Veterans with Pain and Substance Use Disorders:

Opioids Opioids Are Not the Only Concern Concern

Daniel Kivlahan, PhD

Acting National Mental Health Program Director, Addictive Disorders

Office of Mental Health Services, Veterans Health Administration (VHA)

December 2011
Disc osu e State e t losure Statement

• No conflicts of interest to disclose• Previous research funding from:

– National Institute on Alcohol Abuse and Alcoholism– Ni l at onal I i nst tute on Drug Abuse

– VA Health Services Research & Development

– VA Quality Quality Enhancement Enhancement Research Research Initiative Initiative

• No documented expertise in pain managemVETERANS HEALTH ADMINISTRATION 
Overview

• We need collaboration across settings• No easy answers answers to patient patient complexity complexity

– But there are some actions to consider

• Opioids are not the only SUD issue

• Big g pa s in the evidence‐base on pain and S

• Shared responsibility to assure access to pa

centered care

• Ethics of harm reduction

R f f ll

VETERANS HEALTH ADMINISTRATION• Resources for follow‐up
Pai d n an SUD treatmen

• In a sample of 582 Veterans seeking addicti

treatment, excluding excluding opioid dependent dependent pat

pat

– 33% reported persistent moderate‐sever– 47% reported intermittent pain

• Those with persistent pain:

– Received less treatment– Had poorer abstinence abstinence rates at 12 mos– Had greater service utilization and higheCaldiero et al The association of persistent pain with outpatient addiction 

VETERANS HEALTH ADMINISTRATION

Caldiero et al., The association of persistent pain with outpatient addiction 

outcomes and service utilization. Addiction, 2008, 103, 1996‐2005.
Association of pain with abstine

over 12-month follow-up

VETERANS HEALTH ADMINISTRATION
Challenges; No Magic

• Intoxication• Relapse• Patient Motivation• Ethical Dilemmas• Safety/Liability

– Veteran

& provider

• Coordination of Care• Other categories?

VETERANS HEALTH ADMINISTRATION

• Other categories?
What is Motivational Intervie

“A collaborative, person center

center

form of g g uidin

to elicit and strengthen

motivation for change”

Miller & Rollnick, Behavioural and Cognitive Psych

VETERANS HEALTH ADMINISTRATION
10 Things Motivational 

Interviewing is NOT

• The transtheoretical model of change (stag

•

A way to trick people to do what you want

•

A technique

• Decisional balance exercises (pros

& cons

)

• Assessment feedback (e.g., in MET)

• Cognitive

‐behavior therapy

• Client

‐centered therapy (non

‐directive)

• Easy to learn• Treatment as usual (we are not all doing it 

VETERANS HEALTH ADMINISTRATION

•

A panacea
Components of Brief Alco

Intervention (BI)

• Advice

= documentation of:

– Advice to abstain abstain

, if drinking drinking is contraind

contraind

– Advice to drink within limits

• Feedb k ac

k

=

documentation

o

f:

– Personalized feedback linking alcohol use 

patient’s specific health issues

– General feedback linkin

g alcohol to

genera

• VA performance measure

= advice and feedb

• Offer/encourage specialty referral if indicated

VETERANS HEALTH ADMINISTRATION

• Offer/encourage specialty referral if indicated
Alcohol Misuse Screening a

Brief Alcohol Counseling

Measure FY10 FYAnnual Alcohol Misuse Screening w AUDIT-C 97% 97Brief Alcohol Counseling within 14 days of AUDIT-C screen positive 69% 77

VETERANS HEALTH ADMINISTRATION
The Treatment Engagement Cha

Past Year Past Year Perceived Need Perceived Need for and for and Effort Made Effort Made to R

Treatment among Persons Aged 12+ (2008) Treatment among Persons Aged 12+ (2008) - NSDU
P i d B i “T 

Perceived Barr

iers to “Treatm

• Oslin et al VISN

4 MIRECC and VISN

2 CoE

• Primary care patients with alcohol dependenc

in PA and NY; assessed through Behavioral Hea

• Reasons to decline decline referral: referral:

– not perceiving

a need (60%),

– negative negative experience/treatment experience/treatment won t’ work (37%),

– worries about stigma (35%),

– logistical concerns (24%),

– family related concerns (15%).

• Willing to initiate naltrexone in PC 44%

VETERANS HEALTH ADMINISTRATION

• Willing to initiate naltrexone in PC

– 44%
Number of Patients Recei

SUD Specialty Treatme

160,000180,000120,000140,000

38% 36% 33% 32% 32%

32%

31%

31

80,000

100,000

Patients

36%

40,00060,000

0

20,000

VETERANS HEALTH ADMINISTRATION

0

FY02 FY03 FY04 FY05 FY06 FY07 FY08 FY
Annual Prevalence of SUD Dia

among VHA Patients

500,000350 000400,000450,000

6 7%

6.8% 7.0%

7.3%

7.8%

250,000300,000350,000

6.5% 6.4%

6.7%

150,000200,000

50,000

100,000

VETERANS HEALTH ADMINISTRATION

‐

FY02 FY03 FY04 FY05 FY06 FY07 FY08 
Trends in SUD Diagnoses i

250,000300,000200,000250,000

tients

150,000

mber of Pa

50,000

100,000

Num

0

FY02 FY03 FY04 FY05 FY06 FY07 FY08 

VETERANS HEALTH ADMINISTRATION

Alcohol Only DX Drug Only DX Bo
Trends in Specific Diagnoses by 

80,00090,00060,00070,00040,00050,000

ber of Patients

20,000

Num 30,000

0

10,000

VETERANS HEALTH ADMINISTRATION

0

FY02 FY03 FY04 FY05 FY06 FY07 FY08 

Cocaine Opioids Ca
Mental Disorders

1 among 

OEF/OIF/OND V t OEF/OIF/OND V

eterans

Cumulative from 1st Quarter FY 2002 through 3nd Quarter 

Disease Category (ICD 290-319 code) Total Number of OEF/OIF/OND Veterans

3

PTSD (ICD-9CM 309.81) 197,074 

Depressive Disorders (311) 147,659 Neurotic Disorders (300) 126,673 Tobacco Use Disorder (305 1) Tobacco Use Disorder (305.1) 119 248 119,248 Affective Psychoses (296) 89,001 Alcohol Abuse (305.0) 44,611 Alcohol Dependence Syndrome (303) 41,409 Non-Alcohol Abuse of Drugs (ICD 305.2-9) 28,776 Specific Nonpsychotic Mental Disorder due to Mental Disorder due to

Organic Brain Damage (310) 25,038 

Special Symptoms, Not Elsewhere Classified (307) 24,936 Drug Dependence (304) 21,309 

VETERANS HEALTH ADMINISTRATION

Drug Dependence (304) 21,309 


Morasco et al. ~Conclusio

• No demographic or clinical factors that consis

differentiate CNCP patients with or w/o SUD

• SUD patients appear to be at greater risk for a

medication

‐related behaviors

• More likely to get opioid meds and at higher d

• Do not significantly differ in response to treat

• Limited data on predictors of treatment outco

• Quality of the evidence across research quest

uniformly rated low to very low

• Advice: monitor and adapt treatment accordi

VETERANS HEALTH ADMINISTRATION


http://www.healthquality.va

VETERANS HEALTH ADMINISTRATION
Caveats on Guidelines

• An aid in decision making, but strength of evidence i

• Where scientific data were lackin

g , recommendatio

based on the clinical experience of the Working Grou

• This should not prevent providers from using their o

expertise in the care of an individual patient

VETERANS HEALTH ADMINISTRATION
Key Principles from 

VA/DoD Guidelines

 Pharmacotherapy and psychosocial interventions a

important treatment options for Veterans with SUD

 Regardless of the particular intervention chosen, u

motivational interviewing style during therapeutic

encounters encounters with patients patients and emphasize emphasize the comm

elements of effective interventions

 promoting

a therapeutic therapeutic relationship, relationship,

 enhancing patient motivation to stop or reduce substance 

 improving self

‐efficacy for change,

 strengthening coping skills,

 arrange added benefits of recovery, and

 enhancing social s pport for reco er

VETERANS HEALTH ADMINISTRATION

 enhancing social

s

upport for reco

ver

y

 enhancin

g social support for recover

y
Patients Prescribed FDA Appr

Medications for AUD

16000180001200014000

8000

10000

200040006000 

0

2000

Acamprosate Naltrexone Naltrexone Disulfiram To

VETERANS HEALTH ADMINISTRATION

(oral) (inj)
FY07-09 Changes in AUD Pha

IN SUD Specialty Care 

FY07 (Black) and FY09(Red)Facility-level Rates of Pharmacotherpy Rece

in Patients with Addiction Treatment Contact

0.20

eipt

0.15

cotherpy R ec

5 0.10

ate of P harma

.00 0.05

R a

VETERANS HEALTH ADMINISTRATION

0 20 40 60 80 100 

0.

De-identified VHA Facility
FY07-09 Changes in AUD Pha

Outside of SUD Specialty Ca

FY07 (Black) and FY09(Red)Facility-level Rates of Pharmacotherpy Receipt 

in Patients with No Addiction Treatment Contact

0.04

e ceipt m

02 0.03

aco th erpy R R ate of P har

0 .0 1 0.

0 20 40 60 80 100 

0 .0 0

VETERANS HEALTH ADMINISTRATION

De-identified VHA Facility
Change in Opioid Agonist 

Pharmacotherapy FY09-10

Year

Opioid

Diagnosis

Treated*

(num)

Diagnosed 

(denom)

National 

Year Diagnosis (num) (denom) FY09 Dependence 10681 34736 30.1% FY10 Dependence 12149 38484 31.6% 

+1468 +3748 +1.5% 

• Includes office based care (buprenorphine/naloxone),• Opioid Treatment Program (methadone or buprenorphine/na• or fee basis care

VETERANS HEALTH ADMINISTRATION

• or fee basis care
ED Visits for Misuse or Abus

Pharmaceuticals (2004 to 20

E ti t d d t

f th

D Ab W i 

VETERANS HEALTH ADMINISTRATION

E

stima

t

e

d

d

a

t

a

from th

e

Drug Abuse

Warning
Ch i B di i * d 

Chron

i

c Benzodiazep

ines* and 

VETERANS HEALTH ADMINISTRATION *> 90 days of continuous ref
Op g ioid Rx Among PTSD Patients 

Long-term Benzodiazepine Rx (VIS

100

FY 2003 (N = 2637) FY 2010 (N = 5399)

63.1

80

nts

52.0

33.3

4

4060

% of Patien

20

%

0

Any Opioid Use Long‐term Opi

VETERANS HEALTH ADMINISTRATION

Mean days of LT overlap = 2
Setting for Long-term Prescribed B

Opioids in FY 2010 (n = 2,516 in VI

97.8 100

Mental Health Medicine/Surgery Other

74.6

7080905060

24.8

203040

0.7 1.3 

0

10

20

B di i L/T O i id L/

VETERANS HEALTH ADMINISTRATION

Benzodiazepines L/T Opioids L/
Slide 33

DRK1 confused aboiut which sample - patients with both LT BZ and opioids? Might help to indicate a common n i

Daniel Kivlahan, 8/13/2011
Ch ll i h Challenges

wi

th 

Benzos

/O 

p

• In VISN 20, nearly

1 in

6 men and

1 in

4 w

with PTSD were prescribed benzodiazepin

days in FY 2010.

• Among men and women,

– Adjusted prevalence of

> 90 days’ supp

benzodiazepines rose 1% and 5%, resp

– Number prescribed

> 90 days’ supply in

200% and 270%, respectively

• Approximately 47% of patients prescribed 

long

‐term were also prescribed opioid an

VETERANS HEALTH ADMINISTRATION long

‐term.
Drug Diagnoses Over Tim

80,00090,00060,00070,000

s

40,00050,000

ber of Patient

20,00030,000

Num

0

10,000

FY02 FY03 FY04 FY05 FY06 FY07 FY08 

VETERANS HEALTH ADMINISTRATION

Cocaine Opioids Cannab
Directive 2011-004

VETERANS HEALTH ADMINISTRATION
Directive 2011-004

• POLICY: It is VHA policy to prohibit VA pro

from com

p g letin

g forms seekin

g recommen

or opinions regarding

a Veteran’s participa

a State mari

juana p g ro

gram.

VETERANS HEALTH ADMINISTRATION
Directive 2011-004

• VHA policy does not administratively prohib

V t e

terans

w

h

o parti i t c pa

t

e in St t a

t

e marijuana

programs from also participating in VHA su

ab se u programs programs

, pain control control programs programs

, or 

clinical programs where the use of marijuan

considered inconsistent inconsistent with treatment treatment goa

VETERANS HEALTH ADMINISTRATION
Directive 2011-004

• While patients participating in State marijua

p g ro

grams must not be denied VHA services

, 

decisions to modify treatment plans in those 

need to be made

b

y individual

providers in p 

with their patients.

• VHA endorses endorses

a step

‐care model for the trea

trea

patients with chronic pain: any prescription(

chronic chronic pain needs to be managed managed under the 

of such programs described in current VHA p

regarding Pain Management

VETERANS HEALTH ADMINISTRATION

regarding Pain Management
Possession

• Note: Possession of medical marijuana by V

while on fd l e era property places them at ri 

s 

violations of the Controlled Substances Act; 

Department Department of J stice Justice has comm nicated communicated to 

Department of Veterans Affairs its commitm

enforcing the Controlled Controlled Substances Substances Act.

VETERANS HEALTH ADMINISTRATION
Supplemental Informatio

VETERANS HEALTH ADMINISTRATION
Clinical Considerations

• If

a patient provides evidence of State

‐approval 

of Marijuana, the VA provider should:

– Request the Veteran’s written release for info

from the non

‐VA prescriber of marijuana

– Given written release, the VA provider shoul

contact with the non

‐VA provider to assure o

communication and coordination coordination of care

– Document medical marijuana prescription as

medication in CPRS

• Understand the prescription and closely monito

VETERANS HEALTH ADMINISTRATION
Clinical Considerations

• Policy prohibits denying Veterans access to 

clinical

p g ro

grams solel

y because of their

p 

a

in State

‐approved marijuana programs

• VHA Pain Management Management Program Program Office stro

stro

supports this policy

• Decisions Decisions about the use of opioid analgesic

analgesic

balance Veteran rights to pain managemen

Veteran safety

VETERANS HEALTH ADMINISTRATION
Accessing SUD Services

What to Expect

• Policy changes to increase access to SUD S

Deputy Undersecretary (DUSHOM) (DUSHOM) Memo

• VHA Handbook 1160.01, Uniform Mental H

S i erv ces in VA

M di l e ca

Centers

• VHA Handbook 1162.01, Mental Health Re

Rehabilitation Treatment Programs

VETERANS HEALTH ADMINISTRATION
Management Principles for 

DUSHOM Memo 11/0

7

1. Facilities must not deny clinically appropri

because veterans are intoxicated

, activel

y 

substances including non

‐prescribed contr

substances

, or ex

p g eriencin

g withdrawal.

2. All facilities must make medically supervise

withdrawal management management available available when c

c

indicated.

VETERANS HEALTH ADMINISTRATION
Management Principles for 

DUSHOM Memo 11/0

7

3. Appropriate SUD care must not be denied or dela

veterans only on the basis of:

3⁄4L th eng

o

f curren

t

ab ti s nence

3⁄4

# or recency of previous treatment episodes

3⁄4Use of prescribed prescribed controlled controlled substances substances3⁄4Legal history

3⁄4Other co

‐occurring Mental Health conditions

4. Every facility must meet the care needs of veteran

occurring SUD and PTSD or other MH conditions b

an it td n

tegra

t

e

d d l ua di i agnos

s program

3⁄4with services in one setting or closely coordi

programs.

VETERANS HEALTH ADMINISTRATION

programs.
National Ethics Committee 

(March 2010)

• Focused on Vets on long term oxygen thera

who continue to smoke

• Is clinician morally or legally responsible for 

subsequent harm from fire?

• Shared decision making based on non

‐coerc

discussion of risks and benefits benefits

• Applicable harm reduction techniques• Terminate LTOT only in consultation with

multidisciplinary team and Ethics Consultati

VETERANS HEALTH ADMINISTRATION

Service
Harm Reduction Coalitio

Basic Principles 

• People may “choose” harmful behavior

• Risk reduction seeks to minimize the degree 

• Health behavior is complex and on

a continu

safety

• Quality of life, not “compliance”, is the criter

success

• Non

‐judgmental, non

‐coercive availability

& 

of services helps patients reduce risk

• Patients are the primary agents of reducing r

– Risk reduction empowers patients

VETERANS HEALTH ADMINISTRATION
Summary

• We need collaboration across settings• No easy answers answers to patient patient complexity complexity

– But there are some actions to consider

• Opioids are not the only SUD issue

• Big g pa s in the evidence‐base on pain and S

• Shared responsibility to assure access to pa

centered care

• Ethics of harm reductionVETERANS HEALTH ADMINISTRATION
Resources

• http://www.mentalhealth.va.gov/substanceabuse.asp

– Includes self‐screening brochure

• VA/DoD SUD Guideline

– www.healthquality.va.gov

• QUERI too t lki for AUDIT‐C a dn b eri f cou se g n lin

http://www.queri.research.va.gov/tools/alcohol‐misuse/alcoh

• Behavioral Health Lab (BHL) weekly call.

– Tuesday 2:00pm EST; software questions and technical ass

767‐1750, access code 31307#

• VHAANN HSRD PC‐MH Integration –

– Maureen Metzger list owner

• daniel.kivlahan@va.gov

VETERANS HEALTH ADMINISTRATION