December 6, 2017

Opioids are among the most commonly prescribed medications in the U.S. military for pain management. In a 2014 study, over 40% of the U.S. infantry reported chronic pain (here defined as pain lasting at least 3 months) after deployment, and 15% reported opioid use in the month prior to the survey.After combat deployment, soldiers report greater rates of both chronic pain and opioid use than does the civilian population. [1] Because of these high rates of chronic pain and opioid treatment, the misuse of opioid pain medication is a significant health concern in the military. Prescription drug abuse has been increasing at a greater rate in the military than in civilian populations over the past several years (though prescription opioid abuse is rising in both populations).[2] The military has responded to these risks with the Sole Provider Program and the Controlled Drug Management Analysis and Reporting Tool. These programs are used to identify and monitor risks and misuse of opioid pain medication.[3]

Medication-Assisted Treatment for Opioid Use Disorder in Veteran’s Health Care

In 2009, 39,032 patients in the Veterans’ Health Administration were diagnosed with opioid abuse or opioid use disorder, up from 26,818 in 2005.[4] Mirroring underuse of medication-assisted treatment (MAT) for opioid addiction in the US as a whole, some studies have estimated that less than half of diagnosed opioid-dependent patients receive specialty addiction care in the VA.[5] A 2011 survey of healthcare providers for veterans found that opioid-agonist therapies like buprenorphine and methadone are not always offered to veterans struggling with opioid abuse, despite the evidence that these medications are among the most effective treatments for opioid use disorder.[6] While methadone can only be administered at specialized treatment centers, buprenorphine has been approved for prescription by trained physicians in a variety of outpatient, office-based settings, including throughout the Veterans’ Health Administration. In the last decade, new policies have been put into place that require every VHA facility to have buprenorphine available as a covered medication to all veterans for whom the treatment is indicated, such as those whose needs cannot be met by OATP (Opioid-Agonist Treatment Program) methadone centers. In a 2007 survey of VHA medical personnel, there was still wide variability in whether treatment centers were prescribing buprenorphine or connecting patients with methadone clinics. Increasing access to OAT for opioid-dependent veterans has been an ongoing priority for the VHA Office of Mental Health Services (OMHS), and several active efforts have been started to increase buprenorphine acceptance and use in the VHA, such as training more physicians in the prescribing of buprenorphine.[7]

Opioid Abuse and Post-Traumatic Stress Disorder

Substance abuse disorders are common among both civilians and military personnel with Post-Traumatic Stress Disorder (PTSD). Studies have found that prescription opioid use is significantly associated with co-occurring PTSD symptom severity. PTSD patients are also more likely to use prescription opioids in combination with sedatives or cocaine. Females are more than three times as likely as males to have co-occurring PTSD symptoms and prescription opioid use problems. Younger PTSD patients (18-34 years old) are also at higher risk for opioid abuse.[8]

Treatments for opioid use disorder with PTSD

Finding the best treatment for patients struggling with both PTSD and opioid use disorder can be challenging. Patients may deny symptoms of PTSD until they develop trust in their medical provider.[9] Symptoms of PTSD and opiate dependence may also be hard to distinguish. For example, opioid withdrawal symptoms often look like the hyper-vigilance and heightened startle response of patients with PTSD. In fact, some researchers think that PTSD and opioid withdrawal may share the same neurobiologic circuit in the body. Individuals with prescription opioid problems are less likely to do well in treatment when they are also dealing with any kind of co-occurring psychiatric disorders, including PTSD. Opioid agonist therapy with methadone has been helpful in treating opioid addiction in patients with both PTSD and opioid use disorder. The use of buprenorphine has not yet been formally studied in this population, but may also be effective. Beyond medication, psychotherapy can also be very important in the treatment of PTSD. Specific kinds of cognitive behavioral therapy have been designed for individuals with both PTSD and substance abuse, such as the “Seeking Safety” approach.[10] [1]Toblin RL, Quartana PJ, Riviere LA, Walper KC, Hoge CW. (2014.) Chronic Pain and Opioid Use in US Soldiers After Combat Deployment. JAMA Intern Med. Jun 30. [2]Servies T, Hu Z, Eick-Cost A, Otto JL. (2012). Substance use disorders in the U.S. Armed Forces, 2000-2011. MSMR. Nov;19(11), 11-6. [3]Sharpe Potter J, Bebarta VS, Marino EN, Ramos RG, Turner BJ. (2014.) Pain management and opioid risk mitigation in the military. Mil Med. May;179(5), 553-8. [4]Gordon, A. J., Trafton, J. A., Saxon, A. J., Gifford, A. L., Goodman, F., Calabrese, V. S., . ., Liberto, J. (2007). Implementation of buprenor- phine in the Veterans Health Administration: Results of the first 3 years. Drug and Alcohol Dependence, 90, 292–296. [5]Dalton, A., Saweikis, M., & McKellar, J. D. (2006). Health services for VA substance use disorder patients. Comparison of utilization in fiscal years 2005, 2004, 2003, and 2002. Retrieved from http://www.chce .research.med.va.gov/pdf/2005Yellowbook.pdf [6]Gordon, A. J., et al. (2011). “Facilitators and barriers in implementing buprenorphine in the Veterans Health Administration.” Psychol Addict Behav 25(2), 215-224. [7]Gordon, A. J., et al. (2011). “Facilitators and barriers in implementing buprenorphine in the Veterans Health Administration.” Psychol Addict Behav 25(2), 215-224. [8]Meier A, Lambert-Harris C, McGovern MP, Xie H, An M, McLeman B. (2014.) Co-occurring prescription opioid use problems and posttraumatic stress disorder symptom severity. Am J Drug Alcohol Abuse.Jul 40(4):304-11. [9] PCSS-MAT Powerpoint. [10]Fareed A, Eilender P, Haber M, Bremner J, Whitfield N, Drexler K. (2013.) Comorbid posttraumatic stress disorder and opiate addiction: a literature review. J Addict Dis. 32(2), 168-79.