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New Medications Continue to Revolutionize Opioid Addiction Treatment at VA

by U.S. Medicine

January 10, 2012

The problem of prescription opioid addiction is nothing new for U.S. military forces. It stretches back to the mid-1800s, when many wounded Civil War veterans became hooked on narcotics used to control their pain


This is a photo of the Wash. D.C., Sanitary Commission Rest House, taken between 1861 and 1869. Disabled Union servicemen received food, lodging and care here.

Addiction treatment often included a stay in a sanatorium or rest home and administration of small doses of opioids. Despite an extremely high relapse rate, addiction therapy didn’t improve much for the next 100 years.

Finally, in the last few decades, highly effective medications have become available and revolutionized the treatment of addiction. The VA now has the tools to help veterans control addiction and return to functional lives, experts said.

One challenge, according to clinicians, is getting patients to overcome the stigma of drug addiction and seek help. Another is an unexpected consequence of the successful drug regimens: Many patients misunderstand the process and think a quick cure is available.

Instead, it is more like a chronic illness for which treatment is a long-term, if not lifetime, process, pointed out Andrew J. Saxon, MD, director for the Addiction Patient Care Line at the VA Puget Sound Health Care System in Seattle.

“People don’t see opioid addiction as a chronic, relapsing condition,” Saxon said. “The body has undergone some extremely physiologic changes.” As in diabetes and other chronic diseases, “maybe sometime in the future you can get off medication if you do everything perfectly, but most people find it hard to do everything so perfectly.”

The importance of ongoing treatment for opioid addiction was underscored by a recent study finding that treatment with a buprenorphine-naloxone combination was most effective in decreasing dependency in patients addicted to prescription opioids when treatment was extended from two weeks to 12 weeks.

In the multisite trial of more than 600 opioid-dependent outpatients, success rates plummeted when treatment was tapered off, even in those patients receiving counseling, according to the study published last month in the Archives of General Psychiatry.

Daniel Kivlahan, PhD

Daniel Kivlahan, PhD, acting National Mental Health Program director, Addictive Disorders at the VA’s Office of Mental Health Services, said he sees the study as a “message to the treatment system.”

“If someone comes in and says, ‘Gosh, I would like to get off of this stuff,’ you really have to manage the withdrawal strategy,” according to Kivlahan, who added that, while counseling is an important part of the package, “medication is really a critical component.”

New Medications Continue to Revolutionize Opioid Addiction Treatment at VA Cont.

VA at Forefront of Care

About 450,000 veterans treated by the VA have an addiction diagnosis, with one-third of them having direct contact with the national addiction program, said Kivlahan, who also is director of the Center of Excellence in Substance Abuse Treatment and Education (CESATE) at Puget Sound. The other patients address their issues in primary care and other settings.

Of all of those with an addiction diagnosis, 55% identify alcohol abuse alone as their problem, 25% have an addiction to alcohol and another drug, and 20% have a drug-abuse disorder alone.

During the 1970s, methadone was the gold standard for helping addicted veterans taper off of opiates. VA still has 35 methadone programs around the country, Kivlahan said, and that treatment remains effective for some patients.

In the 1980s, an oral form of naltrexone, which blocks the effects of opioids at their receptor sites, was added to the arsenal. However, patients must already have been detoxified.

A big leap forward in treatment came about in 2003 when buprenorphine began being used in the VA system.

“VA was one of the healthcare systems in the forefront of usage of buprenorphine,” said Saxon, who also is a professor in the Department of Psychiatry & Behavioral Sciences at the University of Washington. He added that buprenorphine has a better safety profile than methadone because the partial opioid agonist has a ceiling effect, making it highly unlikely that a patient could overdose. It also gives veterans more flexibility in their treatment, which doesn’t have to be administered in a federally-licensed clinic, as with methadone.

More than 7,000 VA patients are on the medication, a 20% increase over the prior year, Kivlahan said.

Prescription waivers are required for buprenorphine because physicians must meet certain training levels. Kivlahan said 123 of 140 VA facilities have buprenorphine programs, and about 800 physicians are approved to prescribe the drugs. He added that efforts are underway to offer the treatment option to veterans near the remaining medical centers, which tend to be smaller.

Despite the more-effective treatment, trends in the military and the general population suggest that the number of veterans requiring opioid addiction treatment is likely to increase in coming years.

A study published in the American Journal on Addiction in March 2011, noted, “there is considerable concern about the emergence of significant substance abuse among younger veterans of war in the Middle East, especially among those with post-traumatic stress disorder (PTSD),” and sought to quantify the problem. The study found that, of VA patients with a selected mental disorder, 21.0% had a comorbid substance diagnosis. 

VA estimates that 10% to 18% of troops returning from Iraq and Afghanistan suffer from PTSD.

In addition, the 2008 Department of Defense Health Behavior Survey found that prescription drug abuse doubled among U.S. military personnel from 2002 to 2005 and almost tripled between 2005 and 2008. For the population in general, about 5.3 million Americans were current users of pain relievers taken nonmedically, according to a 2009 study from the NSDUH.

“There is no reason to think that veterans have more of problem than the general population, Kivlahan said. “It is very widespread right now.”

He said that part of the problem is that, during the past 15 years, prescribers have been urged to be “more liberal with analgesic medication for chronic pain. That exposed a lot of people to opioids who would not have been exposed otherwise.” Kivlahan said the surfeit of prescriptions also increased the overall supply of drugs that could be sold illicitly.

Now, he said, “There is a little of a paradigm shift going into effect,” with physicians being more cautious about how they manage patients’ pain and prescribe opioids. He said the change is especially noticeable among returning troops whose most common complaint is chronic musculoskeletal pain.

Opioids affect quality of life, he said, and physicians are looking for better ways to manage pain and still allow patients to be fully functional.

New Medications Continue to Revolutionize Opioid Addiction Treatment at VA Cont.

Future of Treatment 

While current medications are “very good and successful,” a new form of injectable naltrexone could significantly improve treatment, according to Saxon. In fact, the injectable form, which is being considered for the VA formulary, would likely be more widely used than the oral form, he said.

The advantage, according to Saxon, is that the effect of the injectable lasts 30 days. Currently, patients take the oral form daily or three times a week and can simply stop taking it if they relapse. The long-acting form would block any “high” from ingesting opioids.

In addition, there is an effort to expand the types of physicians who can provide effective addiction treatment. 

Both Kivlahan and Saxon said the VA would like to see as much treatment as possible in the primary-care setting, especially because the newer medications can be effectively managed there. 

Kivlahan pointed out that, among the average of 1,200 patients in a primary-care practice at the VA, 100 are likely to have substance-abuse disorders and should be treated in a “systematic and effective way.”

The challenge, he said, is to motivate primary-care physicians to take on that responsibility. “The veterans are the best champions. They need to tell primary-care providers, ‘This medication really changed my life.’ ”

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