Over the last several years, the health care community, the federal government, and the media have focused enormous attention on the epidemic of overdose deaths from opioids – including prescription opioid pain relievers and heroin – in the United States. According to the Centers for Disease Control and Prevention (CDC), more people died from overdoses in 2014 than any year on record, with more than 60 percent of those involving an opioid and half of those involving a prescription opioid.
An historical perspective helps to explain the context and precipitating factors of the current epidemic. “Opioid use disorder in the United States has a long history. “The first epidemic in this country was in the late 1800s, and like with the current epidemic, it was multi-factorial.”
The vast topic of pain management is inherent in addressing the opioid problem, and the Department of Veterans Affairs (VA) has concentrated significant effort to develop system-wide approaches to both transforming pain care in the VA and in preventing and treating opioid use disorder (OUD) among veterans.
In addition to the alarming rates of overdose deaths, chronic pain as a major public health problem has also gained increased attention. “Approximately 30 percent of the U.S. adult population have some kind of chronic pain, and it’s much higher in the VA – 50 to 60 percent,” according to Rollin M. Gallagher, MD, MPH, national program director for pain management for the VA and clinical professor of psychiatry and anesthesiology at the University of Pennsylvania.
The VA has seen a huge influx of patients from recent wars who were exposed to extreme battlefield environments. In addition to experiencing severe musculoskeletal injuries, Gallagher explained, veterans have survived blast injuries due to advanced far-forward emergency medicine care, but now return with traumatic limb and facial injuries as well as nerve damage and traumatic brain injury. All these injuries cause pain, which can be compounded by psychological effects of battlefield exposure and post-traumatic stress disorder (PTSD). And, Gallagher said, “We have Vietnam veterans who are developing all the diseases of aging that cause pain. A whole confluence of things make the challenge even more daunting in the VA system.”
A Civil War soldier displays a battle wound to his arm. The problem of wounded service members managing pain with opioids and subsequently becoming addicted has a long history. Library of Congress photo by Henry Ulke
And that complex challenge involves not just pain management, but also opioids and OUD. “The risk of opioid use disorder is a growing problem in the VA over the same period of time that it has been for the larger U.S. population,” said Karen Drexler, MD, acting national mental health program director for addictive disorders in the VA and associate professor of psychiatry at Emory University. “There are similar factors contributing to that as well as some that are unique to veterans. People with post-traumatic stress disorder are at increased risk for developing substance use disorders (SUD), and we know from our own internal VA data that that is certainly true among veterans as well.”
An historical perspective helps to explain the context and precipitating factors of the current epidemic. “Opioid use disorder in the United States has a long history,” said Drexler. “The first epidemic in this country was in the late 1800s, and like with the current epidemic, it was multi-factorial.”
Among those factors, Drexler said, was an accelerated development of new chemistry technology, which allowed isolation of the active ingredient from the opium poppy to develop new medicines like morphine. Injured Civil War soldiers were able to survive what previously would have been fatal injuries by enhanced surgical techniques and improved pain control, but some became addicted to the morphine.