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Addressing Opioid Use Disorder and Transforming Pain Management in the VA

 

“But another development,” Drexler continued, “was that the opioids were included in patent medicines and were widely promoted for treating all kinds of pain – headaches, non-life-threatening types of painful conditions. So by the late 1800s, it was a huge problem that many in mainstream society were addicted. Congress felt compelled to act upon it, and passed the first laws restricting access to opioids, cocaine, and other potentially addicting substances.”

Other major opioid epidemics included the late 1950s and 1960s epidemic that involved heroin, Drexler said, “that made the headlines because of the life-threatening nature of this addiction – that people were dying of overdose. That led to the development of methadone as an effective and life-saving medication for treating opioid use disorder.”

acupuncture

Acupuncture is an alternative method of pain management that has received increased attention from the VA, which has worked with the Department of Defense to train health care providers in battlefield acupuncture.

The 1980s saw changes in thinking about pain management, with advances in cancer treatment and end-of-life care and emphasis on compassion and pain relief. With success in using opioids in those situations, which are closely monitored settings, Drexler said, “doctors began to feel more comfortable prescribing opioids. And then there were a few reports published in the medical literature suggesting that you could provide opioids safely for non-cancer, non-end-of-life care, and that patients would not develop addiction or other adverse events. Those were highly promoted. Doctors were told, ‘You just need to screen folks to make sure they don’t have a substance use disorder, and if they don’t, you can use opioids safely and effectively to treat all kinds of pain.’ And we did.”

Gallagher noted, “The other forces that were sort of pushing our society towards using opioids were the increased recognition that pain is disabling and the costs of pain to employers and to the country in terms of disability, but also the fact that the medical system was not really allowing providers the time, nor training them with the skills, to manage pain.”

Consequently, he continued, “With little time to do comprehensive evaluations, and with little training in terms of how to treat pain except with a pill as documented by the Institute of Medicine (IOM) in its 2011 study, ‘Pain in America,’ and the recently published National Pain Strategy, patients and doctors naturally went to that solution and continued that … so you ended up with a whole spectrum of people taking higher doses, which led to the problems of overdose and addiction.”

Additionally, Gallagher explained, access was minimal to treatments that could substitute for use of medications, like the psychosocial intervention of cognitive behavioral therapy (CBT), or complementary and alternative medicine treatments, like acupuncture, that are effective for pain. “So doctors didn’t know how to start those [treatments], how to get them paid for, and then in due course went to opioids and other pills more exclusively as their treatment of choice,” he said.

In a broad response to that concern, the VA is addressing pain management and tackling OUD with multiple efforts focused on prevention, treatment, and ongoing research.

So in that context, said Drexler, “Sales of opioid pain medicines increased dramatically starting in the early 1990s, and by 2012, the CDC recognized that that increase in sales was also followed by a parallel increase in the number of opioid overdose deaths and in the number of patients seeking treatment for an opioid use disorder. All of these had more than quadrupled over that period of time.

“That got everyone’s attention, and particularly here in the VA, we became concerned about veterans who were receiving opioid pain medicines and also who were at risk for opioid use disorder,” she said.

In a broad response to that concern, the VA is addressing pain management and tackling OUD with multiple efforts focused on prevention, treatment, and ongoing research.

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