Addressing Opioid Use After Service-Related Injuries

Key Takeaways

• Chronic pain from service-related injuries often leads to opioid prescriptions for veterans, raising concerns about misuse and addiction.
• Physical injuries like traumatic brain injuries and musculoskeletal damage, as well as psychological injuries like PTSD, contribute to chronic pain in veterans.
• The CDC has proposed new opioid prescribing guidelines that emphasize careful monitoring, especially at higher doses.
• There has been a 53% increase in drug overdose mortality rates among U.S. military veterans from 2010 to 2019.
• The Veterans Health Administration (VHA) has implemented the Opioid Safety Initiative to improve opioid prescribing practices.
• Non-opioid pain management strategies, including physical therapy and psychological interventions, are being emphasized to reduce opioid reliance.
• Policy recommendations for addressing opioid use among veterans include enhancing healthcare access, improving monitoring, and supporting alternative treatments.
• Technology-based interventions and community care models are being explored to improve access to non-pharmacological pain management for veterans.

Understanding Chronic Pain and Opioid Use in Service-Related Injuries

Service-related injuries among veterans often lead to chronic pain, which can be debilitating and have a significant impact on quality of life. To manage this pain, opioids are frequently prescribed due to their efficacy in blocking pain signals. However, the use of opioids must be approached with caution due to the potential for misuse and addiction. A 2020 systematic review highlighted the importance of understanding the benefits and harms of opioids, dosing strategies, and risk mitigation in patients with chronic pain.

Physical and Psychological Injuries

Physical injuries such as traumatic brain injuries and musculoskeletal damage are common among veterans and are a primary cause of chronic pain. Psychological injuries, like post-traumatic stress disorder (PTSD), can also exacerbate the experience of pain, indirectly contributing to the increased use of opioids. The complexity of managing chronic pain in veterans is underscored by the need to balance effective pain relief with the risks associated with opioid treatments.

New Guidelines and Alternative Strategies

The opioid crisis has prompted a reevaluation of how opioids are prescribed. Efforts are underway to reduce harm by developing alternative pain management strategies and improving opioid prescribing practices. The Centers for Disease Control and Prevention (CDC) has proposed new guidelines that remove dosage caps and emphasize the need for careful monitoring and scrutiny, particularly at higher doses.

Understanding service-related injuries and their management is critical to addressing the challenges posed by chronic pain and opioid use among veterans. It is essential to support research and policies that prioritize safe, effective, and holistic approaches to pain management.

Common Physical Injuries Among Veterans

Veterans returning from service often face a range of physical injuries that can have lasting impacts on their health and well-being. Traumatic brain injuries (TBI) and musculoskeletal injuries are among the most prevalent issues they encounter. TBIs can occur due to bullet penetration, violent impacts, or the shock waves from explosive devices, posing challenges that straddle both neurology and psychiatry due to their complex nature. Musculoskeletal injuries frequently result from intense physical activities, carrying heavy equipment, and exposure to combat. 

Chronic Pain and Its Effects

Common areas affected include the back, neck, knees, shoulders, and the lower body. These injuries can lead to chronic pain conditions such as arthritis and may contribute to difficulties in readjusting to civilian life. According to Statista, nearly 80% of veterans and service members who have served since September 11, 2001, have reported physical or mental health concerns related to their service. The Veterans Health Administration (VHA) recognizes the significance of these injuries and provides health benefits and disability compensation to support affected veterans. 

The Interplay Between Psychological Injuries and Opioid Use in Veterans

Psychological injuries such as Post-Traumatic Stress Disorder (PTSD) are prevalent among veterans and have been linked to an increased risk of chronic pain and subsequent opioid use. Studies indicate that the co-occurrence of PTSD and chronic pain can exacerbate each condition, leading to a compounded impact on a veteran’s overall well-being. The research suggests that traumatic experiences not only intensify the perception of pain but also the distress associated with it, creating a challenging cycle of pain and psychological distress.

Dual Diagnosis Challenges

Addressing the dual diagnosis of PTSD and opioid use disorder (OUD) remains a critical concern, as highlighted by the Substance Abuse Treatment, Prevention, and Policy journal. The co-occurrence of these conditions can perpetuate a cycle of re-traumatization and increased substance use, emphasizing the need for comprehensive treatment approaches that address both psychological and physical aspects of veteran health. Healthcare providers must integrate evidence-based psychological approaches to pain management and opioid risk mitigation as part of a multimodal and interdisciplinary plan of care.

Understanding the Opioid Crisis in Veteran Populations

The opioid epidemic presents a significant public health challenge, particularly among military veterans who often face service-related injuries leading to chronic pain. A review of the latest research reveals the stark reality of this crisis. According to a study published in the National Center for Biotechnology Information, the drug overdose mortality rates for U.S. military veterans increased by 53% from 2010 to 2019. 

Contributing Factors

Factors contributing to the heightened risk among veterans include the prevalence of military sexual trauma, mental health concerns such as PTSD, depression, and a lack of access to adequate healthcare services. The Biopsychosocial (BPS) framework highlights the need to consider not only the physiological aspects of pain but also the psychological and sociological components when addressing opioid use disorder (OUD) among veterans.

Opioid Use Among Veterans: A Statistical Overview

The opioid crisis has significantly impacted U.S. military veterans, with studies indicating a troubling rise in opioid use and associated risks. Data from the 2022 National Survey on Drug Use and Health (NSDUH) suggests that veterans face unique challenges that may contribute to higher rates of opioid use disorder (OUD). For instance, veterans with a history of military sexual trauma were found to have 50% higher odds of an OUD diagnosis, potentially indicating a pattern of self-medication for psychological and emotional pain.

Rising Mortality Rates among Veterans

Furthermore, the opioid overdose mortality rates for veterans increased by 53% from 2010 to 2019, highlighting the growing concern of opioid misuse within this population. The lack of access to healthcare services and low rates of Veterans Health Administration (VHA) utilization pose significant barriers, potentially exacerbating the risk of overdose among veterans, especially those with complex medical needs. These statistics underscore the need for effective prevention and treatment strategies tailored to the veteran population.

Understanding the Impact of Opioid Misuse on Veterans

Opioid misuse among veterans can lead to a cascade of detrimental physical, psychological, and social consequences. The biopsychosocial challenges faced by veterans, such as chronic pain, mental health issues, and social stressors, contribute significantly to the risk of opioid-related overdoses. Misuse often begins with prescribed opioids for pain management but can escalate to dependence and addiction, complicating the transition to civilian life.

Physical, Psychological, and Social Consequences

Physically, opioid misuse can increase the likelihood of overdose death, with mortality rates climbing by 53% from 2010-2019 among veterans. Psychologically, there is a strong association between opioid misuse and suicidal behaviors, as well as with conditions like PTSD and depression, which can exacerbate the cycle of addiction. Socially, factors like unemployment, homelessness, and social isolation can hinder recovery and increase the risk of substance misuse.

Veterans Health Administration’s Efforts in Opioid Safety and Management

The Veterans Health Administration (VHA) has been actively engaged in enhancing opioid safety and management among veterans through initiatives such as the Opioid Safety Initiative (OSI), launched in 2013. The primary goal of the OSI is to ensure the responsible prescribing of opioids to veterans, aiming to balance effective pain management with the reduction of opioid-related risks. Evidence indicates that since the OSI’s inception, there has been a notable decrease in the rates of opioid prescriptions within the VHA system.

Opioid Risk Mitigation

Further efforts by the VHA include the implementation of opioid risk mitigation strategies, which have been integrated into the VHA’s comprehensive health care model. This model serves as an example of opioid stewardship and interdisciplinary pain care, as highlighted in research publications. The VHA has also taken steps to rescind outdated directives and notices related to substance use disorders, thereby updating its approach to opioid use disorder and pain management. Chronic pain, especially conditions like chronic low-back pain (cLBP), is prevalent among veterans, prompting the VHA to adapt its prescribing practices. 

Evaluating the Impact of the VHA’s Opioid Safety Initiative

The Veterans Health Administration’s (VHA) Opioid Safety Initiative (OSI) represents a pivotal effort in combating the risks associated with opioid prescribing among veterans. Launched in 2013, the OSI aims to ensure the safe and effective prescription of opioids, addressing the high rates of chronic pain and the potential for opioid misuse within the veteran population. The VHA has implemented key components such as the dissemination of a dashboard tool that aggregates electronic medical record data to audit opioid-related practices in real-time.

Reduction in Opioid Prescriptions

Studies, including one published in PubMed, indicate that the OSI has been instrumental in reducing opioid prescribing rates across the nation’s VA hospitals. This reduction is attributed to the OSI’s comprehensive approach, which includes risk mitigation strategies and a shift towards integrated, multimodal pain care. The initiative has also expanded the implementation of opioid risk mitigation to improve safety for veterans receiving opioid medication. While the OSI has made notable progress in enhancing opioid safety, it continues to face challenges, including balancing pain management with the risks of opioid use, particularly among special populations like cancer patients undergoing treatment. 

Navigating the Complexities of Opioid Management in Veterans Health Administration

The Veterans Health Administration (VHA) faces multifaceted challenges in managing opioid use among veterans, who are disproportionately affected by the opioid crisis. One significant challenge is the high prevalence of service-related injuries leading to chronic pain, which often necessitates opioid treatment. A study by Bennett et al. highlights the complexity of managing opioid use, emphasizing the need to consider not only physical pain but also psychological factors like PTSD, depression, and the impact of military sexual trauma, which may lead to self-medication with opioids.

Barriers to Healthcare Access

Moreover, the VHA contends with barriers to healthcare access and utilization. Veterans with the most complex medical needs, who are at a higher risk for overdose, tend to use VHA services more frequently, potentially increasing overdose mortality rates within this group. Additionally, the stigma associated with substance use and legal issues can deter veterans from seeking treatment, further complicating the VHA’s efforts to provide effective care.

The VHA’s Veterans Justice Programs aim to bridge gaps in care for veterans involved in the legal system, yet challenges persist, including stigma and limited provider availability to prescribe medications for opioid use disorder (MOUD). Addressing these challenges requires a comprehensive approach that includes expanding access to MOUD, integrating peer support, and reducing stigma to improve the health outcomes of veterans grappling with opioid use disorders.

Non-Opioid Pain Management Strategies for Service-Related Injuries

For veterans who have sustained service-related injuries, managing chronic pain without relying on opioids is a critical concern. Non-opioid pain management strategies offer a range of options that can be tailored to individual needs. Multimodal opioid-sparing analgesia is a key concept in acute pain management, which includes a combination of medications and therapies to achieve pain relief without the heavy reliance on opioids. Some of these non-opioid pain management strategies include the following:

• Transcutaneous Electrical Nerve Stimulation (TENS): TENS may inhibit nociceptive transmission, providing relief in conditions like neuropathic pain and fibromyalgia, though evidence varies in strength.
• Non-Opioid Medications: NSAIDs, acetaminophen, steroids, antidepressants, anticonvulsants, and topical medications are routinely used to treat pain with varying mechanisms of action.
• Spinal Cord Stimulation (SCS): SCS has shown high efficacy in conditions like lumbar failed back surgery syndrome and complex regional pain syndrome (CRPS).
• Epidural Injections: Injections of lidocaine with or without steroids can be effective in treating conditions such as lumbar radiculopathy and spinal stenosis.
• Radiofrequency Ablations: This denervation procedure can provide long-term reduction of facet-mediated spine pain, with varying levels of evidence for different spinal regions.
• Sympathetic Nerve Blocks (SNBs): SNBs are often used in the treatment of CRPS, targeting sympathetic hyperactivity.

Adopting these strategies can be part of a comprehensive pain management plan that minimizes the risks associated with opioid use. The Centers for Disease Control and Prevention (CDC) and other healthcare professionals emphasize the importance of setting realistic goals and exploring low-risk pain relief options. Non-opioid analgesics and nonpharmacologic interventions are increasingly being recognized for their role in effective pain care, offering a safer alternative with reduced risks of adverse events and addiction liability.

Physical Therapy and Exercise in Chronic Pain Management

Physical therapy (PT) and exercise are pivotal in managing chronic pain, particularly among veterans with service-related injuries. PT involves tailored therapeutic exercises that focus on improving muscle strength, flexibility, neuromuscular control, functional mobility, endurance, balance, and locomotion. This approach not only aims to alleviate pain but also to enhance overall physical function and quality of life. The American Physical Therapy Association emphasizes the evolving role of physical therapists in leading pain management strategies.

Exercise Therapy in Chronic Pain Management

Exercise therapy is endorsed by international clinical guidelines as a core treatment for chronic musculoskeletal pain conditions. It includes physical activity and progressive resistance training, which have been shown to have small to moderate beneficial effects on pain, particularly in conditions like knee and hip osteoarthritis and chronic low back pain. Research indicates that a structured regimen starting slowly and increasing in intensity can help patients reach the recommended 150 minutes of activity per week, which is crucial for managing chronic pain.

Empowering Patients in Chronic Pain Management

Empowering patients with knowledge about their condition, pain mechanisms, and how specific exercises can reduce discomfort is a fundamental aspect of physical therapy. By doing so, physical therapists enable patients to actively participate in their recovery and pain management process. For veterans, this knowledge can be especially empowering, as it provides them with the tools to regain control over their pain and improve mobility post-service-related injuries.

Psychological Interventions for Managing Chronic Pain

Psychological interventions, particularly cognitive-behavioral therapy (CBT), have emerged as vital components in managing chronic pain, offering a non-pharmacological approach that addresses the multidimensional nature of pain. CBT is recognized for its effectiveness in reducing the impact of chronic pain by altering the emotional and cognitive responses to pain. Research has shown that CBT and other psychologically-based interventions can be clinically beneficial for adults with chronic neuropathic pain, despite the scarcity of Randomised Controlled Trials.

‘Third Wave’ Cognitive-Behavioral Therapy in Pain Management

Moreover, ‘third wave’ CBT, which includes newer psychological approaches like acceptance and commitment therapy, mindfulness, biofeedback, hypnosis, and emotional-awareness and expression therapy, has gathered evidence for its effectiveness across multiple pain conditions. With the complex and bidirectional relationship between chronic pain and psychological distress, these interventions are designed to tackle the sensory, affective, and behavioral dimensions of pain. A Lancet scientific review recommended pain education and CBT for chronic pain as first-line treatments, emphasizing the need for greater access to these interventions.

Exploring Non-Opioid Medication Alternatives for Chronic Pain Management

Addressing the opioid crisis requires effective non-opioid alternatives for managing chronic pain. Recent developments in medical research have shown promise in this area, particularly with the emergence of new drugs that target pain differently than opioids: 

• Vertex Pharmaceuticals has developed an experimental drug, VX-548, which aims to block pain signals in the peripheral nervous system rather than in the brain, potentially offering a safer alternative for treating moderate to severe acute pain without the risk of addiction associated with opioids. The New York Times reports that Vertex plans to seek FDA approval for VX-548.
• Researchers at The University of Texas at Austin, in collaboration with The University of Texas at Dallas and the University of Miami, have identified a molecule that shows effectiveness in reducing hypersensitivity in animal trials, suggesting a potential non-opioid treatment for neuropathic pain. This research, which was highlighted in UT News, has led to the formation of NuvoNuro Inc., a company that aims to develop a drug based on these findings with the support of a grant from the National Institutes of Health HEAL Initiative.
• Aside from these promising drugs, there are established non-opioid medications that are routinely used for pain management. These include non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, steroids, antidepressants, anticonvulsants, and topical medications. 

A comprehensive review by the NCBI Bookshelf details various medications and their mechanisms, providing healthcare professionals with a range of options for treating patients with chronic pain conditions without resorting to opioids.

Strategic Policy Recommendations for Opioid Use Among Veterans

Addressing opioid use among veterans with service-related injuries demands a multifaceted policy approach. A review of recent literature reveals that veterans are disproportionately affected by opioid use disorders (OUD) and opioid overdose, often due to chronic pain management and psychological trauma such as PTSD. To mitigate this crisis, policy recommendations must prioritize evidence-based strategies that encompass the biological, psychological, and social facets of opioid use and addiction. These policy recommendations seek to accomplish the following:

• Enhance access to healthcare services, especially for veterans not currently utilizing the VA, to ensure comprehensive and continuous care.
• Expand the reach of the VHA’s Opioid Safety Initiative by incorporating current practices and evidence-based guidelines for opioid management in chronic pain.
• Improve monitoring and outreach programs, particularly for subpopulations of veterans like those experiencing homelessness or military sexual trauma, who may self-medicate with opioids.
• Develop community care models to address barriers to opioid-related risk mitigation, providing support outside the traditional VA system.
• Introduce and support alternative pain management treatments, including physical therapy and psychological interventions such as cognitive-behavioral therapy, to reduce reliance on opioids.
• Implement prescription drug monitoring programs to prevent opioid diversion and misuse, while ensuring responsible prescribing practices.
• Facilitate overdose prevention education and naloxone distribution to veterans and service members, enhancing their capacity to respond to overdose situations.

By adopting these policy recommendations, the aim is to create a more robust support system for veterans, reducing the risk of opioid misuse and improving overall health outcomes. Collaboration between government agencies, healthcare providers, and veteran communities is essential to implement these strategies effectively.

Enhancing Veterans’ Access to Alternative Pain Management Treatments

Addressing chronic pain among veterans is a critical aspect of post-service healthcare. Studies indicate that veterans are more likely to utilize non-pharmacological methods (NPM) for pain management compared to non-veterans, with adjusted odds ratios suggesting a significant inclination towards these methods. Some of options for veterans that offer these methods include the following:

• The Veterans Health Administration (VHA) has implemented programs like the Cooperative Pain Education and Self-management (COPES) to encourage cognitive-behavioral therapy for chronic pain (CBT-CP), which is recognized as a first-line non-pharmacological therapy within the VA healthcare system. This approach not only reduces pain but also the associated disability, distress, and potential overuse of opioids.
• The National Institutes of Health (NIH), along with the Department of Defense (DOD) and the VA, established the Pain Management Collaboratory (PMC) to promote a whole-person approach to pain management. This interagency effort focuses on research into non-drug approaches to pain management, addressing the unique needs of service members and veterans. 
• The VHA’s Opioid Safety Initiative and other pain management programs aim to improve access to clinical pain care services, emphasizing the importance of managing pain without over-reliance on opioids.
• Technology-based interventions, such as interactive voice response (IVR) systems, have been explored to improve access to treatments like CBT-CP, allowing veterans to engage in therapy from their homes. 
• The ‘Improving Veteran Access to Integrated Management of Back Pain’ (AIM-Back) trial is another example of efforts to develop care pathways that enhance access to nonpharmacologic treatments. 

These initiatives underscore the need for ongoing support and workforce development to ensure that veterans have comprehensive access to evidence-based, nonpharmacologic pain care options.

Strategies to Enhance Monitoring of Opioid Use Among Veterans

Effectively monitoring opioid use among veterans is crucial for preventing misuse and managing chronic pain. The Veterans Health Administration (VHA) has implemented several strategies, such as the Opioid Safety Initiative (OSI) and informed consent directives, to ensure safe prescribing practices. To further enhance monitoring, the following strategies could be considered:

• Comprehensive Data Tracking: Leveraging VHA prescribing data and opioid risk mitigation strategies to identify patterns and potential risks associated with opioid use among veterans.
• Community Care Models: Expanding access to community care for veterans not connected to the VHA, which includes the integration of overdose prevention resources and substance use services tailored to veterans’ needs.
• Whole Health Interventions: Encouraging participation in Whole Health modalities, which have been shown to significantly reduce opioid use among veterans through a holistic approach to pain management.
• Telehealth Expansion: Increasing the use of telehealth services to reach vulnerable veterans with opioid use disorder (OUD), facilitating access to medication-assisted treatments such as buprenorphine.
• Academic Detailing Service: Providing targeted education to healthcare providers on best practices for opioid prescribing and pain management.
• Engagement with Veterans: Incorporating the perspectives and voices of veterans with lived experience of substance use into the design and implementation of new prevention strategies.

By adopting these strategies, the VHA can better monitor and manage opioid use, potentially reducing the risk of opioid misuse and overdose among veterans.

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