, 2015). Naloxone Rescue Kits have been offered in 23 states since March of 2016. The OEND program was implemented at Fort Bragg, NC. This program prescribed 45,178 Naloxone prescriptions to 39,328 patients at Fort Bragg with impressive success (Goebel, 2011). The Veterans Health Administration has successfully utilized a community based public health approach for patients prescribed opioid analgesics to prevent opioid-related mortality.
The entire field of addiction medicine had been stigmatized and antiquated. In 1914 the Harrison Narcotics Act prevented physicians from prescribing to patients recognized as drug abusers. There is an ongoing need for psychoeducation; addiction must be viewed as a medical issue rather than a moral failure (Volkow ,2017). Mclellon (2017) found that less that 15 percent of U.S. medical schools have been offering course work in addiction. This helps us to further understand and appreciate why clinicians felt like they were dealing with complex challenges when treating opioid addiction. Addiction therapy has not been a focus of medical education; (Kolodny, 2017) reported that only 39,000 of medical doctors can offer treatment to the more than two million people who need it. In some parts of the country, finding a specialist in addiction medicine is nearly impossible. Naloxone can now be given by intranasal spray, intramuscularly (into the muscle) and subcutaneously (under the skin) for opioid overdoses (Davis, 2015). Naloxone rescue kits have been offered in 23 states since March of 2016.
Unlike other medical problems, unfortunately pain is a medical condition that can’t be objectively measured at this time. We do know clinically that chronic pain has the power to impair all domains of functioning (Brag, 2016). Brag also argues that many veterans endure traumatic events and injury resulting from combat and general military activities. Everyone is impacted by their service in some way, although the symptomatology ranges significantly in its presentation. Military duty negatively impacts the fabric of our society by disrupting family relationships and our cultural social support networks. Dart (2015) and Seal (2012) have suggested that clinicians need to work from a dual diagnosis framework with careful and thorough assessment and sensitivity to understanding the ways in which chronic pain triggers a downward spiral. Veterans lives have been ruined by premature death, drug addiction, broken families, incarceration, the trauma of civilian readjustment, social isolation, joblessness, homelessness, post-traumatic stress disorder (PTSD), traumatic brain injury (TBI), depression, aggression and violence.
We need to be proactive about changing the logistical barriers to care given the high risk of veterans living lives of despair. Self -reliance is a major risk factor for adverse health consequences. Self- management of mental health and physical problems can be deadly. Since 2012 we have reduced the number of veterans receiving opioids by 20 percent. Veterans’ health care gap creates a greater risk for opioid abuse. We have to be mindful of the dangerous hole in the system, when veterans are given the ability to obtain outside medical care at the expense of the government. We need to make sure that treatments are appropriately monitored. We know that when physicians stop prescribing opioids, we can have a perfect storm. The timing has the potential to be catastrophic given that heroin is easier, stronger and cheaper than opioids. It is a medical fact that 80 percent of heroin users today first became addicted to prescription opioids.
In conclusion, we need to be well trained academically and prepared to care for our patients. There is a significant amount of data to explain the etiology of prescription opioid misuse among our active duty and veteran populations (Bray, 2012). Prescription opioid misuse has increased over the past decade across the nation. Now is the time for the next chapter in health care where professionals fight along with our veterans to successfully battle the opioid epidemic.
You can reach Dr. Rachel Bush at Drrachelwbush@gmail.com.
