By Annette M. Boyle
PHILADELPHIA — A year ago, the U.S. Drug Enforcement Administration (DEA) rolled out new restrictions on hydrocodone-based painkillers, creating a painful situation for many veterans.
The tightened controls classified the medications as Schedule II drugs, with the same restrictions as morphine, including requiring a written prescription and no more than a three-month supply without another doctor’s visit. At the same time, the VA faced significant congressional pressure to reduce the number of veterans receiving these opioids long-term.
In response, the VA stepped up its Opioid Safety Initiative, a program launched in 2013 to educate both veterans and providers about the risks and benefits of opioids and to use a multimodal, team approach to pain relief to minimize the need for opioids.
More than 50% of veterans receiving care through the VA experience chronic pain. Prior to the focus on reducing opioid use, about 1 million veterans received opioid prescriptions each year, and more than half became chronic users.1
Those numbers have dropped sharply. The VA reported in August that, since July 2012, the number of veterans receiving opioids has dropped by 115,575, and the number on long-term opioid therapy has declined by 100,074.
“Now we provide a comprehensive review with patients in groups, so they can ask questions and learn from each other, as well as from clinicians, about what pain is, the role of the brain, nerves and spinal cord and how stress activates the pain center,” said Rollin “Mac” Gallagher, MD, MPH, deputy national program director for Pain Management at the VA.
The role of patients in the treatment process also has changed, in keeping with the VA’s focus on patient-centered care. “Patients in pain are part of the decision-making team,” Gallagher told U.S. Medicine. “The emphasis is on self-management and the use of evidence-based complementary and integrative approaches such as yoga and acupuncture, which have a much better risk/benefit ratio than medications.”
The news media is replete with reports of war-wounded veterans who had been on hydrocodone-combination drugs for years, only to find out that their medications would not be renewed when they sought a refill. Disabled veterans organizations said they were deluged with complaints from members.
“Best I can tell, VA could have handled the change better and treated veterans affected with more compassion while they suffered through withdrawals,” Benjamin Krause, the creator of the DisabledVeterans.org community, wrote in a blog. “A big problem with the change was that VA failed to warn and did not explain exactly why they change was going on. Veterans that pushed for the painkillers they previously received were labeled as ‘drug seeking.’”
Changing the Paradigm
Gallagher noted that the new policies aim not just to use opioids less, but to focus more on improving veterans’ functionality. “Opioids don’t treat chronic pain itself; they just put a wet blanket on pain in the brain. They do help patients feel better temporarily,” he said.
In some instances, even brief relief can make a significant difference. “The goal is to use them only when necessary. That might be to help a veteran get back to work or get into physical therapy until they don’t need them anymore, or to alleviate pain from a terrible nerve injury where they can’t think because the pain is so bad,” Gallagher said.
The real goal, though, is to shift the paradigm for pain care, again. As Gallagher noted, the medical profession went from largely ignoring pain to recognizing it as a serious condition that affected 30% of adults. At the same time, economic pressures reduced the amount of time physicians could spend with patients, so giving patients a pill that could relieve pain at least temporarily became very appealing.
“But if you have spine disease and poor flexibility and just take a pill for the pain, you’ll lose your conditioning and gain weight, and that will make the back pain worse,” he said. “What’s needed is a package of psychological and lifestyle and coping skills interventions that improve physical and mental functioning while avoiding depression and other issues.”
The challenge has been making alternatives available to a very large and widely spread population, with many patients challenged to come to VA medical centers on a regular basis. The wait time for care can be daunting, and some patients cannot travel.
To address some of these issues, the VA uses the Specialty Care Access Network-Extension for Community Healthcare Outcomes (SCAN-ECHO) to reach veterans in rural and other medically underserved areas. The video teleconferencing system has proved a particularly effective way to deliver cognitive-behavioral therapy (CBT), which has strong evidence of effectiveness in reducing chronic pain.
For veterans with osteoarthritis pain, who may be demoralized, have limited activity and find that their pain pills make them sleepy, CBT can help them think differently. They might put themselves on a schedule or initiate a meditative sequence when pain starts so they don’t stress out, said Gallagher. If they start moving more, that will strengthen their legs and change the physiology of the knee. They may lose weight with the increased exercise and rebuild the muscle support structures around the knee. All these changes can reduce pain for the long term.
The VA also has trained 1,700 practitioners in auricular acupuncture, also known as battlefield acupuncture, which uses needles in specific locations in the ear to relieve pain. Medical acupuncturists have also been hired to train even more therapists in the technique, so that acupuncture is now available in primary care programs at most VA facilities.
“The message is pretty clear from the top of the VA down through the clinics that we’ve made a large investment in addressing substance abuse and developing new treatments for pain,” Gallagher said. “The focus is not just on using medications but improving quality of life for the wounded warriors and heroes who have come to us for care.”
1 Sullivan M, Hudson T, Bradley CM, Edlund M, Fortney J, et.al. National Analysis of Opioid Use Among Veterans. Poster session presented at: the 30th Annual Meeting of the American Academic of Pain Medicine; 2014 March 6-9, Phoenix.