MAUREEN CAVANAUGH: This is KPBS Midday Edition, I am Maureen Cavanaugh. Our top story on Midday Edition, the VA hospitals are dedicated to relieving suffering and helping veterans overcome the wounds of war, but one method used to treat this promises to become a problem of its own. The Veterans Administration is noticing the fact that addiction to painkillers is increasing among veterans; addictions that can lead to death. Doctors within the system say they are developing alternatives to prescription drugs to manage pain, but this is a challenge for both doctors and veterans struggling to deal with pain problems. I would like to welcome my guest Doctor James Mickelson, welcome to the program. And Jack Lyon is founder of Veterans Village in San Diego. Welcome to the program. Doctor Mickelson, the prescription drugs causing the most concern are opioids, what kinds of drugs are these and what are they prescribed for? JAMES MICHELSEN: Opiate medications are short acting medicines such as methadone and OxyContin, Vicodin or Percocet. They are used to both treat acute and chronic pain, and the shorter acting medicines are the ones that patients are more likely to run into problems with. MAUREEN CAVANAUGH: Last year the Center for investigative reporting studied what kinds of painkiller prescriptions were being written at the VA health systems, and so VA systems there are writing enough prescriptions being written to cover every patient that the system actually sees, how does San Diego compare with that? JAMES MICHELSEN: The San Diego VA uses opiate painkillers for about 17% of our patients. Any prescription drug per year. We use a lot of opiate pain prescriptions and the number in San Diego is lower than in the national, but we still use a paramount of opiate pain pills. When we look at the 76,000 veterans that we have, 13,000 who have received opiate pain pills within a year. MAUREEN CAVANAUGH: Another statistic recently found by the American Medical Association that veterans suffering from PTSD are more likely to be prescribed pain killers, why is that? JAMES MICHELSEN: someone with PTSD is four times more likely to wind up on opiate painkillers and there are several reasons, posttraumatic stress disorder changes the way that pain is perceived. Someone with PTSD perceives more pain. They are more likely to not have success with other treatments. So it is a challenge when our America's heroes return with posttraumatic stress disorder and end up on opiate painkillers more often. Additionally someone with PTSD may not have only suffered mental consequences of war, but physical consequences as well. MAUREEN CAVANAUGH: During an emotional testimony last year, the testimony about people who had abused painkillers that they received from the VA and one of the wives of the man who ultimately died because he was addicted to painkillers she said that the VA wants to keep patients ìdoped up and happy,î how do you respond to that? JAMES MICHELSEN: I think the words ìwant to keep patients doped up and happyî is a little to the extreme, but over the last 10 to 15 years, pain experts not only at the VA but nationwide have really pushed for more opiate use. The initial thought is that opiates work really well for treating cancer pain, why are we not using them for more for noncancer pain? Because of that prescriptions have gone up 300%. The VA nationally is looking at the side effects of opiates which can include sedation and mental slowing. They realize that we need to scale back on opiates especially high-end doses. That can cause those problems. MAUREEN CAVANAUGH: What kind of impact have painkillers had on the veterans like at Veterans Village? JACK LYON: What happens sometimes is the kids do not go through the entire treatment program and will bounce off for one reason or another, and that can have a devastating impact on the body and that is important to recognize. This is not a moral issue, are you a good or bad person, are you strong or weak, we start down this path pretty soon, the medicine will take you, rather than you taking the medicine. That is the fear. What happens, if you bounce out of the system you will want the same sort of pain relief and from an economic point of view, heroine is a better answer. There you go. Occasionally the kids that we get into the Veterans Village are homeless and they have problems with drugs or alcohol, that is an impact that can come from this and I think the answer or part of the answer is education. Knowing that when you write the script or when you as the husband of the young lady and start taking this for a good medical reason you have to understand that sooner or later you're going to probably have to wean off of it and understand that the consequence of this can be very deleterious. MAUREEN CAVANAUGH: How easy is it to get addicted to these kinds of painkillers and our veterans are informed enough to dangers of addiction? JAMES MICHELSEN: There are two separate issues we're taking opiates one is addiction and what is tolerance. Tolerance is something that occurs when someone has been taking opiates for a while in the body gets used to them. That happens to most people that take higher doses and when you stop, you have withdrawal symptoms just like someone who drinks 6 cups of coffee a day will have withdrawal if they suddenly stop coffee. That happens to most people and as far as addiction, addiction is someone where someone is taking medication for reasons other than pain and that can happen oh happen to a lot of people but is more likely to happen to someone who has PTSD or traumatic brain injury. MAUREEN CAVANAUGH: There is a new program that started at the San Diego Veterans Administration to reduce prescription painkillers and it is now being tried nationally. What does that consist of? JAMES MICHELSEN: It's called the opiate safety initiative and it has nine parts. The first part is to educate providers, the pain community has been increasing opiates for years and now the new tinnitus chose to do this dangerous especially in the high-end and the fullback. The rest of the initiative is to collect data about our individual veterans and how many of them are high in high-dose therapy is and how many are mixing opiates with other prescriptions such as Valium, and then monitoring how we're doing it keeping track of the prescription use in ensuring that it is as safe as it can be such as measuring toxicity screens to make sure that you are not bring in other substances that bring you into a higher risk of overdose. Each VA is being asked to look at each patient and weigh risk and benefit. MAUREEN CAVANAUGH: You are also trying to get people to find new ways of managing pain? JAMES MICHELSEN: Absolutely. There are many studies over the last two years that show a bio-psychosocial model where we look at the whole individual more successfully for pain treatment rather than just prescribing a painkiller. You want to look at their mental health and coping skills and nutrition are extraordinarily important for pain. Getting exercise, it's more challenging to treat pain then prescribing medicine but it's a better way of fixing pain. MAUREEN CAVANAUGH: We will have a story to address this issue on our home page, pain killers may not be the right prescription for veterans, there is more in that article than we could touch in this interview. I would like to thank my guests very much, James Michelson and Jack Lyon. Thank you very much, you've been listening to KPBS Midday Edition.
If you use the universal 10-point pain scale to measure concern about the thousands of San Diego County veterans facing addiction to prescribed painkillers, you reach about a seven. That’s the estimate from officials at the VA San Diego Healthcare System.
That equates to moderate to severe pain and requires prompt attention, which is why the Veterans Administration in San Diego is taking steps to help veterans manage their pain and their painkillers.
Studies show that a high percentage of veterans are in chronic pain, particularly those who served in the Iraq and Afghanistan wars. They’re often prescribed opioids, which are effective painkillers, but the drugs can also lead to dependency and addiction.
Last month, the American Academy of Pain Medicine released a study that for the first time found that more than half of the 1 million veterans prescribed painkillers took them for 90 days or longer.
“That’s the challenge,” said Dr. James Michelsen, a primary care physician at the San Diego VA. “Remove the drugs without leaving the veterans in pain.”
Michelsen is the San Diego coordinator of the VA’s new opioid reduction program that went nationwide in late February.
VA officials are trying to dial back opioid use, which has nearly tripled throughout their system in the past decade while more than doubling within the VA San Diego system.
“It’s a substantial problem,” Michelsen said. “No doubt about it.”
The numbers bear him out.
Roughly 13,000 of the 76,000 veterans enrolled at the VA in San Diego are on prescribed painkillers, according to the healthcare system. Nearly 5,000 veterans fill recurring prescriptions for the drugs, putting them at particular risk of becoming hooked on the drugs.
A red flag that these prescription medications were ravaging the U.S. veteran population came in 2011, when researchers found vets dying of narcotic overdoses at more than twice the national average.
That same year the Centers for Disease Control and Prevention named painkiller abuse a national epidemic. The White House launched a campaign to reverse a trend that saw misuse of prescription drugs, misusage become America’s fastest-growing drug problem.
Meanwhile at the Department of Veterans Affairs, prescriptions for hydrocodone, methadone, morphine and oxycodone -- all widely used and highly addictive painkillers, or opioids -- had surged 270 percent, while its patient pool had increased just 41 percent in the preceding war-weary decade.
Hearings On VA And Painkillers
Last fall, congressional hearings into the skyrocketing use of doctor-approved opioid analgesics by the VA revealed still more concerns.
A former VA doctor in Virginia testified she was ordered to prescribe the painkillers against her medical judgment and was fired in 2010 when she objected. Four of her colleagues would later tell investigators they felt pressure to prescribe narcotic prescriptions to patients not assigned to them.
Veterans And Their Pain
In 2013, the Wounded Warrior Project surveyed nearly 14,000 veterans who suffered injuries during their military service. Nearly 99 percent of those who responded were wounded post-Sept. 11, 2001. Here are the group’s findings:
• 63 percent had been hospitalized because of their wounds or injuries.
• 68 percent had suffered blast injuries.
• 17 percent suffered bullet or shrapnel wounds.
• Nearly 61 percent of those hospitalized for their injuries said their bodily pain interfered with their normal work (work outside the home and housework) moderately, quite a bit, or extremely.
Other witnesses told a House Veterans’ Affairs subcommittee that the drugs were killing some veterans while turning others into drug addicts.
“Keeping our men and woman doped up to keep them quiet and happy is not treatment. It is cruelty and torture and in too many cases it’s manslaughter,” Heather McDonald told lawmakers.
She is the widow of Iraq and Afghanistan veteran Scott McDonald, who died from an accidental overdose of anti-depressants and pain drugs prescribed him by the VA.
Justin Minyard, a medically retired soldier, added at the hearing, “I started an intense opioid pain medication regimen. The metaphor I think best gives people an idea of what it is like is: Once I started on high-dose, opioid pain pills, once that train left the station, it was going 1,000 miles an hour and wasn’t making any stops.
“At my worst point, I was taking enough opioid pain medication to treat four terminally ill cancer patients. My dependency happened so fast. It felt like I blinked, and then I looked up and my life revolved around getting my fix.”
Compounding the prescription drug problem among veterans, the witnesses testified, is the penchant by VA doctors to dispense large quantities of powerful pain pills with little monitoring, while offering few, if any, alternatives to pain relief.
“VA’s Band-Aid approach to suppressing the symptoms of pain rather than treating the root causes must stop,” Rep. Dan Benishek, R-Mich., said at the October hearing. Benishek chairs the House Veterans’ Affairs Subcommittee on Health and was a doctor at the Oscar G. Johnson VA Medical Center in Michigan.
The VA issued a statement on painkillers that read in part:
“There's a great national effort now, both within and outside the VA, to draw attention to the concerns that we have about prescription opioid medications. We want to continue to promote access to these medications, but in a way that is safe or at least mitigates risk.
"In addition, VA has uniform guidelines and procedures for providing pain management care in compliance with generally accepted pain management standards of care. These guidelines are currently being reinforced with additional measures to support safe opioid prescribing through further education and training of clinicians, facility leadership and patients."
Veterans Particularly At Risk
While issues linked to painkillers aren’t confined to former service members, as a group they are particularly vulnerable to dependency and misuse.
More than half the veterans the VA treats complain of pain. Vets also suffering from post traumatic stress or depression are not only more likely to be prescribed narcotic painkillers then their peers but are also more prone to over-medicate with painkillers in sometimes deadly combination with psychotropic drugs, especially benzodiaepines.
Drug withdrawal from these prescriptions is often harsh and accompanied by depression and insomnia that can last for months and spark veterans to turn to substitute drugs or alcohol.
Even when the painkillers are used as directed, the chances of veterans – or anyone – becoming dependent upon them is high after just a few weeks of daily use, according to the Physicians for Responsible Opioid Prescribing.
On average, veterans are on these addicting medications far longer than a few weeks before seeing a pain specialist.
The alarming degree to which the VA and its veterans have become dependent on painkillers was underscored in September when the Center for Investigative Reporting found that many, if not most VA medical centers, wrote more than 100 opioid prescriptions for every 100 patients. That’s a nearly 300 percent increase in the past 10 years.
It’s a trend that VA medical centers nationwide are struggling to curb, including the one in San Diego, where the painkiller prescription rate is 70.2 for every 100 patients, according to the CIR report.
This is a 210 percent jump in the past decade for a healthcare system that treats about 27,000 Iraq and Afghanistan veterans – the largest population of its kind in the nation.
Pain Treatment Alternatives Tried in San Diego
Jack Lyon, a founder of the Veterans Village of San Diego and a volunteer mentor to troops being treated at San Diego Naval Medical Center, said it’s not surprising that people become addicted to painkillers even after just a few weeks of use.
“What people need to know about this is that it’s not about willpower or character. It’s about your body. There’s not a whole hell of a lot you can do about it,” Lyon said. “The pills don’t care who you are or who you think you are. Everyone in the medical profession knows this. At first you take the drugs and then the drugs take you.”
He said painkiller addiction had become an issue with some of the seriously wounded being treated at the Naval Medical Center. The center now has a policy outlining how the men and women will be weaned off the drugs before they are even prescribed.
“Addiction to painkillers was a real problem until we (as volunteer mentors) sat down with all involved and explained up front to the warriors that they could expect to become addicted,” Lyon said. “But we told them we would be there for them with medical supervision when it was time to detox, and that they wouldn’t have to go cold turkey on their own.”
Michelsen at the VA uses the word “challenging” often to describe the difficulty in convincing veterans, long accustomed to pilling their pain away, that non-drug alternatives work better and are much safer in the long run.
“If you look back 10 to 15 years, pain experts really believed that we were under-treating pain and that patients were being left in pain, and that opiates weren’t being used enough and they really encouraged their use,” Michelsen said.
“With 10 years of experience of using more and more opiates, the pain world has been able to look back and collect data,” Michelsen said. “And what they’ve really found is the use of higher-dose opiates many times causes more harm than good.”
Army veteran Beverly McNeil, 55, knows first-hand the dark path that painkiller abuse can lead someone down. Two overdoses, a crippled marriage, a failed rehab stint and a lost career led her to a treatment program at the Veterans Village of San Diego in November.
“I didn’t feel I could live without the pain pills before I came here,” said McNeil, who had struggled with prescription narcotic addiction for years but hit bottom after getting painkillers last year from the VA for knee pain.
“I’d take five or six pills two or three times a day. I was so high that I couldn’t read a book or have a complete thought,” McNeil said.
Now, she said, after months of therapy, exercise and acupuncture, she’s more pain free than she ever was during her medication days.
“You can’t live the rest of your life on narcotics,” McNeil said. “Prescription pain pills are not the answer, believe me.”
San Diego and other VA medical centers are attempting to counter the perception that opioids are magic bullets for pain, and urging veterans to embrace alternatives, like McNeil has done.
“The misconception is opiates cure pain. They don’t. For most, they will take the edge off of pain, but they are not a cure to pain,” said Melissa L.D. Christopher, a doctor of pharmacy at the VA in San Diego.
She also runs the VA’s Opiate Safety Initiative for California, Nevada and Hawaii. The initiative educates doctors and patients about the painkillers.
“When opiates are used, they are not as effective as physical therapy, cognitive behavioral therapy and exercise for specific pain conditions,” Christopher said. “We want our veterans to live life in high definition and not be fogged by opiates. We want them to maintain control over their pain and transition to a better quality of life. That’s the new message we’re delivering to our veterans.”
That message might be slowly taking hold.
“We are starting to turn the tide,” Michelsen said. “This year, for the first time, we’ve seen a downturn in the number of opiate prescriptions.”
He said painkiller prescriptions at San Diego’s VA have dropped slightly – from 18.2 percent to 17.2 percent – in the past year.
“And that is telling, considering that we are seeing more patients then ever,” Christopher said. “There is hope that we can turn this around.”
Rick Rogers is a San Diego-based freelance reporter who writes about military issues. He can be reached at rick.w.rogers@gmail.com.
