Pain Management and Opioid Use with Veterans and Service Members

Military service brings a risk for serious injury, and with it, the possibility of severe or chronic pain. Such pain may be treated with prescription medication – sometimes opioids – which carry a risk for overuse or misuse. SAMHSA has been working with the U.S. Department of Defense (DoD) and the U.S. Department of Veterans Affairs (VA) to enhance informed prescribing practices and prevent misuse that can result in overdose or even death.

Controlling Pain

Injuries incurred during military service can be complex and the management of chronic pain requires attention. According to Friedhelm Sandbrink, M.D., VA’s Acting National Program Director for Pain Management, up to 75 percent of older veterans experience chronic pain. Prevalence of severe pain is strikingly more common in veterans than in the general population, particularly in younger veterans and in veterans who served during recent conflicts. Complicating matters even more are co-occurring disorders experienced by veterans, such as posttraumatic stress disorder and traumatic brain injury, for which additional psychotropic medications may be prescribed. Medication interaction is an important consideration.

“The challenge for those prescribing medications in the military and in the VA is to find the right balance to get the pain under control and to keep the patient safe,” said Dr. Sandbrink. “We want to ensure that patients are finding relief and taking medications as prescribed, and that we are aware of other sedating medications or alcohol use that could increase the risk of overdose.” He added, “in order to find the right balance, we nowadays rely less on medication and make much greater use of other approaches, including behavioral therapies, physical therapy and integrative health modalities, and emphasize physical and mental function.”

Providers outside the military systems and VA are accessed by more than half of those who serve, so they also need to be aware of population-specific guidance for veterans and service members. This is particularly true for members of the National Guard and Reserve, whose home communities may not include military supports.

The High Risk Of Relapse – For individuals in recovery from a substance use disorder who relapse, the risk of overdose is greatest. Tolerance of a drug during sobriety decreases, so if a person resumes at the same dosage as before recovery, that use can be lethal. For this reason, it is important to educate family members on the possibilities of misuse and how to respond.

The DoD currently has a pilot project called Building Healthy Military Communities that addresses the unique needs of geographically dispersed service members and their families that may affect readiness, resiliency, and wellbeing. SAMHSA also supports this work to address the mental health needs of service members and their families in communities throughout the U.S.

Interagency Task Force

The DoD, VA, and HHS participate in the Interagency Task Force on Military and Veterans Mental Health, created in 2013 to ensure that veterans, service members, and their families can access the services and supports that they need. SAMHSA represents the U.S. Department of Health and Human Services on this Task Force. Through this partnership, SAMHSA provides a number of resources to DoD and VA providers, including:

• Online trainings and webinars, including medication-assisted treatment training, that not only educate prescribing professionals, but also family members who might need to administer medication if overdose occurs.
• SAMHSA review of Management of Substance Use Disorder and Management of Opioid Therapy for Chronic Pain Clinical Practice Guidelines and the subsequent development of new areas, including:
  • patient-centered care,
  • substance use disorder and co-occurring conditions,
  • engagement strategies,
  • addiction-focused medical management,
  • accreditation standards,
  • shared decision-making, and
  • management of substance use disorders in DoD healthcare settings.
• The Service Members, Veterans, and their Families Technical Assistance Center (SMVF TA) that provides technical assistance to states and territories and offers policy academies, where all three departments work together to determine ways to strengthen behavioral health supports at the state level.
• Video modules on safe opioid prescribing practices. 
• Screening, brief intervention, and referral to treatment (SBIRT) training to recognize and mobilize if someone may be at risk for or have a substance use disorder.
• MAT-X mobile app to support medication assisted treatment of opioid use disorder.

 SAMHSA and Veterans Affairs in Action

Dr. Karen Drexler, M.D., the National Mental Health Program Director for Substance Use Disorders in the VA, explained that, “SAMHSA resources and trainings are excellent. We are currently using many SAMHSA resources such as the PCSS-MAT and PCSS-O to educate Veterans, their families and clinicians about the best approaches to care.”

SAMHSA has been instrumental in training the prescribing workforce in the military to limit the length of opioid and other pain medication use, recognize the signs of misuse, be aware of treatment options, and understand DEA waivers to prescribe Buprenorphine (medication-assisted treatment to help people reduce or quit their use of opiates, such as pain relievers like morphine). SAMHSA uses evidence-based practices to develop these trainings that have substantially reduced dosages to stay within the recommended ranges and have encouraged providers to limit opioid use to three months.

“SAMHSA’s contribution on the Task Force has led to some specific advancements that support military service members, veterans, and their families,” said Cicely Burrows-McElwain, SAMHSA’s Military and Veteran Affairs Liaison. “In addition to reviewing the clinical practice guidelines, SAMHSA also worked with the other agencies to relay and report prescription drug information to Prescription Drug Monitoring Programs which helps to prevent over prescribing and overmedicating.”

The VA also worked to eliminate the co-pay on drugs like naloxone that are used if someone overdoses, making it much more accessible to patients and their families.

Dr. Drexler’s experience with SAMHSA’s trainings and work on the Task Force has changed the way she thinks about treatment. She explained that she had a patient with multiple medical problems that increase the risk for overdose such as sleep apnea and emphysema who was stable on medication-assisted treatment for opioid use disorder, but life stressors led him to relapse to benzodiazepine use. “Every time he came in, he was intoxicated, so we couldn’t have a meaningful discussion about treatment and I was especially concerned about overdose because he lived alone.”

The SAMHSA training encourages providers to think creatively about care and who to involve in overdose prevention and education. As a result, Dr. Drexler reached out to her patient’s sister and shared information learned in the SAMHSA training and prescribed a naloxone rescue kit. Educating his sister helped her to assist in limiting his access to illicit pills.  “My very next visit with him, he was alert, and I was able to have a meaningful talk with him about recovery and safety.”

“The federal coordination made it possible to look at risks and safety concerns across an entire spectrum of federal efforts,” said A. Kathryn Power, M.A., Executive Lead for SAMHSA on the Interagency Task Force. “The coordination, weekly communication, and measured positive outcomes all point to better care for military service members and veterans. That has been, and continues to be, our driving force.”

Although advancements have been made to better equip treatment providers with information and training to prevent circumstances that could lead to addiction, opioid misuse continues to be a serious public health concern. Providers in the DoD and VA continue their efforts to address pain and limit opioid use, while discussing potential associated risks with military service members, veterans, and their families. SAMHSA’s work with the Task Force, and work done to support states across the country through the SMVF TA Center,  will ensure that the support, resources, and training to improve care and prevent substance use disorders is accessible no matter where military service members and veterans go for care.

 

 

Resources

• Management of Substance Use Disorder Clinical Practice Guidelines
• Management of Opioid Therapy for Chronic Pain Clinical Practice Guidelines
• SAMHSA’s Service Members, Veterans, and their Families Technical Assistance Center
• SAMHSA’s Veterans and Military Families
• Veterans and Military Families: Publications and Resources
• Opioid Overdose Prevention Toolkit
• The Facts about Buprenorphine for Treatment of Opioid Addiction
• The Facts about Naltrexone for Treatment of Opioid Addiction
• What Every Individual Needs to Know About Methadone

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