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Editor in Chief

Right actions in the future are the best apologies for bad actions in the past. Tryon Edwards (1809-1894)

by Chester Buckenmaier III, MD COL (ret), MC, USA

December 11, 2018

The Department of Defense recently underwent an internal review of opioid use within three major military treatment facilities through the Inspector General office. The report remains preliminary and has not yet been released to the public, although, unsurprisingly, it revealed some issues with overprescribing of opioids within the military healthcare system. When the document was discussed with DoD pain leaders, considerable discussion centered on methodological concerns with the IG process and challenges to the conclusions. While these concerns might be valid, I think the value of this IG process was the formal recognition that opioids remain a problem for the DoD, just like the rest of the country, and military healthcare investment in efforts to deal with this issue are not wasted.

The report noted issues with provider communication regarding opioids, concerns over patient satisfaction with pain care, apprehension over how opioid control measures will impact on clinical systems and other concerns. I see no reason why providers should be sheepish concerning the IG report and findings since this country, to include the U. S. military, has a problem with opioids. I was one of those providers overprescribing opioids 10 years ago and, like most providers, I am not pleased with that fact, but I am also not ashamed. Just like everyone else I was told by some unscrupulous drug manufacturers that pain patients will not get dependent or addicted to opioids and that opioids were the only truly effective management tool for pain.

That contention was blatantly (and, for some drug companies, criminally) false. I believed along with my colleagues this erroneous information at the time, it certainly influenced the way I managed pain patients, and I was wrong! There, I said it; I feel better for it, but that does not make me a bad doctor. In fact, I feel I am a better physician for recognizing that I can make mistakes and that my understanding of medicine can be flawed, but, more importantly, I can learn from these mistakes and adjust my practice to improve care of my patients.

Perhaps I came to the conclusion that opioids and pain management standards were an issue a bit faster than some, but my involvement in the past 18 years of armed conflict as a federal healthcare provider has tended to clarify medical issues with a speed and intensity not present in civilian medicine. I have no fear of the IG report pointing out shortcomings in our present system; I prefer to embrace it, as I recommend to our leadership that we double down on our efforts to improve pain management within the DoD in response to the opioid plague that has gripped this country. In fact, there is much to be proud of concerning the federal medicine response to the ongoing pain and opioid crisis in this country.

VA Secretary Robert Wilkie recently published a commentary in Newsday describing VA leadership in improving pain management and opioid safety for veterans and offering these innovations to civilian medicine for emulation.1 Spurred by the Comprehensive Addiction and Recovery Act (P.L. 114-198) signed into law by President Barack Obama on July 22, 2016, Secretary Wilkie outlines an impressive list of actions the VA system has implemented in response to the crisis. The secretary ended this commentary by stating, “There is still more to learn and more to do, and a national solution will require national collaboration.” I could not agree more. Now is not the time to lament the mistakes and missteps of the past; now is the time for positive action to evolve our pain management practices and improve our understanding of opioids and the appropriate use of this class of medications.

Please note that I am calling for better use of opioids, not the elimination of these important medications from our system. Opioids are not bad; the way we in the medical profession have been using them is the problem. Some have advocated for a simplistic solution to the opioid crisis through elimination of these medications in the care of patients. As an anesthesiologist and physician with experience caring for combat trauma patients, I can state categorically that this would be a bad idea. Nobody who has just sustained a traumatic amputation in war has called out for “acupuncture stat!”

Opioids have an important role in the management of surgery and trauma patients acutely, and, yes, acupuncture often has a role in the recovery and rehabilitation of these patients. Both tools are important. I mention this because there was some recent negative press concerning Food and Drug Administration approval for a new sufentanyl microtab (DsuviaTM) that some critics were warning would be as bad as fentanyl or Oxycontin. In fact, this medication was developed in a partnership with the DoD to replace the use of morphine and fentanyl lozenges with this safer pain management option following combat trauma. In short, this is a smarter use of an old standby, opioids, for battlefield pain control that is sorely needed.

The history of medicine is rife with examples of practices and ideas thought to be helpful and therapeutic for patients that providers today look upon with amazement that our predecessors could possibly condone these ideas and practices. Of course, today we have the advantage over our ancestors of learning from their mistakes. There is no shame in the errors and missteps of our medical forerunners. They were products of their time, and they provided the medical foundation upon which our system of medicine rests today. They are to be applauded for being open to new knowledge and allowing their practices to adjust as they received innovative and improved ideas. Practitioners of the future demand we do the same today. The best apology we can make to our patients for the opioid crisis we are experiencing today is the work we do today to change pain management and opioid care practices for the better patient care practices of our posterity.

1. https://www.newsday.com/opinion/commentary/fighting-pain-and-addiction-for-veterans-1.22436162



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