Washington, DC – The military services, especially the Army, are walking a tightrope on how to appropriately treat wounded warriors’ pain without feeding into the growing problem of misuse of pain relievers and other prescription drugs among troops.
Several recent events have thrown a spotlight on the dilemma.
In March, Secretary of the Army John McHugh told Congress that misuse of painkillers among troops is “a serious problem. We consider it one of the primarily indices we track in terms of stress on the force.”
Then, in April, the secondary analysis of the 2008 Department of Defense Survey of Health Related Behaviors Among Active Duty Military Personnel was released, with findings suggesting that the strongest predictor of prescription drug misuse in the military is having received a prescription for pain medication within the past month or past year.
Diane Jeffery, PhD, director for the Center for Health Care Management Studies and the study investigator for the secondary analysis, said that she could not give physicians medical advice in terms of prescribing but emphasized the role of the clinician in helping to stem the tide of drug abuse in the military.
“It is really important to have that individual’s full prescription history probably prior to the examination encounter,” Jeffery said. “The other is the importance of asking individuals about any kind of residual symptoms. If an individual did receive a pain medication in the past, well, ‘How are the symptoms today?’ I would want to know whether or not the individual is attempting to self- regulate those symptoms.”
The problem, according to what McHugh told the House Appropriations Committee Defense subcommittee, is that many soldiers have an ongoing need for pain relievers because they are suffering from wounds that likely would have caused loss of life 15 years ago.
McHugh said that “the pain medications are not just appropriate, but necessary in terms of caring for those soldiers,” adding, “No one, I think, goes in and purposely becomes addicted to pain medication.”
Also speaking to the House subcommittee, Chief of Staff of the Army Gen. George Casey Jr. said that prescription painkiller use among soldiers is “part of the cumulative effects of eight-and-a-half years at war. It’s something—not a pretty thing—something we need to get on the table and deal with.”
Drug Misuse Increasing
DoD’s 2008 survey on health-related behaviors found that prescription drug misuse doubled from 2% in 2002 to 4% in 2005 and almost tripled from 2005 to 2008, going from 4% to 11%.
Of the respondents in the 2008 survey who said they had misused prescription drugs in the previous year, 17% reported misusing pain relievers, 6% tranquilizers, 2.9% sedatives and 2.3% stimulants.
While the original survey showed prescription drug misuse had increased, it did not ask respondents about the reason behind their drug misuse, Jeffery said. “We have no idea how individuals are defining misuse and we don’t know motivations for it, she said. “It could be a one-time extra pill, it could be every day. We have no idea how each individual who responded defined it.”
In response, DoD requested an examination of the motivation for prescription drug misuse that includes the secondary analysis of the 2008 survey as well as two additional studies. The findings of the studies will be incorporated into a final report on prescription drug misuse.
The secondary analysis specifically examined predictors for the reported misuse.
“Very consistent in the literature is that if someone who had received a prescription for pain relievers—opioids in particular—that was usually considered to be a very high predictor of misuse,” Jeffery said.
Having received a prescription for anxiety or depression in the past month, year, or more than a year ago also increased the likelihood of prescription drug misuse, as did stress, according to the study.
The secondary analysis also showed that of those who reported misusing pain relievers, a greater number were in the Army as compared to the Navy or Air Force—47% were in the Army, versus 20% in the Navy, 13% in the Marine Corps, and 23% in the Air Force.
Army Aware of Problem
That came as no surprise to the Army, which already has made significant efforts to address the problem.
McHugh told legislators that an Army report on pain management had come back with 109 recommendations to make sure there is tight oversight of the prescription-drug program. Among the changes being made, the Secretary of the Army said, is greater emphasis on informed consent, making patients aware of the dangers of pain medication ahead of time, and use of new technologies such as the Electronic Medication Management Assistant (EMMA), piloted at Walter Reed Army Medical Center (WRAMC), which mechanically manages a soldier’s drugs. Under that system, “you can only get one dose at the proper time,” McHugh said.
There is only so much the Army can do, however, according to McHugh, who pointed out that soldiers are free to go outside military medicine for treatment.
At the local level, such as the Warrior Clinic at WRAMC, efforts to appropriately reduce pain medication already have decreased the potential for prescription drug misuse. While in 2008, about 83% of the injured troops assigned to WRAMC’s Warrior Transition Brigade were using prescribed narcotics, that number was reduced to 10.2% at the end of the first quarter of FY 2011.
Dr. Christopher Spevak, an anesthesiologist and pain physician at the clinic, said that the Warrior Clinic’s success stems from a pain management program that uses an interdisciplinary and holistic approach to help patients manage pain with medications as well as other options. “We will shortly be publishing some of our results showing that we are getting improved pain, improved function and using less opioids and controlled substances,” he said.
Since the report from the Army’s Pain Management Task Force a year ago, the military has been focusing on efforts to make sure that patients and medical providers are not over-relying on medications but are taking advantage of other treatment modalities for pain management. That May 2010 report examined pain management at DoD facilities and suggested a holistic, multimodal and multidisciplinary approach to pain management that also included Complementary Alternative Medicine (CAM).
Col. Kevin Galloway, chief of staff for the Army’s Pain Management Task Force, said that there is a serious commitment on the part of the Army Surgeon General to see the Task Force’s recommendations implemented. “When we delivered the task force report, he told us to go out and make this happen,” he said.
One important aspect of the Army’s pain management strategy is that it focuses on early, effective interventions in pain management. “You want to decrease the number of people who require opioids,” Galloway said. “The more effective you are at the beginning, the less likely you will be to have these chronic conditions that require long-term use.”
Another key feature of the Army’s plan to improve pain management involves multi-disciplinary teams at MTFs.
“We have a plan that involves every medical treatment facility, regardless of size, that we are in the process right now of funding,” Galloway explained. “They are doing renovations to accommodate the new group of people who we are tasking to manage pain in their facility and in their region, in some cases, and then building the network of people who will be a part of this cultural transformation of pain management in the U.S. Army Medical Command.”
While pain management resources may have varied from facility-to-facility in the past, Galloway said that the Army is seeking to “brand” its new pain management approach, so that it is recognizable to both patients and providers as they move across the MHS and even the VA. That standard approach to pain management should offer comfort to patients as they transition from MHS facility-to-facility or even MTFs to VAMCs, he said.
A memo in March from Assistant Secretary of Defense for Health Affairs Jonathan Woodson to the services said that the report’s recommendations were presented to the VA/DoD Joint Executive Council (JEC), which, in turn, chartered a work group to actively collaborate on a standardized VA/DoD approach to pain management.
Efforts to improve pain management systems will not end with these plans, according to Galloway, who noted that mechanisms are being put into place to continuously collect data on what pain interventions are most effective for patients.
Spevak also suggested that the need to address the issue of pain medication overuse will continue.
“One of the things we are up against is that we have, just like the civilian world, a ‘pill society’ and we are trying to overcome some of those barriers,” Spevak said. “What we have seen mirrors what is going on in the civilian population with the prescription medication that is used.”
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