Waiting for Effective Pain Care at the VA

By Steve Pitkin, Guest Columnist

As a veteran of Vietnam and as a chronic pain sufferer, I am so glad that Pain News Network has been a consistent voice for 100 million Americans who are basically being told to "go off and die somewhere" by the DEA, CDC and other government agencies who are supposed to be protecting us.

I started on morphine, clonazepam and temazepam in 2001, and was constantly monitored by a team of psychiatrists, psychologists and my primary care physician at the VA Medical Center in West Palm Beach, Florida. I did not get "high" from the treatment, but it gave me a quality of life that I could not have with other medications.

I was in a car wreck after I retired from the military in 1997. In September of that year, I was taking my youngest daughter to an orthodontist appointment when our vehicle was hit by a truck right after a rain storm.

The crash seriously injured my daughter, who was clinically dead for over 6 minutes before being brought back to life by a helicopter rescue team. She still suffers from a traumatic brain injury, as well as pain issues herself.

The accident worsened the already extensive injuries to my cervical spine and lower back area. I started to lose strength in both arms, and a civilian doctor attempted an ulnar nerve release. That worked for about a week, before the pain and numbness came back.

STEVE PITKIN

STEVE PITKIN

I eventually moved to Montana and was treated by a new primary care physician at the VA clinic in Missoula. He and his nursing team were not very helpful, so I asked to be transferred to a new doctor last year.

I was called back to the clinic and was introduced to my new physician. He took one look at my medical records and said, “The amount of painkillers you are on is borderline medical malpractice and we're going to have to get you off of them as soon as possible."

I nearly hit the roof when he said that. I had three failed right knee procedures, my cervical and spinal pain had grown worse, and here he's telling me that I was a victim of too many painkillers?

I have been pretty much bedridden since my dosage of morphine and the other medications were reduced. I have also been told I need to have both knees and both shoulders replaced. However, I was refused surgery on my neck by a neurologist who said, “If I were to operate on you, the amount of painkillers you’d need would kill you. You need to get off the morphine and benzodiazepines first, then come see me."

I told the neurosurgeon that I was an ex-Green Beret medic and had already gone through surgery several times with no serious side effects. But I was talking to a blank wall.

I went to see another primary care physician about the problems I was having with the lower dosage. He laughed at me when I asked if he could raise the dose. “You signed this paper saying you agreed to it," he said while waving the paper at me.

I didn't have any choice in the matter. I was told either to sign it or be cut off altogether.

I have written to both the House and the Senate Veterans Affairs Committees and was told there was nothing they could do to help me. When I found out that Montana Sen. John Tester was on the Senate Committee that helped the VA pass these measures, I was livid and told him so.

I even emailed President Obama and received a reply from him, saying something to the effect that it was important to keep heroin off the streets and to stop illegal sales of prescription pain meds.

There’s no doubt about that, but we who need those medications are being lumped into the same pile with drug abusers. The veteran suicide rate is estimated 20 a day and many vets, as well as civilian chronic pain patients, have been forced into buying illegal drugs and are dying from them.

I have always been a patriotic American and didn't hesitate to volunteer for the draft when I was 18. But if I knew that the government I served for so long would declare me an enemy, I think I never would have gone into the military. If not for my strong faith as a Christian, I would have killed myself long before writing this.

I can only hope that President Trump realizes that waiting in line for healthcare is not the only problem with the VA, and that wars injure and maim people for life.

Was it all really for nothing?

Steven Pitkin lives in Montana.

Pain News Network invites other readers to share their stories with us.  Send them to:  editor@PainNewsNetwork.org

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Tougher Opioid Guidelines for U.S. Military and Veterans

By Pat Anson, Editor

It’s going to be even harder for U.S. military service members and veterans – especially younger ones -- to obtain opioid pain medication.

The Department of Veterans Affairs and the Department of Defense have released a new clinical practice guideline for VA and military doctors that strongly recommends against prescribing opioids for long-term chronic pain – pain that lasts longer than 90 days.

The new guideline is even more stringent than the one released last year by the Centers for Disease Control and Prevention (CDC).

It specifically recommends against long-term opioid therapy for patients under the age of 30.  And it urges VA and military doctors to taper or discontinue opioids for patients currently receiving high doses.

The 192-page guideline (which you can download by clicking here) is careful to note that the recommendations are voluntary and “not intended as a standard of care” that physicians are required to follow.

But critics worry they will be implemented and rigidly followed by military and VA doctors, just as the CDC guidelines were by many civilian doctors.

“I am concerned that many of these veterans with moderate to severe pain who may be well-maintained on long-term opioid therapy as part of a multidisciplinary approach or whom have already tried non-pharmacological and non-opioid therapies and found them insufficient will be tapered off their medication for no good reason except that their physicians will be fearful to run afoul of these new guidelines,” says Cindy Steinberg, National Director of Policy and Advocacy for the U.S. Pain Foundation, a patient advocacy group.

Although much of the research and clinical evidence used to support the new guideline was considered “low or very low” quality, a panel of experts found “mounting evidence” that the risk of harm from opioids -- such as addiction and overdose – “far outweighed the potential benefits.”

“There is a lack of high-quality evidence that LOT (long term opioid therapy) improves pain, function, and/or quality of life. The literature review conducted for this CPG (clinical practice guideline) identified no studies evaluating the effectiveness of LOT for outcomes lasting longer than 16 weeks. Given the lack of evidence showing sustained functional benefit of LOT and moderate evidence outlining harms, non-opioid treatments are preferred for chronic pain.”

The panel of experts was comprised of a diverse group of doctors, nurses and pharmacists within the Departments of Defense and Veterans Affairs, including specialists in pain management and addiction treatment. 

“We recommend against initiation of long-term opioid therapy for chronic pain,” reads the first of 18 recommendations of the expert panel, which said that only “a rare subset of individuals” should be prescribed opioids long term.

Instead of opioids, the panel recommends exercises such as yoga and psychological therapies such as cognitive behavioral therapy to treat chronic pain, along with non-opioid drugs such as gabapentin (Neurontin).

“In light of the low harms associated with exercise and psychological therapies when compared with LOT these treatments are preferred over LOT, and should be offered to all patients with chronic pain including those currently receiving LOT.”

Another strong recommendation of the panel is that opioids not be prescribed long-term to anyone under the age of 30, because of the damage opioids can cause to developing brains. 

“Some may interpret the recommendation to limit opioid use by age as arbitrary and potentially discriminatory when taken out of context; however, there is good neurophysiologic rationale explaining the relationship between age and OUD (opioid use disorder) and overdose.”

Of the seven studies used to support this claim, four were rated as “fair quality” and three were considered “poor quality.”

“That strikes me as an extremely weak evidence base for such a sweeping recommendation,” said Steinberg. “There is no mention of severity of pain condition which is extremely relevant in this population, many of whom sustained devastating and gruesome battlefield injuries such as blown off limbs.”

The panel recommends alternatives to opioids for mild-to-moderate acute pain. If opioids are prescribed temporarily for acute short-term pain, immediate release opioids are preferred.

Risk of Suicide Discounted

Pain is a serious problem for both active duty service members and veterans. A study found that nearly half the service members returning from Afghanistan have chronic pain and 15 percent reported using opioids – rates much higher than the civilian population.

The incidence of pain is even higher among veterans being treated at VA facilities. Over half suffer from chronic pain, as well as other conditions that contribute to it, such as depression and post-traumatic stress disorder. Even more alarming is a recent VA study that found an average of 22 veterans committing suicide each day.

The new guideline recommends that patients be monitored for suicide risk before and during opioid therapy, but curiously there is no mention that undertreated or untreated pain is also a risk for suicide. For patients being tapered or taken off opioids, doctors are advised not to take a threat of suicide too seriously.

“Some patients on LOT who suffer from chronic pain and co-occurring OUD, depression, and/or personality disorders may threaten suicide when providers recommend discontinuation of opioids. However, continuing LOT to ‘prevent suicide’ in someone with chronic pain is not recommended as an appropriate response if suicide risk is high or increases. In such cases, it is essential to involve behavioral health to assess, monitor, and treat a patient who becomes destabilized as a result of a medically appropriate decision to taper or cease LOT.”

Many patients could find themselves being tapered or taken off opioids if the guideline is taken literally by their doctors. The expert panel strongly recommends against opioid doses greater than a 90 mg morphine equivalent (MME) daily dose and urges caution for doses as low as 20 MME. 

“This again fails to recognize that patients differ widely in severity of pain, individual response to medication, body size and weight and tolerance for pain,” says Steinberg.

“I worry that, as we have seen with the CDC guidelines, clinicians will begin tapering patients who may be well-maintained on stable does of medication for fear of running afoul of sanctioned limitations rather than being guided by what is best for their patients. These limitations are in direct conflict with FDA approved labeling which is based on safety and efficacy trials and does not include dose thresholds.”

The VA and Department of Defense opioid guideline will affect millions of service members, veterans and their families. Nearly 1.5 million Americans currently serve in the armed forces and over 800,000 in the National Guard and Reserves.  The Veterans Administration provides health services to another 6 million veterans and their families.

The guideline is the second major initiative by the federal government so far this year aimed at reducing opioid prescribing. As Pain News Network has reported, the Centers for Medicare and Medicaid Services (CMS) has announced plans to fully implement the CDC’s opioid prescribing guidelines.

CMS is taking those voluntary guidelines a step further by mandating them as official Medicare policy and taking punitive action against doctors and patients who don’t follow them. CMS provides health insurance to about 54 million Americans through Medicare and nearly 70 million through Medicaid.

Wide Disparity in Opioid Doses in Veteran Overdoses

By Pat Anson, Editor

The difference between controlling chronic pain and risking an opioid overdose can vary widely from patient to patient, according to a new study that found the threshold for safe prescribing may be lower than many doctors think.

Researchers at the University of Michigan Medical School and the Veteran Administration’s Ann Arbor Healthcare System studied the medical records of 221 veterans who died from accidental opioid overdoses and compared them to an equal number of veterans who took opioids for chronic pain, but did not overdose.

The average dose that the overdose victims had been prescribed was over 70 percent higher than what the comparison group received. The average daily dose for the overdose patients was 98 MEM (morphine-equivalent milligrams), compared to about 48 MEM for those who did not overdose.

But the researchers did not find a specific dose that clearly differentiated between patients at risk and those not at risk for overdose. In fact, some overdose victims had prescriptions for well under 50 MEM daily.

Despite that discrepancy, the researchers recommend lowering the recommended dosage threshold below 100 MEM. Lowering the number of high doses, they say, would help more people than it hurts.

“As the United States grapples with the rising toll of accidental overdoses due to opioids, our findings suggest that changing clinical practices to avoid escalating doses for patients with chronic pain could make a major difference in the number of patients who die,” said first author Amy Bohnert, PhD, an epidemiologist at the University of Michigan.

Bohnert was part of the “Core Expert Group” that helped draft the CDC’s controversial guidelines for opioid prescribing. Two co-authors, Joseph Logan and Deborah Dowell, work at the CDC’s National Center for Injury Prevention and Control, which oversaw the guidelines’ development.

The CDC guidelines recommend that primary care physicians start at the “lowest effective dosage” of opioids and should avoid increasing dosages over 90 MEM. Even a daily dose as low as 50 MEM increases overdose risk, according to the guidelines.

“Avoiding prescribing large doses also has the benefit of reducing the amount of the medications going to patients’ homes that has the potential to be taken by others who live with the patient, like children and teenagers,” said Bohnert. “This is important because an opioid that is a larger dose per pill, compared to a smaller one, is going to be deadly to a child or adult who hasn’t been taking the medication regularly.”

The study, which was funded by the Veterans Administration, is published in the journal Medical Care.

The study was based on the veterans’ medical, pharmacy and death certificate records. It did not include those who died by suicide using opioids, or veterans receiving hospice or palliative care.

Veterans were selected only if they filled a prescription for an opioid medication and had a diagnosis of chronic pain during the years 2002 to 2009. The researchers included veterans who had been prescribed codeine, morphine, oxycodone, hydrocodone, oxymorphone, hydromorphone, fentanyl, meperidine, pentazocine, propoxyphene, or methadone.

Under a federal spending bill passed by Congress and signed into law by President Obama, the Veteran’s Administration is required to follow the “voluntary” CDC opioid guidelines. The VA provides health services to 6 million veterans and their families. Over half of the veterans treated by the VA are in chronic pain.   

VA to Adopt CDC Opioid Guidelines

By Pat Anson, Editor

The massive $1.1 trillion spending bill passed by Congress and signed into law by President Obama last week contains an early Christmas present for the nation’s veterans.

Or it could be a lump of coal -- depending on your view about opioid pain medication.

Buried in the 2,009 page document is a provision requiring the Veteran’s Administration to implement a number of measures to stop the “overdose epidemic” among veterans, including adoption of the controversial opioid prescribing guidelines being developed by the Centers for Disease Control and Prevention (CDC).

Those guidelines, which discourage primary care physicians from prescribing opioids for chronic pain, have now become official government policy at a federal agency before they’re even finalized. 

“To address mounting concerns about prescription drug abuse and an overdose epidemic among veterans, the bill directs VA to adopt the opioid prescribing guidelines developed by the Centers of Disease Control; to develop IT systems to track and monitor opioid prescriptions; to ensure all VA medical facilities are equipped with opioid receptor antagonists to treat drug overdoses; and to provide additional training to medical personnel who prescribe controlled substances,” Sen. Barbara Mikulski (D-Maryland), Vice Chairwoman of the Senate Appropriations Committee, said in a summary of the omnibus bill sent to colleagues.

The VA was also instructed to report to Congress within 90 days on alternative treatments to opioids, as well as “how VA can better facilitate the use of safe and effective complementary and integrative health therapies for pain management.”  

The CDC, which recently delayed implementation of the opioid guidelines after widespread criticism from patients and advocacy groups, has repeatedly said the guidelines are “voluntary” and not intended for anyone other than primary care physicians.

But adoption of the guidelines by a federal agency that provides health care services to over 6 million patients is an early sign they will have a much broader impact, voluntary or not. Critics have warned that state regulators, licensing boards and professional medical societies could also adopt the CDC's guidelines, which would likely have a chilling effect on all doctors who prescribe opioids.

"This is disturbing. It doesn't help solve the opioid problem by codifying low evidence or no evidence recommendations," said Lynn Webster, MD, past president of the American Academy of Pain Medicine.

"The opioid crisis is serious, requiring thoughtful interventions that are evidence based.  There are many evidence based recommendations that could be promulgated but have been ignored.  I am very concerned that the soldiers who have sacrificed so much are not going to receive the treatment they deserve."

According to an Inspector General’s study, more than half of the veterans being treated at the VA experience chronic pain, as well as other conditions that contribute to it, such as post-traumatic stress disorder. Because veterans are at high risk of opioid abuse and overdose, the VA implemented the Opioid Safety Initiative in 2013 to discourage its doctors from prescribing the drugs. The number of veterans prescribed opioids fell by 110,000, but alarms were raised when some vets turned to street drugs or suicide to stop their pain.

"Veterans are now required to see a prescriber every 30 days, but at the El Paso VA, they are unable to get an appointment, so they go without, or they do something they shouldn't — they buy them on the street," Rep. Beto O'Rourke, (D-Texas), told Military Times. “At a minimum, these veterans are suffering and in some cases, I would connect that suffering to suicide."

Several veterans have written to Pain News Network recently about their difficulty obtaining opioids from the VA for their chronic pain.

“The VA will only prescribe 10 mg oxycodone 3 times a day. This gives me no relief at all and now I'm very worried about what may come next,” wrote an Army veteran with diabetic nerve pain who had a toe amputated. “When I asked to have this increased my VA PC (primary care) doc raised my gabapentin script and says if that doesn't work for my increased pain levels we may try Lyrica next . He ignores my statement that 15 mg of Oxy works in reducing my pain by 30%”

“After taking opiate pain meds for nearly 15 years, the VA has now decided to take them away. I had a decent life while on these, and now they have cut them in half, I am in constant pain. I wish some of these people that make these stupid decisions had to live like I do,” a Vietnam veteran who had a leg amputated above the knee wrote to PNN.

“The pain meds allowed me to have some semblance of a normal life. Now that is gone. I don't know what I am going to do. I can understand now why vets turn to alcohol and other street drugs, because you have to do something to take the edge off this constant pain. But do they care? Not one whit. They practically throw this stuff at you when I first started going, now it is up to me to figure out how I am going to make it without any of it.”

The federal spending bill provides $7.2 billion in funding for the CDC, which is $278 million more than last year.  That includes $70 million to support state efforts to address prescription opioid abuse – more than triple the amount included in last year’s bill. 

The bill also provides $3.8 billion to the Substance Abuse and Mental Health Services Administration (SAMHSA), which is $160 million more than last year.  Nearly $50 million is directed to address the “epidemic” of prescription drug and heroin overdose, $25 million is for addiction treatment in high-risk states, $12 million for naloxone distribution in 10 states; and $10 million for drug abuse prevention efforts in up to 20 states.