Staff Perspective: Opioid Misuse in the Military
Back in 2001, I was a young Lieutenant in the Navy and the most junior psychologist in my department. That meant that I got assigned the collateral duties that none of the more senior providers wanted, like representing the department on the hospital’s newly established pain committee. The goal of the pain committee at that time was to decide how to meet a new JACHO initiative to better address chronic pain. We implemented policies such as requiring every provider in the hospital to have each patient rate their pain on a 10-point scale. We also encouraged prescribers to increase access to pain medications, including opioids like the relatively new drug OxyContin. Released in 1996, OxyContin is a sustained-release oxycodone preparation that was aggressively marketed as a safe treatment for chronic pain. According to a 2009 article in the American Journal of Public Health by Dr. Art Van Zee, sales of OxyContin increased “from $48 million in 1996 to almost $1.1 billion in 2000” (Van Zee, 2009, p. 221). This dramatic rise in sales and marketing was timed perfectly to fit in with the then military’s new pain initiatives and for the start of the wars with Iraq and Afghanistan, Veterans of which have high rates of chronic pain complaints (Toblin, Quartana, Riviere, Walper, & Hoge, 2014).
A study of non-treatment-seeking infantry soldiers who had been deployed to Afghanistan or Iraq Tobin, et al (2014) found that 44.0% reported chronic pain (pain for more than 90 days). Of those chronic pain suffers, 48.3% reported symptoms for over one year. Additionally, 15.1% of this non-treatment-seeking sample was using opioids. The comparable rates of civilian chronic pain and opioid use at the time of this study were 26.0% and 4.0%. Alarmingly, 44.1% of soldiers reporting opioid use also reported mild to no pain in the past month and 5.6% reported no pain (Tobin, et al, 2014).
The use of opioids in the absence of pain raises the possibility of misuse and runs contrary to recommendations that these medications be reserved for treatment of moderate to severe pain. According to the National Institute on Drug Abuse, the “rates of prescription opioid misuse are higher among service members than among civilians” (NIDA, 2018, p. 1). It is important to note that misuse is not equivalent to addiction, but involves problematic behaviors that can lead to addiction, dependence, or overdose. Interestingly, according to the Defense Health Agency, the rate of opioid addiction among active duty Service members is less than 1% (Slaughter, 2018). That may be related to zero-tolerance policies for drug use in the military, which can quickly move Service members screening positive for drug use out of the active duty system and into Veteran status.
The rates of opioid use and misuse in the military highlight the need for effective treatment that is easily and willingly accessed by Service members. Military service, particularly deployment to combat zones, can provide unique physical and emotional stressors and exposure to injuries that can result in chronic pain. Yet, the historic lack of confidentiality in military substance abuse treatment programs and zero tolerance policies may create stigma for seeking help when Service members develop problematic substance use, particularly opioid misuse (NIDA, 2019). The Department of Defense (DoD) and the Veterans Health Administration (VHA) have worked diligently over the past decade to develop comprehensive pain management plans and implement evidence-based treatments for Opioid Use Disorder (OUD) (NIDA, 2018; Slaughter, 2018). In 2010, the DoD and Veterans Administration (VA) teamed up to develop the Pain Management Task Force, and complete a comprehensive Pain Management Campaign, which resulted in 109 specific action items, joined the Office of The Army Surgeon General. This was a forward-thinking approach to the opioids epidemic and predated the 2011 Institute of Medicine report calling for such comprehensive plans (Jonas & Schoomaker, 2014). As of 2015 both the VHA and DoD allow treatment of active duty Service members with methadone or buprenorphine, both considered first line treatments for OUD, which should be used, with all opioid dependent patients. However, the utilization of Medication Assisted Treatment (MAT) for OUD remains underutilized in VHA facilities. About a quarter of OUD patients seeking treatment in VHA facilities receive MAT. In addition to educating patients about the efficacy and availability of MAT, physicians also require education about opioid agonist treatment. Furthermore, efforts to reduce stigma about substance using populations must continue to overcome this epidemic.
News articles about the opioids crisis always makes me think back to that time in 2001, when the best intentions of military medicine coincided with the aggressive marketing of OxyContin. If only we had possessed perfect foresight or a giant crystal ball to see the looming opioids epidemic and could have developed the much more sophisticated and comprehensive pain management strategies that the military has been instituting for the past 9 years. Hindsight is 20/20, and even so, this is a crisis we have yet to fully conquer in our nation and in our military and Veteran populations. We must all keep fighting to find what the Office of The Army Surgeon General Pain Management Task Force (2010, p. E-2) called “holistic, multidisciplinary, and multimodal” solutions that use technology and quality care to provide “optimal quality of life for (Service members) and other patients with acute and chronic pain.”
CDP Presents: A Multidisciplinary Approach to the Management of Pain and Opioid Misuse Prevention
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Libby Parins, Psy.D., is the Assistant Director of Training and Education at the Center for Deployment Psychology (CDP). Dr. Parins has worked at CDP since 2007, serving in many different capacities including as a faculty member on APA-accredited psychology internship programs, and as a project developer and trainer in military and civilian programs. She began her professional career as a Naval Officer. Currently, she is based in North Carolina.
References
Jonas, W.B. & Schoomaker, E.B., (2014). Pain and Opioids in the Military: We Must Do Better. JAMA Internal Medicine; 174(8):1402–1403. Retrieved from https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/1885985
NIDA. (2018, June 8). Medications to Treat Opioid Use Disorder. Retrieved from the National Institute on Drug Abuse https://www.drugabuse.gov/publications/research-reports/medications-to-treat-opioid-use-disorder on 2019, October 15
NIDA. (2019, October 11). Military. Retrieved from the National Institute on Drug Abuse https://www.drugabuse.gov/related-topics/military on 2019, October 16
Office of The Army Surgeon General (2010), Pain Management Task Force: Final Report, May 2010. Retrieved from Defense & Veterans Center for Integrative Pain Management https://www.dvcipm.org/site/assets/files/1070/pain-task-force-final-report-may-2010.pdf
Slaughter, E. (2018). How the Military Health System Registry Targets the Opioid Epidemic. MD Magazine. Retrieved from https://www.mdmag.com/medical-news/how-the-military-health-system-registry-targets-the-opioid-epidemic.
Toblin R.L., Quartana P.J., Riviere L.A., Walper K.C., Hoge C.W., (2014). Chronic Pain and Opioid Use in US Soldiers After Combat Deployment. JAMA Internal Medicine; 174(8):1400–1401. Retrieved from https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1885986
Van Zee, A (2009). The Promotion and Marketing of OxyContin: Commercial Triumph, Public Health Tragedy. American Journal of Public Health; 99(2) 221-227. Retrieved from National Center for Biotechnology Information https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2622774/
Back in 2001, I was a young Lieutenant in the Navy and the most junior psychologist in my department. That meant that I got assigned the collateral duties that none of the more senior providers wanted, like representing the department on the hospital’s newly established pain committee. The goal of the pain committee at that time was to decide how to meet a new JACHO initiative to better address chronic pain. We implemented policies such as requiring every provider in the hospital to have each patient rate their pain on a 10-point scale. We also encouraged prescribers to increase access to pain medications, including opioids like the relatively new drug OxyContin. Released in 1996, OxyContin is a sustained-release oxycodone preparation that was aggressively marketed as a safe treatment for chronic pain. According to a 2009 article in the American Journal of Public Health by Dr. Art Van Zee, sales of OxyContin increased “from $48 million in 1996 to almost $1.1 billion in 2000” (Van Zee, 2009, p. 221). This dramatic rise in sales and marketing was timed perfectly to fit in with the then military’s new pain initiatives and for the start of the wars with Iraq and Afghanistan, Veterans of which have high rates of chronic pain complaints (Toblin, Quartana, Riviere, Walper, & Hoge, 2014).
A study of non-treatment-seeking infantry soldiers who had been deployed to Afghanistan or Iraq Tobin, et al (2014) found that 44.0% reported chronic pain (pain for more than 90 days). Of those chronic pain suffers, 48.3% reported symptoms for over one year. Additionally, 15.1% of this non-treatment-seeking sample was using opioids. The comparable rates of civilian chronic pain and opioid use at the time of this study were 26.0% and 4.0%. Alarmingly, 44.1% of soldiers reporting opioid use also reported mild to no pain in the past month and 5.6% reported no pain (Tobin, et al, 2014).
The use of opioids in the absence of pain raises the possibility of misuse and runs contrary to recommendations that these medications be reserved for treatment of moderate to severe pain. According to the National Institute on Drug Abuse, the “rates of prescription opioid misuse are higher among service members than among civilians” (NIDA, 2018, p. 1). It is important to note that misuse is not equivalent to addiction, but involves problematic behaviors that can lead to addiction, dependence, or overdose. Interestingly, according to the Defense Health Agency, the rate of opioid addiction among active duty Service members is less than 1% (Slaughter, 2018). That may be related to zero-tolerance policies for drug use in the military, which can quickly move Service members screening positive for drug use out of the active duty system and into Veteran status.
The rates of opioid use and misuse in the military highlight the need for effective treatment that is easily and willingly accessed by Service members. Military service, particularly deployment to combat zones, can provide unique physical and emotional stressors and exposure to injuries that can result in chronic pain. Yet, the historic lack of confidentiality in military substance abuse treatment programs and zero tolerance policies may create stigma for seeking help when Service members develop problematic substance use, particularly opioid misuse (NIDA, 2019). The Department of Defense (DoD) and the Veterans Health Administration (VHA) have worked diligently over the past decade to develop comprehensive pain management plans and implement evidence-based treatments for Opioid Use Disorder (OUD) (NIDA, 2018; Slaughter, 2018). In 2010, the DoD and Veterans Administration (VA) teamed up to develop the Pain Management Task Force, and complete a comprehensive Pain Management Campaign, which resulted in 109 specific action items, joined the Office of The Army Surgeon General. This was a forward-thinking approach to the opioids epidemic and predated the 2011 Institute of Medicine report calling for such comprehensive plans (Jonas & Schoomaker, 2014). As of 2015 both the VHA and DoD allow treatment of active duty Service members with methadone or buprenorphine, both considered first line treatments for OUD, which should be used, with all opioid dependent patients. However, the utilization of Medication Assisted Treatment (MAT) for OUD remains underutilized in VHA facilities. About a quarter of OUD patients seeking treatment in VHA facilities receive MAT. In addition to educating patients about the efficacy and availability of MAT, physicians also require education about opioid agonist treatment. Furthermore, efforts to reduce stigma about substance using populations must continue to overcome this epidemic.
News articles about the opioids crisis always makes me think back to that time in 2001, when the best intentions of military medicine coincided with the aggressive marketing of OxyContin. If only we had possessed perfect foresight or a giant crystal ball to see the looming opioids epidemic and could have developed the much more sophisticated and comprehensive pain management strategies that the military has been instituting for the past 9 years. Hindsight is 20/20, and even so, this is a crisis we have yet to fully conquer in our nation and in our military and Veteran populations. We must all keep fighting to find what the Office of The Army Surgeon General Pain Management Task Force (2010, p. E-2) called “holistic, multidisciplinary, and multimodal” solutions that use technology and quality care to provide “optimal quality of life for (Service members) and other patients with acute and chronic pain.”
CDP Presents: A Multidisciplinary Approach to the Management of Pain and Opioid Misuse Prevention
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Libby Parins, Psy.D., is the Assistant Director of Training and Education at the Center for Deployment Psychology (CDP). Dr. Parins has worked at CDP since 2007, serving in many different capacities including as a faculty member on APA-accredited psychology internship programs, and as a project developer and trainer in military and civilian programs. She began her professional career as a Naval Officer. Currently, she is based in North Carolina.
References
Jonas, W.B. & Schoomaker, E.B., (2014). Pain and Opioids in the Military: We Must Do Better. JAMA Internal Medicine; 174(8):1402–1403. Retrieved from https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/1885985
NIDA. (2018, June 8). Medications to Treat Opioid Use Disorder. Retrieved from the National Institute on Drug Abuse https://www.drugabuse.gov/publications/research-reports/medications-to-treat-opioid-use-disorder on 2019, October 15
NIDA. (2019, October 11). Military. Retrieved from the National Institute on Drug Abuse https://www.drugabuse.gov/related-topics/military on 2019, October 16
Office of The Army Surgeon General (2010), Pain Management Task Force: Final Report, May 2010. Retrieved from Defense & Veterans Center for Integrative Pain Management https://www.dvcipm.org/site/assets/files/1070/pain-task-force-final-report-may-2010.pdf
Slaughter, E. (2018). How the Military Health System Registry Targets the Opioid Epidemic. MD Magazine. Retrieved from https://www.mdmag.com/medical-news/how-the-military-health-system-registry-targets-the-opioid-epidemic.
Toblin R.L., Quartana P.J., Riviere L.A., Walper K.C., Hoge C.W., (2014). Chronic Pain and Opioid Use in US Soldiers After Combat Deployment. JAMA Internal Medicine; 174(8):1400–1401. Retrieved from https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1885986
Van Zee, A (2009). The Promotion and Marketing of OxyContin: Commercial Triumph, Public Health Tragedy. American Journal of Public Health; 99(2) 221-227. Retrieved from National Center for Biotechnology Information https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2622774/