Veterans Day provides an opportunity to recognize a hardship facing many American military personnel after they come home: struggles with opioid use disorder (OUD). About 68,000 veterans had the disorder in 2015, a threefold increase in 12 years. In addition, they are twice as likely as nonveterans to die from accidental opioid overdoses, according to a 2014 report from the U.S. Department of Veterans Affairs (VA).
Post-traumatic stress disorder (PTSD) and chronic pain are common diagnoses in this population, and both are associated with high rates of opioid prescribing. Between 2001 and 2009, opioid prescriptions written by military physicians quadrupled to close to 3.8 million, mirroring trends for the nation as whole. But the VA has taken steps in recent years to improve the safety of opioid prescribing and to increase treatment for those with OUD.
The response of the VA and prescribers
In response to the increasing number of opioid prescriptions, the agency in 2013 launched the Opioid Safety Initiative. The VA developed a tool that displays real-time opioid prescribing to veterans graphically using data from electronic health records, a step that allows it to better track overall opioid use by this population. The initiative also provided guidelines, materials, and toolkits for VA health care providers on treating pain, with the goal of better educating them, as well as resources to inform patients.
In the years since the initiative was implemented, the VA has worked to address the factors that contribute to opioid overdose risks. For example, fewer veterans now receive high doses of opioids and fewer receive them in combination with a class of medications prescribed for anxiety known as benzodiazepines, which together increase the risk of opioid overdose.
Moreover, the VA mandates that health care providers check a patient’s medication history on statewide prescription drug monitoring programs (PDMPs) before initiating therapy with a controlled substance, and again at least annually or more frequently if obligated by state law. The VA Prescription Data Accountability Act of 2017 requires the agency to enter controlled substance prescription information into state PDMPs. Together, these policies help VA and community providers identify patients who have received controlled substances from multiple providers and prevent potential misuse and diversion.
Access to treatment
Just as important as improved opioid prescribing is the VA’s use of evidence-based treatment for OUD. Medication-assisted treatment (MAT), which combines Food and Drug Administration-approved medications with behavioral therapies, has been found to be more effective than other treatments or no treatment. Studies show that compared with other approaches, MAT significantly increases patients’ adherence to treatment, reduces illicit drug use, and helps prevent relapse.
Only 1 in 9 Americans—11 percent—with substance use disorder receives any treatment. In 2017, however, 34 percent of VA patients diagnosed with OUD received MAT, up from 25 percent in 2004.
This increase in use of evidence-based treatment can be attributed partly to improved identification of this disorder following educational initiatives for VA providers, implementation of MAT clinical practice guidelines, and development of partnerships with other federal agencies. These VA practices and systems can serve as models for other parts of the health system.
Despite clear progress, 2 of 3 veterans with OUD are not receiving evidence-based treatment and recovery services. More veteran health care services could help close this gap through approaches such as telemedicine and efforts to increase the number of providers. At the same time, the health care system must continue to address factors associated with increased risk of OUD in this population, such as high rates of PTSD and depression. By expanding the use of MAT and increasing access to care, the United States and the VA can better serve those who served their country.
Beth Connolly is project director of The Pew Charitable Trusts’ substance use prevention and treatment initiative.