Opioid Crisis

By Spring 2018 M-VETS Student-Advisor

Much has been made of what has been variously termed the “opioid crisis” and the “opioid epidemic” by politicians and the mainstream media. And for good reason. In 2016, more than 42,000 Americans died of opioid overdose,[1] a 28% increase compared to 2015.[2] The number of annual deaths has increased every year since the CDC began keeping statistics on opioid-related deaths in the 1990s.[3]

How did we get to this point, where it’s practically expected that opioid drugs will take the lives of enough Americans this year to fill a Major League Baseball stadium?

The problem can be traced back to the 1990s, when the medical community and the pharmaceutical industry vastly underestimated the addictiveness of opioid painkillers.[4] Doctors then began to prescribe opioid painkillers at a greater rate.[5] By the time the medical community realized that the drugs were indeed highly addictive, dispersion and misuse of opioids had become widespread, and overdose rates began to skyrocket.[6] By 2015, an estimated 2 million Americans suffered from a substance use disorder related to prescription opioids.[7]

The federal government has engaged in a lot of talking about the opioid epidemic. On March 27, 2017, President Donald Trump announced a special commission to investigate the opioid crisis and provide recommendations to the White House.[8] The commission’s final report contained 56 recommendations, which included streamlined bureaucracy and collaboration with states and private entities.[9] On October 26, 2017, President Trump declared the opioid crisis to be a national health emergency.[10] On March 1, 2018, President Trump hosted a summit on the crisis, during which he spoke with recovery and prevention experts as well as members of the law enforcement community.[11]

Not to be outdone, Congress also has had a lot to say on the issue. In April 2018, Congress returned from recess with a full slate of bills on the agenda designed to address the crisis. The Senate was busy on the Opioid Crisis Response Act of 2018, which included many of the programs and initiatives being considered by the White House.[12] In the House, nearly three dozen opioid-related bills had been filed and were awaiting markup in committee.[13]

America’s veterans compose the group that has been most devastated by the opioid crisis. According to a statement by a VA official before the Senate, 60 percent of veterans who return from active service experience chronic pain; this figure is double the proportion of the general population.[14] Given the high incidence of pain among veterans combined with an overburdened VA and the recent emergence of opioid painkillers as the go-to treatment for chronic pain, opioids quickly became the norm for veterans returning home from action in the post-9/11 Middle East.[15] As a result, the number of veterans addicted to opioids rose 55 percent between 2010 and 2015, to a total of 68,000, or approximately 13 percent of the total population of veterans taking opioids.[16]

Veterans are uniquely susceptible to opioid addiction. Many veterans return home with PTSD as a result of the toll taken by combat on the human psyche. Those who suffer from PTSD often turn to alcohol or drugs as a means of coping.[17] With such a high percentage of the veteran population receiving opioids for their pain, there is considerable overlap with PTSD cases, and a vicious cycle often develops.[18]

The enormity of the opioid crisis may seem bewildering to those bound to fix it. Where does one begin to tackle such a problem? One solution that may appear obvious is to start with veterans, for a number of reasons. First, as discussed above, opioid addiction is disproportionately prevalent among veterans relative to the population at large. Second, any problem that afflicts veterans on such a scale deserves our attention, given the debt of gratitude we owe to each of them. Third, as a healthcare and treatment organization run exclusively by the federal government, the VA is uniquely situated to serve as a laboratory for what works and what doesn’t in addressing the opioid epidemic at large.

A glimpse of what this might look like has already been provided by the Louis Stokes Cleveland VA Medical Center, a VA facility in Cleveland, Ohio, which has developed “a culture . . . of evidence-based tests and practices of opioids for over a decade.”[19] Only 3 percent of the Cleveland VA’s patients are prescribed opioids to treat their pain.[20] This rate, the lowest in the country, is due, in addition to the steps taken as part of the overall VA-mandated push to reduce opioid prescriptions, to “a mix of available resources and educating care providers on how best to prescribe opioids.”[21]

According to Dr. Ali Mchaourab, Chief of Medicine, the facility’s success in fighting opioid dependence has been achieved because its “providers, from primary care to the most specialized, have so many tools and so many things available to them, including complementary alternative medicine, advanced technology, surgeries—anything and everything that’s available in science, is available at the Cleveland VA.”[22] In addition, the Cleveland VA’s 13-member pain management team has embraced the philosophy that investment of time is necessary to properly care for their patients.[23] Thus, rather than handing out a bottle of pills, the team ensures that each patient sits down with a psychologist and a physician for as long as necessary to “understand the patient.”[24] The team also looks for innovative ways to use technology to stay up to speed on ways to treat pain without resorting to opioids.[25]

To stop the opioid epidemic, we have to start somewhere. The VA could be the place. Through new partnerships, uniform standards for painkiller prescription, smart allocation of budgetary resources, and the kind of good, old-fashioned hard work seen in Cleveland, the VA may be perfectly positioned to provide America with the blueprint on how to defeat this crisis.

[1] Christopher Ingraham, CDC Releases Grim New Opioid Overdose Figures: ‘We’re Talking About More Than an Exponential Increase’, Washington Post Wonkblog (Dec. 21, 2017), https://www.washingtonpost.com/news/wonk/wp/2017/12/21/cdc-releases-grim-new-opioid-overdose-figures-were-talking-about-more-than-an-exponential-increase/?noredirect=on&utm_term=.eaa4206a4f8e.

[2] Id.

[3] Id.

[4] Opioid Overdose Crisis, https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis (last visited May 19, 2018).

[5] Id.

[6] Id.

[7] Id.

[8] The White House, Trump Administration Response to the Final Recommendations of the President’s Commission on Combatting Drug Addiction and the Opioid Crisis, 1 (2017).

[9] Id.

[10] President Donald J. Trump is Taking Action on Drug Addiction and the Opioid Crisis, https://www.whitehouse.gov/briefings-statements/president-d https://www.whitehouse.gov/briefings-statements/president-donald-j-trump-taking-action-drug-addiction-opioid-crisis/Donald-j-trump-taking-action-drug-addiction-opioid-crisis/ (last visited May 19, 2018).

[11] President Donald J. Trump Is Combatting the Opioid Crisis, https://www.whitehouse.gov/briefings-statements/president-donald-j-trump-combatting-opioid-crisis/ (last visited May 19, 2018).

[12] Sarah Karlin-Smith, Congress Comes Back to a Raft of Opioid Bills, Politico, Apr. 9, 2018.

[13] Id.

[14] Statement of Dr. Carolyn Clancy, M.D. Interim Under Secretary for Health Veterans Health Administration (VHA) Department of Veterans Affairs (VA) before the Cmte. on Veterans’ Affairs, United States Senate, 2 (2015).

[15] Ken Blaker, Bandaging Veterans’ Pain with Opioids Is Proving Deadly, Must Stop, Observer, http://observer.com/2017/11/high-risk-for-opioid-abuse-veterans-become-fatalities-of-overprescription/ (Nov. 16, 2017).

[16] Sarah Childress, Veterans Face Greater Risks amid Opioid Crisis, Frontline, https://www.pbs.org/wgbh/frontline/article/veterans-face-greater-risks-amid-opioid-crisis/ (Mar. 28, 2016).

[17] Sonia Tagliareni, Veterans and Addiction, DrugRehab.com, https://www.drugrehab.com/addiction/veterans/ (May 11, 2018).

[18] Id.

[19] James Clark, The Best Effort to Fight Opioid Addiction May Be at This VA Hospital in the Center of America’s Epidemic, Task & Purpose, https://taskandpurpose.com/va-opiate-prescription-rates/ (Jan. 15, 2018).

[20] Id.

[21] Id.

[22] Id.

[23] Id.

[24] Id.

[25] Id.