Overview

The United States is in the midst of an unprecedented drug epidemic.  Since 2000, overdoses from opioids in the United States have tripled.  Last year alone there were over 64,000 opioid related drug overdoses.  In fact, opioids kill more people in the United States than breast cancer.[1] A small, but significant portion of those deaths were veterans under the care of the U.S. Department of Veterans Affairs (the VA).  After nearly eighteen years of war in Afghanistan, Iraq, and countless unnamed Overseas Contingency Operations, over 60% of veterans report suffering from chronic pain that requires some form of medication or treatment.  For much of that time, invariably, opioids were the prescribed drug of choice.[2] Unfortunately, veterans represent one of the most vulnerable communities in America, reporting higher rates of chronic pain, post-traumatic stress, depression, chronic homelessness, and suicide.  Since America’s veterans are at the nexus between the opioid epidemic and overdoses, any improvements or fixes implemented within the veterans health system have immediate wider applications for the rest of America. 

Research

Until 2013–14, the VA policy on opioid prescriptions would be best described as liberal.  Hundreds of thousands of veterans were prescribed staggering amounts of opioid pain killers such as Vicodin and OxyContin.[3] Many veterans report prescription “plans” consisting of 20+ concurrent medicines.[4] Just as the opioid epidemic entered the national conscience at the end of 2014, the VA reviewed and ultimately revised its prescription policies, aiming for an across the board reduction in prescription rates.  In a complete reversal of its previous policy — and in a vain effort to combat what it perceived as systemic abuse — the VA took a top-down approach and implemented what can best be described as a “cold-turkey” policy on opioids; instantly cutting some 230,000 veterans off from their prescribed pain medications.[5] The VA touts this as a success, reporting its Opioid Safety Initiative has resulted in “99% of VA facilities [reducing] prescription rates since 2012.”[6] Not every veteran would agree with the VA assessment.  Robert Rose Jr., in an interview with Liz Lohuis at WSMV Channel 4 in Nashville, described the new VA policy as “a death sentence for people like me. ”[7]

Although the VA now recognizes the dangers of its former liberal practice of prescribing opioids, citing the publication of the “Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain” in 2010 as the tipping point towards epidemic, the VA failed to provide an effective road-map for veterans to wean themselves from opioids.[8] Furthermore, most veterans report the VA implemented the “cold-turkey” policy with little to no input or feedback from their primary care providers.[9] The current alternative offered by the VA consists of educational material and prescriptions for yoga, chiropractic treatment, and acupuncture.[10] It is not as if their somatic symptoms suddenly disappeared.  Unfortunately, especially in the face of the Justice Department’s intransigence regarding non-addictive pain-management alternatives, now many veterans are following the rest of America’s lead by turning to the black market to obtain drugs to self-medicate.[11]

America’s veterans are a microcosm of the nation’s addiction to opioids, while also suffering from higher rates of over-prescription, addiction, and suicide.  These issues are especially prevalent among veterans who served in the “Post-9/11” era.  In the State of the American Veteran: The Chicagoland Veterans Study conducted by the USC School of Social Work’s Center for Innovation and Research on Veterans & Military Families, surveys show that “Post-9/11” veterans not only struggle more with transitioning back to civilian life, they report “feeling disconnected from the world” around them at double the rate of “Pre-9/11” veterans.  Worse still, the aforementioned years of combat and Overseas Contingency Operations have contributed to higher rates of being “bothered a lot” by issues related to: pain or problems with arms, legs, and joints; trouble sleeping; chronic back pain; feeling overly tired; bowel problems; headaches; and for female veterans, menstrual cramps and difficulties.  The study cites a key factor among “Post-9/11” veterans as an overarching sense of “being [physically] and [emotionally] exhausted when they left the military…suggesting service members are leaving the military today with significant unmet physical health issues. ”[12]

As a sixteen-year Air Force veteran with a tour in Iraq that has battled with Post-Traumatic Stress, I completely agree with this sentiment.  Personally, although I only had four more years to retirement eligibility, continued service did not seem physically or emotionally possible without major sacrifices in my personal well-being.[13] I loved my job.  I was great at it.  I could not do it anymore. 

Prescribers, The VA, and Pill Manufactures

At a time when between 20 and 30 veterans commit suicide every day, the veterans of this era return to civilian life at greater risk than their predecessors.  Seemingly, the VA is only capable of lurching from one reactive pain management policy to another.  The Department of Veterans Affairs operates over 1000 treatment facilities and hospitals in all fifty states.  Over 9 million of America’s 22 million veterans receive their primary medical treatment at a VA or DoD facility.[14] This makes the VA the 10th largest healthcare network in America.  This is both a blessing and a curse. 

One contributing factor to the VA’s over-prescription of opioids was the pill manufacturers themselves.  These companies took advantage of a government agency constantly on the defensive — one desperate, especially after the Iraq invasion, to be seen as doing something, anything to help veterans — by pushing the use of manufactured opioids for pain management.  Furthermore, these manufacturers used the VA as a publicly funded propaganda arm to spread the lie that these opioids were non-addictive and safe for wide use in pain-management.[15]

From Pain Management and Opioid Safety — VA Educational Guide (2014)

The manufacture of OxyContin, Purdue Pharma, contributed $200,000 in 2001 to the VA’s pain management policy team and directly participated in developing the VA’s initial guidelines on opioids, ensuring the drug was cited as “rarely addictive. ”[16] Worse still, as the VA increased use of opioids for pain management, so followed the rest of America.  There is a direct correlation between America’s rate of OxyContin abuse and the tremendous profits of its producer Purdue Pharma.  In 1995, the company, noting the drugs addictive properties, cited the goal of selling the smallest effective dose to the smallest number of patients.  In a marked reversal of mindset, by 2002 Purdue Pharma sales reps received specific training to overcome any clinician objections and questions about addition in order to complete a sale.[17] Finally, and this despite the growing opioid epidemic and dropping prescription rates, the company was valued at $14 billion in 2015, up from $95 million in 1995.[18] In a quantitative study conducted for the National Bureau of Economic Research, Christopher J. Ruhm examined county-level drug mortality rates — specifically for opioids — from 1999–2015 finding the marked increase in deaths was unlikely due to any contributing economic or societal factor, but instead was directly tied to the availability and cost of the drugs.[19] In short, the fault of the opioid epidemic can be laid directly at the feet of the government, sanctioned prescribers, but also opioid manufacturers. 

From Pain Management and Opioid Safety — VA Educational Guide (2014)

The Trump Administration Response — The Return of Just Say No

The current administration response to the opioid epidemic does not inspire hope in veterans.  The former head of the VA, Secretary David Shulkin, spent an inordinate amount of time on Capitol Hill answering questions regarding inappropriate use of government funds during official travel to Europe, where the New York Times reported he spent most of his time playing tourist.[20] This was a needless distraction for an organization on the front lines of this deadly epidemic.  Fortunately, there are suggestions that the VA is changing its cultural mindset with its Opioid Initiative Toolkit; which contains documents geared towards safe opioid prescribing while “recognizing the clinical challenges to successfully managing pain and prescribing safely for our Veterans. ”[21] Though, this is tempered by the VA’s history of mismanagement in times of crisis. 

Furthermore, outside of a well-received speech wherein President Trump declared America’s opioid addiction a public health emergency, the President did not immediately request additional funds to combat the crisis.[22] In fact, President Trump did not address funding the fight against opioids until he published his 2019 budget on 12 February 2018.  He requested an additional $30 billion in new federal funding to combat opioids, while reducing the Health and Human Services budget by $17.9 billion (21%).  In the intervening 109 days between declaring a state of emergency and proposing funding, almost 20,000 Americans overdosed on opioids and in upwards of 3000 veterans committed suicide.[23] The fear among veterans is that, much like past government initiatives, it will be too little, too late and will inevitably focus on the wrong priorities. 

This fear was reflected in a speech given by then Attorney General of the United States, Jeff Sessions, who stated, “I am operating under the assumption that this country prescribes too many opioids,” which is true, but he continued, “people need to take an aspirin sometimes and tough it out a little. ”[24] The Attorney General’s views on drugs, and crime for that matter, hearken back to the failed “Just Say No” D.A.R.E. campaign era under the Reagan administration.[25] In his view, there is no alternative but abstinence and empty quips when it comes to the opioid epidemic.  This much was clear after he announced the Justice Department was ending the Obama Era guidance that shielded states with medical and legal marijuana laws on the books.[26] This, despite studies showing marked drops in opioid overdoses in states that legalized marijuana.[27]

Conclusions

The Chicagoland Veterans study makes it clear that today’s veterans are facing greater transition challenges than any previous generation, with nearly 1/3 of Chicago’s cohort considered “at-risk” of suicide the day they take off the uniform.  Terribly, “Post-9/11” vets were twice as likely to be considered a suicide risk as compared to their “Pre-9/11” peers.[28] Despite the lack luster responses from the current administration, there are sizable resources devoted to addressing the acute and chronic needs of veterans at the local level.  Though, the Chicagoland report laments the “lack of attention given to preventing these conditions or proactive early intervention to prevent conditions from being chronic. ”[29] The study further laments the absence collaborative synergy between veterans support organizations, not just in Chicagoland, but nationally as well.  There is no formal structural schema for these organizations to collaborate and work together.  As the report states, these various governmental and non-government organizations “tend to focus on one or two veteran needs.  Thus, the only means by which veterans will receive a holistic support network is through all veteran support organizations working together. ”[30]

Veterans today balk at the simple notion that “an aspirin” and “tough[ing] it out a little” is a viable policy solution for the opioid epidemic.  First, any veteran would point out while in the service most trips to the doctor resulted in a prescription for an absolute mountain of 800mg Ibuprofen.  We spent our whole careers on “aspirin.”  Not to mention, as the Chicagoland study rightly pointed out, further “bike rides, expeditions to the North Pole, and athletic competitions [that] might appeal to fundraisers and generate ‘feel-good’ reactions among participants and civilians…do very little to address many of the more serious issues impacting [veterans].”[31] Though a marked improvement over getting spit-on at the airport, these events are not policy solutions.  Finally, “Post-9/11” veterans spent the last 18 years at war.  We are a generation of tough.  If anything, we are its literal embodiment.  Tough is not the issue.  The issue of Americans on opioids, like its veterans on opioids, is complicated.  Instead of a one-off slogan, the issue will require a multifaceted, complex, coordinated, frankly veteran-led solution. 

[1] “Increases in Drug and Opioid Overdose Deaths — United States, 2000–2014,” accessed February 13, 2018, https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6450a3.htm; Rose Rudd et al., “ Increases in Drug and Opioid Overdose Deaths — United States, 2000–2014,” January 1, 2016, https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6450a3.htm; “Drug Overdose Death Data | Drug Overdose | CDC Injury Center,” January 5, 2018, https://www.cdc.gov/drugoverdose/data/statedeaths.html; “Opioid Data Analysis | Drug Overdose | CDC Injury Center,” January 19, 2018, https://www.cdc.gov/drugoverdose/data/analysis.html. 

[2] Mark Brunswick, “Veterans Struggle to Live with VA’s New Painkiller Policy,” Star Tribune, accessed February 13, 2018, http://www.startribune.com/cut-off-veterans-struggle-to-live-with-va-s-new-painkiller-policy/311225761/.

[3] “Department of Veterans Affairs Opioid Prescribing Data | Data.va. Gov,” accessed February 13, 2018, https://www.data.va.gov/story/department-veterans-affairs-opioid-prescribing-data. 

[4] One veteran described his daily “cocktail” consisted of over 100 pills.  Jim Axelrod, “VA’s Overmedication of Vets Widespread, Inspector General Finds,” CBS News, May 14, 2014, https://www.cbsnews.com/news/vas-overmedication-of-vets-widespread-inspector-general-finds/.

[5] Brunswick, “Veterans Struggle to Live with VA’s New Painkiller Policy.” 

[6] “Department of Veterans Affairs Opioid Prescribing Data | Data.va. Gov.”

[7] Liz Lohuis, “TN Veteran Sues VA for Cutting off Pain Med Prescription,” accessed February 13, 2018, http://www.wsmv.com/story/36916192/tn-veteran-sues-va-for-cutting-off-pain-med-prescription. 

[8] “Opioid Safety Initiative (OSI) — VHA Pain Management,” General Information, accessed February 15, 2018, https://www.va.gov/PAINMANAGEMENT/Opioid_Safety_Initiative_OSI.asp. 

[9] Brunswick, “Veterans Struggle to Live with VA’s New Painkiller Policy.” 

[10] Brunswick. 

[11] Joe Eaton, “Selling Prescription Medications, Opioids Illegally,” AARP, accessed February 15, 2018, http://www.aarp.org/health/drugs-supplements/info-2017/selling-prescription-medications-opioids.html; Axelrod, “VA’s Overmedication of Vets Widespread, Inspector General Finds.” 

[12] Sara Kintzle, Janice Rasheed, and Carl Castro, “The State of the American Veteran: The Chicagoland Veterans Study” (USC School of Social Work / Loyola University Chicago School of Social Work, April 2016), http://cir.usc.edu/wp-content/uploads/2016/04/CIR_ChicagoReport_double.pdf. 

[13] I spent 16 years and 24 days as a United States Air Force Arabic Cryptologic Language Analyst and Intelligence Analyst for the National Security Agency.  Nearly every moment was either spent training for or fighting in the Global War on Terror against Al Qaeda in Iraq and the Islamic State. 

[14] “Department of Veterans Affairs Opioid Prescribing Data | Data.va. Gov”; Art Levine, “How the VA Fueled the National Opioid Crisis and Is Killing Thousands of Veterans,” Newsweek, 12 Oct 17, http://www.newsweek.com/2017/10/20/va-fueled-opioid-crisis-killing-veterans-681552.html. 

[15] Levine, “How the VA Fueled the National Opioid Crisis and Is Killing Thousands of Veterans.” 

[16] Levine; Richard Florida, “Don’t Blame Economic Despair for the Opioid Epidemic,” CityLab, accessed February 15, 2018, https://www.citylab.com/life/2018/02/the-real-cause-of-the-opioid-crisis/553118/; Christopher J. Ruhm, “Deaths of Despair or Drug Problems?,”  Working Paper (National Bureau of Economic Research, January 2018), https://doi.org/10.3386/w24188. 

[17] Patrick Radden Keefe, “The Family That Built an Empire of Pain,” The New Yorker, October 23, 2017, https://www.newyorker.com/magazine/2017/10/30/the-family-that-built-an-empire-of-pain. 

[18] Chase Peterson-Withorn, “Fortune Of Family Behind OxyContin Drops Amid Declining Prescriptions,” Forbes, June 29, 2016, https://www.forbes.com/sites/chasewithorn/2016/06/29/fortune-of-family-behind-oxycontin-drops-amid-declining-prescriptions/#55463a506341. 

[19] Ruhm, “Deaths of Despair or Drug Problems?” 

[20] Dave Philipps, “Report Faults V.A. Secretary Shulkin Over Travel to Europe,” The New York Times, February 14, 2018, sec.  U.S., https://www.nytimes.com/2018/02/14/us/veterans-affairs-shulkin.html. 

[21] “Opioid Safety Initiative (OSI) — VHA Pain Management.” 

[22] Alessandra Potenza, “Trump Declares Opioid Crisis a Public Health Emergency, but It Falls Short of What He Promised,” The Verge, October 26, 2017, https://www.theverge.com/2017/10/26/16552440/opioid-crisis-public-health-emergency-donald-trump-heroin-epidemic. 

[23] 65,000 opioid deaths in 2016/356=178 per day*109.  30 veterans per day*109. 

[24] Attorney General Jeff Sessions Recommends Aspirin in Tampa Bay, accessed February 11, 2018, https://www.youtube.com/watch?v=kyR98CeYPkQ; Sky Palma, “Jeff Sessions: Chronic Pain Sufferers Should ‘Take an Aspirin and Tough It Out,’” accessed February 11, 2018, http://deadstate.org/jeff-sessions-chronic-pain-sufferers-should-take-an-aspirin-and-tough-it-out/; Attorney General Jeff Sessions Recommends Aspirin in Tampa Bay, YouTube (Office of United States Attorney — Middle Distric of Florida, 2018), https://www.youtube.com/watch?v=kyR98CeYPkQ.

[25] “Common Sense for Drug Policy: Drug Abuse Resistance Education (DARE),” accessed February 16, 2018, http://www.csdp.org/news/news/darerevised.htm; review of Youth Illicit Drug Use Prevention: DARE Long-Term Evaluations and Federal Efforts to Identify Effective Programs, by Marjorie Kanof, U.S. Government Accounting Office, no.  GAO-03–172R (January 15, 2003), https://www.gao.gov/products/GAO-03-172R.

[26] Corky Siemaszko, “Sessions to End Obama-Era Policy on Legalized Marijuana,” NBC News, January 4, 2018, https://www.nbcnews.com/storyline/legal-pot/sessions-end-obama-era-policy-legalized-marijuana-n834591. 

[27] Melvin D. Livingston et al., “ Recreational Cannabis Legalization and Opioid-Related Deaths in Colorado, 2000–2015,” American Journal of Public Health 107, no.  11 (October 11, 2017): 1827–29, https://doi.org/10.2105/AJPH.2017.304059. 

[28] Kintzle, Rasheed, and Castro, “Chicagoland Veterans Study,” 38. 

[29] Kintzle, Rasheed, and Castro, 39. 

[30] Kintzle, Rasheed, and Castro, 39. 

[31] Kintzle, Rasheed, and Castro, 39. 

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