Wednesday, December 8, 2010
Learn about the growing number of veterans who are reportedly abusing pain medication, and find out what military doctors are doing to address the problem.
By Rick Rogers - for The North County Times
Pain management is becoming a big issue among doctors treating veterans injured in Iraq and Afghanistan. Chronic pain is leading to prescription drug abuse and that has consequences, one of which can be homelessness. We'll hear what's being done to address the issue.
Harlan Bergum, is director of the Veterans Rehabilitation Center at the Veterans Village of San Diego.
Dr. Toby Moeller-Bertram, is an anesthesiologist and co-director of the Stress and Pain Unit at the VA Hospital in San Diego.
MAUREEN CAVANAUGH: I'm Maureen Cavanaugh, and you're listening to These Days on KPBS. The annual veterans' village winter homeless shelter opens today. The tent village will not only provide shelter for homeless vets but offer services in an effort to make positive changes in their lives. One of the many reasons that veterans become homeless is because of substance abuse. And among veterans of Iraq and Afghanistan, the substance that is increasingly abused is prescription drugs. It's a complex problem that has to do with the difficulty of pain management and the particular physical and emotional injuries that are being sustained in those wars. I'd like to introduce my guests, Harlan Bergum is director of the Veterans Rehabilitation center at the Veterans' Village of San Diego. And Harlan, good morning. Welcome to these days.
HARLAN BERGUM: Good morning, Maureen, thank you for having me on.
MAUREEN CAVANAUGH: And my guest, doctor Toby Moeller Bertram. He is an anesthesiologist, and direct offer of proof of the pain unit of the VA hospital in San Diego. Doctor Moeller-Bertram, welcome.
TOBY MOELLER-BERTRAM: Thank you. Good morning, Maureen.
MAUREEN CAVANAUGH: Now, Harlan, in an article published last week by the North County times, reporter Rick Rogers quotes the executive officer of Veterans' Village, saying there's been really a dramatic increase in young, homeless veterans, and many of them are addicted to prescription drugs. I'm wondering what's been your observation at the veterans' village in San Diego.
HARLAN BERGUM: Philly perceptions are very accurate. We are seeing an exponential increase in the relationship between prescription drug abuse and homelessness that is happening to our young vets much quicker than, let's say, the Vietnam era. And actually our numbers are increasing much quicker than we had anticipated with regards to bringing in young vets to our program.
MAUREEN CAVANAUGH: I read in this article by Rick Rogers that in the past you were thinking that it took, you know, years, several years for a decline in perhaps substance abuse in veterans to lead to homelessness. Now you're seeing kids, young men and women on the street after their service in the military almost only a year after they have been discharged. ; is that right?
HARLAN BERGUM: Yes. Oh, and I think there are a couple of factors, Maureen. One of them being our awareness. The Vietnam era taught us so much. So we're much more aware of what's happening to our vets. And I just want to give credence to that. I think the other piece is that our vets during this war, or Afghanistan and Iraq, are deployed much longer and more frequently. So they're exposed to a lot more of the traditional trauma and the physical trauma than previous vets have been. So it's impacting them much quicker. Does that make sense?
MAUREEN CAVANAUGH: Yes, it certainly does. Doctor Moeller-Bertram, as codirector of the pain unit in the VA hospital here in San Diego. What do you make of the report that the use of pain medication is something that's rising dramatically?
TOBY MOELLER-BERTRAM: Well, that's something that I can account for here too. It is, I think, a combination of the problem that we have an increased rate in PTSD syndromes compared to the gulf war conflicts in the past. And the comma bitty of pain symptoms of that. What comorbidity means is that you have a lot of combined pain problems so the need for treatment is there. And then combining that with the known risk of PTSD to cause abuse problems is just, I think, compounding this problem.
MAUREEN CAVANAUGH: And PTSD, of course, posttraumatic stress disorder.
TOBY MOELLER-BERTRAM: Yes.
MAUREEN CAVANAUGH: What is the connection between pain, chronic pain and Postraumatic Stress Disorder?
TOBY MOELLER-BERTRAM: At this point they're just theoretically models. We haven't really come down to the exact reason for that, the physiological under pinning. Two main models are proposed. One is called shared vulnerability. What that basically means is that factors that make you prone to develop PTSD has a very high overlap with factors that make you prone to develop chronic pain. And the other one is mutual maintenance, and what that means is that the factors in PTSD, or the behaviors and things that come with PTSD, negatively affect pain, and the other way around, if you have the chronic pain problems, it negatively affects and maintains your PTSD simple the so these are the two plain theoretically models explaining the comorbidity. And the other thing that researchers are looking into right now are the physiological changes that you have in PTSD. And what I mean by that are the changes that you see at hormonal levels and neuroendocrine levels so the way your body works in PTSD, can affect the nervous system that is transmitting the pain connection. So there may be a connection just on that level too.
MAUREEN CAVANAUGH: Doctor Moeller-Bertram, is there anything that the VA is doing? Does the VA address the number of vets who are abusing pain medications, prescription drug medications? Is the VA aware of this? What if anything do you know that they're doing about it?
TOBY MOELLER-BERTRAM: Absolutely. They are aware of the problem. And this is something that the VA is very much trying to address and focus on. The way that we do it here at the San Diego VA are several things, I would say. Number one is that we try to concert the treatment of PTSD and pain as much as possible. So if we see pain patients that get medications for treatment particularly the ones of high abuse potential like opioids, we make sure that we clear them with psychiatrists and we have them closely in the loop for the treatment. We do have a pharmacologist who is specialized in following patients with higher risk of abuse that we can refer to that the primary care doctor can refer to and that the psychiatry doctor can refer to. And also obviously we have addiction specialists that are aware of that problem. And they are available as a resource for both the patients and the treating physicians.
MAUREEN CAVANAUGH: I'm speaking with doctor Toby Moeller-Bertram, he is codirector of the VA pain unit at the VA hospital in San Diego, and Harlan Bergum, he is director of the Veterans' Rehabilitation Center at the Veterans' Village in San Diego. And we are talking about a rise in the abuse of prescription drugs, especially by veterans of the Iraq and Afghanistan wars. And I'm wondering, Harlan, where -- if this is indeed this increase in prescription medication abuse among a certain amount of veterans, where -- do you know where they're getting the medications.
HARLAN BERGUM: Well, in two places. When they're deployed, they're being prescribed medications. And of course, when they come out -- and I think the other issue that we see is the med sharing that happens with prescription drugs. That a lot of the vets will share, if they've got Vicodin orroxy contin with themselves, that they'll share that. So there's some liberalized use if that makes sense.
MAUREEN CAVANAUGH: Yes, it does, and thank you for answering the question. We do have a caller on the line. Victoria is calling from Encinitas. And good morning, Victoria, welcome to These Days.
NEW SPEAKER: Good morning, and excellent show as always.
MAUREEN CAVANAUGH: Thank you.
NEW SPEAKER: I want to make a point gently here, because I think it's an important one. I am a person who -- I have a chronic illness, neurological condition very much like MS which is quite painful. And so when -- you know, when there's a story about the use of pain medications, I listen for carefully. And I think we need to make the distinction between taking medications that are prescribed appropriately for physical conditions as opposed to people who are taking opioid medications for psychological relief.
HARLAN BERGUM: And uh-huh.
NEW SPEAKER: And those are two very different things. I take opioid and nonopioid medications, neither of which controls my pain civil. It's together which allows me to function, and be a productive member of society. And I'm not gonna break into your house and steal your stereo to gettoxy contin. So I think it's important that we make that distinction of people who are prescribed [CHECK AUDIO].
MAUREEN CAVANAUGH: Victoria, thank you. And let me get a reaction to that. Of that's a very fine line to tread, isn't it, doctor Moeller-Bertram?
TOBY MOELLER-BERTRAM: Well, not actually -- two points, I think, [CHECK AUDIO] and Victoria brought up a really good point there. Opioid medications are a corner stone for a lot of painful diseases and if used adequately and responsibly can be a very helpful tool. However, it is something that you have to -- you know, adhere to certain rules and regulations. And I think that the patients have to take their part of the responsibility. And what I mean by that is that, you know, sharing of drugs or using drugs for nonprescribed reasons, this is when we really talk about abuse.
MAUREEN CAVANAUGH: Right.
TOBY MOELLER-BERTRAM: Let me just make this quick point that we have a lot of returning veterans with PTSD, and we know that they have a significantly higher number of a lot of different chronic pain problems. So the fact that the PTSD people or the veterans with PTSD will end up getting more pain medications compared to veterans without PTSD just is based on that fact. And this is medication that is and will be prescribed for the absolute correct reasons. Now, what the opiates medications in particular often do have as a side effect, for example, is kind of like a sedation, [CHECK AUDIO] part, and this is exactly where, you know, PTSD veterans will see some sort of relief, but using a pain medication with the purpose of relieving pain to relieve either anxiety or hyper arousal, which is one of the main symptoms of PTSD, is not appropriate use. And this is whether the abuse of the medication comes into play. So just like Victoria said, using pain medications for pain treatment is adequate. But using it for something different, this is where we cross the line.
MAUREEN CAVANAUGH: And doctor, the line that I was mentioning before would be in -- you know, when a doctor prescribes let's say to a veteran who is experiencing chronic pain, the fine line that I was talking about is trying to address the issues of pain that the patient is suffering. But at the same time not going over, not prescribing too much. And yet if you don't prescribe adequately, the patient may take things into his or her own hands and begin to over medicate.
TOBY MOELLER-BERTRAM: Absolutely correct. And this is where I think that Doctor Law from the center of excellency at the VA has done the right step where we are trying to closely concert psychiatry and pain management. And I mean, there has been -- it's something that we've been doing here at the VA for quite a while. Where we try to really address patients' mild disciplinary, and also keep the primary care physician who is usually prescribing the medications close in the loop. We give them food back for it. And one thing that I think is gonna be very important to make sure that the veterans get their adequate pain control, but also, you know, don't get over prescribed or abuse it, that it is quite clear to both the treating physicians as well as to the veterans that opiate medications or medications with abuse potential come with a responsibility. And one way of doing that is, for example, to make what's called an opiate contract. Where you basically spell out that things like getting prescription medication from several different doctors and something that the patient has to not do, otherwise it would be inappropriate for them to get their medications. Because that's also a problem, referring to your question earlier about where patients get their medications from. You may have a patient getting the adequate amount of medications, but getting it from three different doctors issue each one of them not knowing that other people are writing for it too. And this is how you could, as a treating physician, do the right thing but end up being part of a best of my recollection problem for the veteran.
MAUREEN CAVANAUGH: Harlan bergam, as director of the veterans' rehabilitation center at veterans village, if a veteran comes in who has -- is struggling with an abuse problem, a prescription drug abuse problem or any kind of an abuse problem, what does veteran village have in terms of drug treatment and rehabilitation.
HARLAN BERGUM: Well, our problem is rather holistic, Maureen. We address, of course, the substance abuse issues, but we also have our mental health component where we address the occurring issues of we are both didactic and experiential in that we want our vets to go through a very serious program of education and application. We really take at a look through both the lens of the AOD perspective and the mental healtheg perspective and do comprehensive assessments on each area. And then we individually design the treatment plan for that person. The first phase usually lasts about a hundred and 20 days of the second phase around three months, and then the third phase is when they're starting to move towards independent living.
MAUREEN CAVANAUGH: Now, Harlan, is there anything that surprises you about what you're seeing about veterans at veterans' village these days.
HARLAN BERGUM: Yeah. I think the -- the piece that's pretty hard to regulate is what we're calling the moral injuries, that the vets are exposed to some pretty treacherous tragedies over in Iraq and Afghanistan. And most of the vets that we deal with, and I had in particular, have an emptiness about themselves, a spiritual emptiness that I totally understand their use and abuse of substances as a way to avoid that kind of emotional pain.
MAUREEN CAVANAUGH: And is there anything the veterans' village is doing to address that.
HARLAN BERGUM: Absolutely. We include that within your treatment program.
MAUREEN CAVANAUGH: I see.
HARLAN BERGUM: That's what I meant about being --
MAUREEN CAVANAUGH: The holistic. I see. And doctor Moeller-Bertram, there are reports, in fact, it was part of this article that I referred to in the North County times earlier, that the military has a certain pharmacological bent, that is that troops are medicated person the average person, and that has not to do with the level of injury, but just sort of like prescribing pills a lot. Do you think that's fair?
TOBY MOELLER-BERTRAM: That's actually a question where I can't make a very good statement. I see them back when they enter the VA system. And here I can tell you that there's no difference in terms of prescribing. We as pain specialists here at the VA also are part of the UCV system and see patients over at UCSD, and there's no difference in terms of approach or prescribing habits that we have specific for veterans. I am aware of the fact that the, you know, the military numbers of prescribing pain medications has gone up significantly over the last decade. But it would be too speculative for me to look or come up with any reasons for that.
MAUREEN CAVANAUGH: You work, though, doctor with trying to use psychiatry and other methods, alternatives to prescribing drugs for pain. ; is that right?
TOBY MOELLER-BERTRAM: Absolutely. I think there has been a -- rightfully so a pain treatment approach for the VA over the last several -- well, at least for the last decade, is what I can refer to, is that studies have shown over and over again, that if you address pain from multiple domains, the outcomes are just the best. Just like pain is a very complex problem that affects, you know, the emotional components, the habits, the daily life, the over all quality it is of a patient. If you have combine both interventional therapies that we over here, medication management, but also acupuncture, physical therapy, cognitive behavior therapy, and all that, you get the most effect. And research has shown actually it's just emerging for PTSD and pain, but I'm aware of some studies that have shown if you address PTSD symptoms, you can decrease pain problems. So I think the approach this we take here at the VA where we try to address both PTSD and pain when they are combined at the same time, would significantly help with both symptoms.
MAUREEN CAVANAUGH: Doctor, is there something bound Postraumatic Stress Disorder? Is there something about the injuries being received by Iraq and Afghanistan war veterans that lend themselves to chronic pain?
TOBY MOELLER-BERTRAM: Certainly. I think that the one thing that we see compared to conflicts, military conflicts in the past is that the, you know, the body armor has significantly improved for veterans. So a lot of injuries that have been nonsurvival in the past now lead to patients who have injuries causing chronic pain problems. Of the other thing is that treatment can be started early, but also increasing the pool of patients surviving, otherwise nonsurviving injuries. Besides that, I think the use of the roadside bombs improved, explosive devices and those kind of things are pretty prominent in the current conflicts with surfers and the kinds of injuries they cause, also cause a lot of soft tissue injury that basically make patients prone to that. And this is all related to injury related pain. The other thing with PTSD is you are more prone to develop chronic pain regardless of whether you sustained injury during comment.
MAUREEN CAVANAUGH: And doctor, my final question to you about this, and that is, are you also experimenting with the use of injectable pain medication rather than prescribing pills to a patient?
TOBY MOELLER-BERTRAM: Absolutely, it's actually not something that we're experimenting with. It's part of our comprehensive treatment. Exactly. Where we try to address pain problems that can be addressed with injections. A lot of spinal pain problems, disk problems, problems with little joints in your back, where we can do injections [CHECK AUDIO] we try to make this part of the treatment to, again, with the idea behind tackling the pain problems with many different tools that we have is gonna decrease the side effects and risk from one particular treatment and also is ultimately giving the veteran the best outcome.
MAUREEN CAVANAUGH: And Harlan Bertram -- Bergum. I'm sorry. I wanted to ask you about the veterans' winter village, veterans' winter village shelter opening today. What kinds of veterans are coming to veterans' village today for help.
HARLAN BERGUM: Do we see all ages.
HARLAN BERGUM: It is all ages. Although we're inanticipating -- [CHECK AUDIO] to peacetime to the gulf war. So it will be a wide range demographic.
MAUREEN CAVANAUGH: And how many vets does the shelter accommodate.
HARLAN BERGUM: We accommodate a hundred and 50 vets.
MAUREEN CAVANAUGH: I see. And for how long?
HARLAN BERGUM: From December today and through the end of March, I believe. Of.
MAUREEN CAVANAUGH: And will that be the same 150 all through that time, or do you have a turnover?
BERGUM: There's a turnover. We do allow them to retain their bed space. But if they should happen to relapse or come under the influence and are argumentive, they would be asked to leave.
MAUREEN CAVANAUGH: I see. Would you tell us what services available -- you told us about this holistic approach that you take to substance abuse. What other services are available at veterans' village.
HARLAN BERGUM: We have employment services, we also -- within the venue of treatment, we, as doctor berg tram was referring to, we've incorporated acupuncture, we use, MDR, we have expressive therapies. We've begun a collaboration with an equine therapy facility up in North County. And we also collaborate with San Diego state university through some music therapy issues.
MAUREEN CAVANAUGH: And forgive me, that equine therapy is with horses.
HARLAN BERGUM: Yes.
MAUREEN CAVANAUGH: Okay. I just wanted to make sure I understood that. Of.
HARLAN BERGUM: Yes.
MAUREEN CAVANAUGH: And are there any attempts perhaps to place some of these homeless veterans in more permanent facilities, in housing.
HARLAN BERGUM: That's our goal. That's our treatment goal. So a vet will come in home little and our goal is either to move them to more advanced transitional housing or their permanent housing in an apartment or a shared living environment.
MAUREEN CAVANAUGH: And I describe this as an open tent village. Is that what it is.
HARLAN BERGUM: It is one large tent structure.
MAUREEN CAVANAUGH: Okay. And where is the structure located.
HARLAN BERGUM: On the lobed off of Rosecranz. I don't have the exact address.
MAUREEN CAVANAUGH: That's okay. I'm sorry, Harlan, I didn't want to put you on the spot there. Do you know how many years this has been operating.
HARLAN BERGUM: Since 1997.
MAUREEN CAVANAUGH: All right. Well, I want to thank you both so much for speaking with us today. Doctor Toby Moeller-Bertram, thank you.
TOBY MOELLER-BERTRAM: Thank you for having me.
MAUREEN CAVANAUGH: And Harlan Bergum, thank you so much.
HARLAN BERGUM: Thanks Maureen.
MAUREEN CAVANAUGH: If you would like to comment, please go on-line, KPBS.org/These Days.