According to a new report released by Human Rights Watch, more than one million veterans enrolled within the VA primary care system are taking prescription opioids for chronic pain. At the same time, an unprecedented number of veterans are dying as a result of both accidental and intentional drug overdoses. The report, which was released earlier this month, brings to light the growing concern that veterans of all ages are struggling with pain, which results in chronic use of prescription opioids. It argues that the VA “should remove barriers to ensure access to evidence-based drug dependency treatment and make overdose prevention programs available to veterans in the community.”
One of the primary recommendations of the Human Rights Watch report is a push the availability of naloxone, a prescription medication that reverses the effect of an opioid overdose. This past year naloxone injections were brought to market in an auto-injector under the brand name EVZIO. The pen was designed for individuals without medical training who may need to inject a patient during an opioid overdose situation. This medication can save someone’s life when his/her respiration system is shutting down due to an opioid overdose. from substances such as hydrocodone or heroin. However, the injection must be administered by someone other than the individual having the overdose. It also causes a violent reaction in the body of the receiver because it puts the body into a state of instant detox, resulting in nausea, vomiting, and at times, violent anger due to the sudden pain of detox. While naloxone is a temporary solution in the life-and-death moments of an overdose, it is not long-term solution for anyone with a drug addiction. If veterans receive access to EVZIO/naloxone pens, they also need to be receiving access to programs that provide long-term solutions to drug dependence, as well as prevention, yet, these recommendations are largely absent from the report.
The second concern is the HRW’s recommendation to increase veteran access to methadone and buprenorphine for long-term treatment of drug dependency. According to HRW senior health researcher and author of the report Megan McLemore, “Only one of three patients at the VA who need methadone or buprenorphine is getting it.” From a medical standpoint, switching from one medication to another is not a realistic solution to treat most drug dependent individuals. These medications must be prescribed and monitored under specialized programs through certified doctors and pharmacists due to the high risk of accidental death. Methadone precautions include central nervous system depression, hypotension, QT prolongation, and respiratory depression. This means that methadone patients can experience changes in their heart rate that can lead to the heart no longer beat in rhythm, which is a medical emergency. Methadone, can also contribute to severe depression in addition to respiratory depression, which can be fatal.
The population of veterans most impacted by drug dependence, illegal or legal, is the chronically homeless who often struggle with mental health conditions, post-traumatic stress, and depression. These veterans should not be placed on medications to treat their addictions since these treatments require extensive stability and regulation. Rather, these veterans need programs like HUD-VASH, which provides permanent housing to chronically homeless veterans. In previous years, HUD-VASH required veterans to prove their abstinence from drugs or alcohol before receiving housing; now it “provides housing as the first step and then surrounds the individual with a range of supportive services.” While this shift allows the VA to reach those who are “most vulnerable” to drug and alcohol abuse, the risks of replacing one dangerous medication --- for instance, methadone --- with another still remains. Currently, there are four VA pilot programs that are pushing medical treatments such as acupuncture, aqua therapy, pool therapy, and physical therapy as alternative ways of treating pain.
One additional concern with doctors prescribing medication to treat drug addiction among veterans is that within the VA healthcare system, doctors are not held to the same level of reporting for prescribing and dispensing controlled substances. When any doctor in the private sector writes a prescription for a controlled substance, the pharmacy must check that substance against a state database, and report any other controlled substances dispensed to the patient. Currently, the VA and military pharmacies do not report to these prescription-controlled medication monitoring programs; therefore, providers have no idea what the patient might already be taking, and if the interaction with drugs will cause harm to the patient. Without this checks-and-balance system, doctors run the risk of harming patients, or providing them with access to an unlimited supply of controlled substances.
In the end, there is no magic pill to treat drug abuse and dependence. Just because a drug is a prescription medication, does not make it safe. Treatment needs to start with a societal change in how we view and take prescription pain medication, and start broadening our list of possible solutions to include alternative therapies and behavioral treatment. Additionally, patients and providers need to establish realistic benchmarks in the reduction of pain from the start. Patients and family members should both be informed of what signs to look for when pain treatment is not effective, and when dependence and addiction are becoming a risk. Finally, the veterans community need to remember our greatest strength that was ingrained in us throughout our military service: We were trained to work as a team, and leave no one behind.
L. Joy Ohnstad, is an Army and Air Force veteran. She is a graduate of University of Wyoming’s College of Business, and is currently completing a dual Doctorate of Pharmacy and a MBA at the University of Wyoming. She is also a Tillman Military Scholar and is implementing a program on the University of Wyoming campus to improve the academic success of women veterans.