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.