In addition to pain management education, Drexler pointed to another prevention effort. “We have been increasing our screening [for SUD] by teaching primary care providers and others who are managing pain about opioid use disorder, its risk factors, how to recognize signs and symptoms, and how to make appropriate referrals for treatment of opioid use disorder,” she said. This is in conjunction with integrating onto the primary care team mental health professionals, who can assist with making a diagnosis of OUD if appropriate and with bringing addiction medicine into pain management.

In addition to prevention strategies and education to reduce the risk of OUD, Drexler said another of their targeted efforts in the VA is to increase access to medication-assisted treatment for those diagnosed with OUD.

With the significant challenges and broad scope of combating the serious problem of OUD, the VA has already seen positive effects from its efforts, and continues those efforts on multiple fronts.

“We follow the VA/DOD clinical practice guidelines, which were just updated in 2015 based on systematic reviews of the evidence using the well-respected GRADE methodology for reviewing the literature and developing recommendations based on evidence,” said Drexler. “And that guideline recommends for opioid use disorder medication-assisted treatment using either buprenorphine/naloxone [which is] also known by the brand name Suboxone, methadone provided through a federally regulated opioid treatment program (OTP), or extended release injectable naltrexone.”

The good news for veterans, Drexler said, is that the medications that can be prescribed – buprenorphine and injectable naltrexone – are available through the VA national formulary. For methadone treatment, the VA has 32 OTPs at facilities nationwide, but many veterans also receive treatment in non-VA community OTPs. Even with increased demand for treatment, Drexler said currently approximately 34 percent of veterans diagnosed with OUD receive medication-assisted treatment, up from about 26 percent when the effort began.

Research is another essential component in focusing on pain and OUD. “We have a very robust team research enterprise,” Gallagher said, regarding VA research on these topics. Funding for pain relevant research for FY 2016 is approximately $31 million supporting more than 100 projects, with an additional $20 million for SUD research. “There’s an overlap, too, because some of our pain research is about opioids. So it’s a nice confluence of efforts,” he said.

Projects include studies ranging from the mechanism of pain itself to opioid use and how to prevent it with interventions such as a combination of CBT and meditation, for example. The research leads to opportunities for trials to develop new treatments, with implementation research – where a new approach based on a clinical trial can be evaluated not only by research evaluation instruments, but also by its effect on patients’ clinical behavior in a facility setting – being an important part of the portfolio.

Regarding SUD research, Drexler said, “Areas where we can learn more, and we’re actively researching, are things like preventing overdose death through our opioid Overdose Education and Naloxone Distribution program (OEND).” A component of the OSI, the OEND distributes naloxone rescue kits to VA facilities and families and trains them in their use to reverse opioid overdose.

“We have distributed over 35,000 naloxone rescue kits,” said Drexler, adding that they have at least 173 reports of rescues nationwide in a voluntary reporting system.

There are many challenges in providing the necessary care to veterans with pain or SUDs. “One of the biggest challenges for us in SUD treatment is getting that treatment out to veterans, particularly in rural areas and at small clinics,” said Drexler.

Gallagher agreed, noting that it’s crucial to have the ability to utilize technology to reach veterans “who may be distant or have trouble getting to the hospital because of their injuries, pain, or disabilities. So we’re working on telemedicine, tele-health, e-consultation, all sorts of ways of doing these things.

“For example,” he said, “we do have cognitive behavioral therapy for pain that can be done over the telephone. And we’ve done research to show that actually works. So access to our multi-modal integrative care is one big challenge in making sure that we have those kinds of assets available to our patients.”

Another challenge is rehabilitation, “and getting patients who are very complex the kind of intensity of care that they need to really get back to a quality of life and functioning that they desire,” said Gallagher. “We’ve been very successful in the VA in developing CARF [Commission on Accreditation of Rehabilitation Facilities] accredited rehabilitation programs for chronic pain. We’ve gone from two in 2010 to over 20 currently, and a couple more are in development across the country. These facilities care for more complex patients including some of those with substance use disorders as well as pain, but others with just severe, chronic, disabling pain.” Some are inpatient programs and others are domiciliary with patients coming in for intensive treatment during the day, and, Gallagher said, are very successful at getting people back to functioning again.

But, Gallagher summarized, “I think the big challenge we have, like the nation, is a large number of patients on opioids who may need to be tapered from their opioids to lower doses, or off the medications, and get on to a more comprehensive self-management and integrated team management approach to their pain care. And that’s always a challenge because it’s hard work, particularly for those who have substance use disorder.”

With the significant challenges and broad scope of combating the serious problem of OUD, the VA has already seen positive effects from its efforts, and continues those efforts on multiple fronts.

This article was first published in Veterans Affairs & Military Medicine Outlook magazine.