Opioid Use in the Veteran’s Administration System

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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. (1)

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.

Of particular interest, out of the 130 VA systems evaluated, Mountain Home, Tennessee, ranked as the sixth most frequent prescriber of opioids. Located in Johnson City, TN, this VA system had a rate of 138.8 opioid prescriptions per 100 patients for 2012. The worst system was Muskogee, OK, with 160.7 per 100 patients, followed closely by Beckley WV, Lexington, KY, and Huntington, WV. (But remember, Tennessee’s Department of Mental Health said there was no need for an opioid treatment center to be located in Johnson City. Nope. No problem there.)

We already know that in some states, the numbers of U.S. citizens who die from drug overdoses outnumber deaths from motor vehicle accidents. But veterans treated by VA doctors die from prescription drug overdoses at almost twice the rate of civilians. (1)

To be fair, we need to consider the changing nature of war injuries. Soldiers are surviving catastrophic injuries which would have been fatal in the past. This is partly due to better body armor and partly because of better and quicker medical care at the time of the injury. Some experts say some Iraq and Afghanistan soldiers have survived severe burns and amputations that killed Vietnam-era soldiers.

These patients surely need heavy opioids, at least early in their treatment. No compassionate doctor would skimp on pain medication for an acutely injured person. But acute pain is different from chronic pain. As the patient recovers, it’s time to consider backing off on opioids, and consider trials of non-opioid means of pain control. Patients often need help getting off prescribed opioids, which may mean tapering them over weeks to months, in order to prevent opioid withdrawal. This often takes more time and patience than writing another opioid prescription.

Due to the nature of the Iraq and Afghanistan wars, thousands of veterans have been diagnosed with traumatic brain injury (TBI). We are only beginning to understand the relationship between TBI and the risk for developing addiction. Similarly, war veterans have higher rates of PTSD (post-traumatic stress disorder) and depression. These mental disorders increase the risk for developing addiction to drugs including alcohol in all people, including war veterans.

I’ve admitted a few war veterans to the opioid treatment programs where I work. I dread trying to coordinate care with their VA doctors. Many times, after getting a release from the patient, I’ve called the VA to talk with their doctor. I can’t think of one time when I’ve reached the doctor to whom I wanted to speak. Sometimes I got a nurse, and left a message for the doctor to call me back, knowing I’d never hear from them.

I don’t have any way to know what those VA doctors are prescribing for my patients. Often, at least in my area, it’s a heavy benzodiazepine or two, and one or more opioids. Because the VA doesn’t report medication to my state’s prescription monitoring program, I’m left in the dark. I hear that’s supposed to change, but not soon enough for me.

The VA can fix this problem of inappropriate prescribing. I’ve been at ASAM (American Society of Addiction Medicine) conferences, and have met knowledgeable VA physicians. I’ve heard them lecture at these meetings. The VA must allow these experts teach their colleagues who are dated or oblivious in their prescribing habits.

I hope to see the time come when it’s as easy for a war veteran to access treatment for addiction as it is to get opioid prescriptions. These treatments should, of course, include medication-assisted treatments with buprenorphine and methadone.

Our veterans deserve the best care possible.

1. http://cironline.org/node/5261

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4 responses to this post.

  1. Posted by Chenoa Brown on October 19, 2013 at 2:05 am

    Dr. Burson,

    Thank you for posting this. I had no idea of the statistics of prescription drug overdoses of VA veterans versus civilians and the rate of prescribed opioids by VA doctors to veterans is startling! At the end of the month, I will begin “experiential learning” through a program with the Navy. The training will be with SARP (Substance Abuse Rehabilitation Program), a Navy treatment program. I’m not sure of their knowledge of opioid dependence and addiction but I am looking forward to training with them and maybe getting to share some of my experience and knowledge of MAT. Surely, they have seen an increase of prescription drug abuse in recent years.

    Thanks again for continuing your blog! I always look forward to reading them.

    Reply

  2. I have known of this serious issue for years in a few states with a few different people close to me. I actually lost an uncle a few years ago, after he overdosed it was discovered his ONE VA doctor had been treating him with high dosages of 3 opioids (two CII and one CIII) and 3 different benzodiazepines (sleep, muscle spasms and PTSD) daily, being sent to him in the mail every month with less-than-yearly follow up visits. A few of these medications were likely responsible for his ultimate overdose death; he received them in the mail the day he overdosed. Somehow the VA doesn’t have to follow legalities and submit to the same practices other agencies do?!?

    Reply

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