So having seen what opioid abuse has done to the civilian population in the previous blog (“Opioid abuse may be fueling a heroin epidemic”), let’s take a look at what it is doing to our nation’s vets.

“More than 50 percent of all veterans enrolled and receiving care at VHA (Veterans Health Administration) are affected by chronic pain, which is a much higher rate than in the general population,” said a 2014 VA report. “Veterans who suffer from chronic pain also experience much higher rates of other co-morbidities (post-traumatic stress disorder, depression, traumatic brain injury,) and socioeconomic dynamics (disability, joblessness) that may contribute to the challenges of pain management when treated by opioids.”

However, prescription painkillers became the preferred tool for dealing with that pain.

The Center for Investigative Reporting, using data provided under the Freedom of Information Act, said prescriptions for four opioids (hydrocodone, oxycodone, methadone and morphine) surged by 270 percent between 2000 and 2012, leading to addictions and a fatal overdose rate that was twice the national average.

In 2014, the VA said it issued 1.7 million prescriptions for opioids to 443,000 vets to be taken at home.

Citing a VA Office of Inspector General’s report, the Center for Ethics and the Rule of Law (CERL) said: “Between 2010 and 2015, the number of veterans addicted to opioids rose 55 percent to a total of roughly 68,000. This figure represents about 13 percent of all veterans currently prescribed opioids.”

Alarmed, the VA began cutting back its painkiller prescriptions in 2010. The agency says it reduced the number of vets receiving painkillers by 115,575 individuals between 2012 and 2015 and that it has 100,000 fewer vets on long-term opioid therapy.

Still, it says it treated 66,000 vets for opioid addiction in fiscal 2016.

“We owe it to the nation’s veterans to help them end their dependence on opioids,” said VA Secretary Robert McDonald, “and break the downward spiral that all too often leads to homeless, prison or suicide.”

McDonald said vets are 10 times more likely than the average Americans to abuse opioids and that such abuse is a leading cause of homelessness among vets.

However, one problem is that there’s no adequate replacement for prescription painkillers. “We do not have another silver bullet that we can say, ‘Instead of opioids, try this,’” Dr. Carolyn Clancy, the VA’s deputy under-secretary for health, told FRONTLINE Enterprise Journalism Group. “It’s much more a matter of individualizing and trying different alternatives, and that can be really frustrating for patients, as well as clinicians.”

Some VA centers have started to introduce programs on managing chronic pain by use of yoga, acupuncture, qigong and tai chi, but those programs are rarities. Most therapy is still cognitive behavioral, which isn’t very effective for chronic pain.

Furthermore, the VA system is currently overloaded, and most physicians don’t have the time to experiment with alternative therapies. And doctors are often pitted against their skeptical colleagues in trying to provide pain relief in a way that’s effective, but not dangerous to the patient.

Even the regulations adopted by the federal Drug Enforcement Administration have had a backlash by forcing vets to return every month to a VA facility to renew their medications. This only increases the patient load at facilities that may have a three- to six-month wait even to get an appointment.

So what does this do to our vets? Listen to the stories that some of them have told the nation’s news media in the past few years:

 

Robert Deatherage, a 30-year-old Army vet, told the Wall Street Journal that he has battled addictions to pain pills and heroin after suffering severe injuries in Afghanistan. He said he hit rock bottom a year before when he took refuge in an empty church in Fayetteville, N.C., and tried to kill himself – twice.

“I was just so sick of being as sick as I was,” he told the WSJ. First, he tried to shoot himself, but the gun misfired, so he injected himself with all the drugs he had, but he didn’t overdose.

Believing he might recover after all, Deatherage walked to a nearby VA Medical Center, but it was full so they sent him back onto the street with a jacket from the lost and found and the phone number for a homeless vets coordinator. After he picked up his disability check a few days later, however, he checked into a motel that he knew was frequented by vets and addicts.

“It gets discouraging,” Deatherage told the Journal. “”It makes it easier just to say, ‘F—k it, I’ll just keep doing what I’m doing.”

The youngest son of a single mom, Deatherage adored his grandfather, a Vietnam helicopter pilot who died when he was 10. Shortly after enlisting in 2006, Deatherage was prescribed Percocet for a back injury during helicopter training and continued taking the painkillers during his deployment to Afghanistan in 2009-10.

“I got blown up seven times,” he told the WSJ. “I would go see my medic, get bandaged, get Percs and get on with it.” During that time, he suffered back, neck and facial injuries, and he suffered a traumatic brain injury when he cracked his skull during an explosion.

Later stationed on the West Coast, he was prescribed opioids for his pain and began buying additional relief from other soldiers. He lost his job, his savings and his marriage, and he received a medical discharge for substance abuse in 2014.

“They threw me out of there and said ‘Take care of yourself,’” he told the WSJ. “So I did.”

Deatherage spent the next two years either in jail or homeless, according to the Journal. At the time of publication, he remained in jail.

 

Craig Schroeder, a former Marine corporal, was injured by a roadside bomb in the “Triangle of Death,” a region south of Baghdad, according to the Washington Post. He suffered a traumatic brain injury and lost some hearing, memory and movement. Due to pain from a broken foot and ankle, as well as a herniated disc in his back, he has had a steady supply of prescription opioids.

But after the DEA regulations were put in place to reduce opioid prescriptions, he was unable to get an appointment to see his doctor in North Carolina for nearly five months, he told the Post.

“It was a nightmare,” he said. “I was just in unbearable, terrible pain. I couldn’t even go to the ER because those doctors won’t write those scripts.”

His wife Stephanie told the Post that getting her husband a VA appointment became her main mission in life, but she said the VA seemed to become hostile toward patients who asked for painkillers.

“Suddenly, the VA treats people on pain meds like the new lepers,” she told the Post. “It feels like they told us for years to take these drugs, didn’t offer us any other ideas, and now we’re suddenly demonized, second-class citizens.”

 

Jeffrey Waggoner, a former paratrooper, was sent to a VA hospital in southern Oregon for detoxification from a brutal addiction to painkillers, but instead of sobering Waggoner up, medics doped him up, the Center for Investigative Reporting reported.

CIR obtained medical records in which one doctor said, “when not stimulated, (he) lies on the gurney and rapidly falls asleep.” And a nurse reported that Waggoner’s “eyes were like slits and he appears to be overly sedated” as he was rushed to the emergency room after falling out of bed.

Waggoner told a nurse at the Roseburg, Ore., VA hospital that he had been taking painkillers since he had been injured by a rocket-propelled grenade blast in Afghanistan and that he suffered from severe flashbacks that interrupted his sleep.

“Then, inexplicably, the VA released him for the weekend with a cocktail of 19 prescription medications, including 12 tablets of highly addictive oxycodone,” CIR reported. “Three hours later, Wagoner, 32, was dead of a drug overdose, slumped in a heap in front of his room at the Sleep Inn motel.”

“As a father, you’d want to know why this happened to your child,” his father, Greg Waggoner, told the center. “You send your child to a hospital to get well, not to die.”

The center also reported that medical records showed doctors at the southern Oregon VA hospital where Waggoner was treated prescribed eight times as many opioids as their colleagues at the VA hospital in Manhattan.

 

Ken Grady, a 45-year-old Air Force veteran, has been prescribed OxyContin, Percocet, Vicodin, and fentanyl patches throughout the 2000s to relieve pain from a series of surgeries for back injuries, the Wall Street Journal reported.  “The VA made it so easy,” he said. “It was endless, and I abused it.”

When he couldn’t get prescriptions, he was able to buy opioids on the street, often outside the Fayetteville, N.C., VA hospital from patients who had just had their own prescriptions re-filled. While he has been struggling to stay clean, Grady told the Journal that he has spent all but 65 days of the preceding two and a half years in VA-funded treatment or in jail.

During one stay at the VA’s mental health unit, a doctor prescribed him Percocet for chronic back pain, he said, but he told the doc “Please don’t give me that.”

More recently, the WSJ reported, Grady had several teeth pulled by a VA contractor who prescribed him Vicodin for pain. He took the pills that time, relapsed, bought some more on the street and landed in jail again, where he remained at press time.

 

Army veteran Joshua Renschler developed liver damage after years of taking 13 drugs, including opioids, to numb his back pain following a mortar blast in Iraq, according to FRONTLINE.  In testimony before Congress, he said doctors in Washington kept prescribing pills to manage the pain and the side effects of the medication, but offered few other solutions.

“When it comes to opioids, if we’re relying on the VA to provide this care, it almost mandates the need for opioid-based therapy, as sad as that is,” Renschler said, adding that he still struggles with severe pain, but now avoids medications due to his liver damage.

“I’m just about as good as I’m going to get,” he said.

FRONTLINE also interviewed Jim Reed, an Army veteran and anesthesia provider who is concerned about the Army’s reliance on prescription painkillers. Although he suffers from chronic neck pain, he refused a VA doctor’s prescription for opioids, as well as one pill to help him sleep and another pill to help him stay awake. Instead, he said he take Motrin and practices relaxation techniques.

But most vets don’t question the doctor, he added. He routinely sees vets in their 20s and 30s who are taking a “laundry list” of medications.

“We’re sentencing these young people to a life of chemical dependency,” Reed told FRONTLINE. “They’re living these lives of despair because we’re just not doing things that make sense, that are evidence based.”

 

Finally, the Center for Investigative Reporting told the story of Tim Fazio. Fazio started getting opioids from the VA in 2008 and has received nearly 4,000 oxycodone pills and more than a dozen bottles of Tramadol, another opioid painkiller.

But Fazio told CIR that he’s never been in serious physical pain – he uses the painkillers to blot out feelings of guilt for surviving when many of his close friends have not. On a shelf, he keeps a picture of four of his Marine Corps buddies; one killed himself, another was found dead in a Florida ditch after battling opioid addiction and PTSD, and a third was charged with murder.

“Last year, researchers at the San Francisco Medical Center published a paper in the Journal of the American Medical Association that found VA doctors prescribed significantly more opioids to patients with PTSD and depression than to other veterans – even though people suffering from those conditions are most at risk of overdose and suicide,” CIR reported.

Dr. Stephen Xenakis, a psychiatrist and retired brigadier general, told the center such prescriptions are counter-productive. “Opioids have an adverse effect for most of these patients,” said Xenakis, who was commanding general of the Army’s Southeast Regional Medical Command. “They make sleep more difficult because they disrupt your usual sleep pattern, and as your sleep gets worse, your mood and your anxiety get worse, and you find yourself not being able to think as clearly.”

Furthermore, opioids are downers, so they tend to make depressed vets even more depressed, Xenakis said.

Hospital records indicate that the VA knew Fazio was an addict in 2009 and provided him with detox. But VA doctors continued to prescribe opioids for three more years until his parents hired an attorney and threatened to sue the agency for medical malpractice, CIR reported.

“It’s so sick. It’s so wrong,” his mother, Kathy Fazio, told the center. “The kid is flagged everywhere with what he’s addicted to, and they’re still giving him Percocets. He’s better off to the Veterans Administration dead than … paying all that money to help him.”

 

Two new reports underscore the danger of over-reliance on prescription painkillers like OxyContin.

The first report, from Johns Hopkins University, suggests that our current heroin epidemic may have been fueled by people originally addicted to painkillers (opioids) who switched to illegal drugs after their prescriptions (or their cash) ran out. The second, from the University of Pennsylvania’s Center for Ethics and the Rule of Law (CERL), shows that our nation’s veterans are particularly at risk of becoming addicted to painkillers.

Let’s look at the civilian side first.

In the fall of 2016, Johns Hopkins Magazine reported on OxyContin, which had been introduced in 1996 by Purdue Pharma. The drug supposedly blocked pain for a full 12 hours, but its low dosage of opioids made it much safer than similar drugs and so there was much less possibility of addiction, the company told regulators and doctors.

Opioids had been primarily used to control pain in cancer and surgical patients, but primary care physicians quickly began prescribing OxyContin for less severe pain. From 1999 to 2014, prescriptions for OxyContin nearly quadrupled nationwide.  According to the Los Angeles Times, sales of OxyContin topped $3 billion in 2010.

But there were problems. Many patients didn’t get a full 12 hours of pain relief, and doctors began prescribing larger and larger dosages in response. Secondly, OxyContin – which is a chemical cousin of heroin – was more addictive than doctors and their patients realized.

Then in 2007, Purdue Pharma and three of its top executives pleaded guilty to misleading regulators, doctors and patients about the hazards of OxyContin and agreed to pay more than $600 million in fines and damages.

West Virginia, Kentucky and southeastern Ohio were particularly hard hit, due to their heavy reliance on the coal industry. Coal mine injuries are frequent, and opioids like OxyContin seemed to be an attractive way of managing that pain. So the pharmaceutical companies began flooding the Tri-State area with drugs.

Then the Charleston (WV) Gazette and other newspapers began writing about the abnormally large number of opioid prescriptions in their area. And the West Virginia Attorney General’s office began suing individual pharmacies. In one suit, the AG’s office said a rural pharmacy in Raleigh County had dispensed 2.3 million hydrocodone pills and another 2.3 oxycodone pills in the preceding seven years in a town with 2,700 residents.

The lawsuit said the pharmacy “made substantial profits from providing opioids to the citizens of West Virginia.”  It also said sales of the combined prescriptions dropped from 905,000 in 2010 to 267,000 in 2016 as the danger became more widely recognized.

Johns Hopkins reported that opioids killed more than 28,000 people in 2014, more than any year since the Centers for Disease Control began keeping track. It also quoted the CDC as estimating that 2.6 million Americans are addicted to prescription painkillers.

But when the supply of opioid prescriptions began drying up, many of those addicts began switching to heroin, which is similar in structure to opioids but much cheaper on the black market. Between 2002 and 2013, the CDC said, the number of women using heroin doubled, while the number of men using heroin increased by 50 percent.

According to a study published in “JAMA Psychiatry,” 75 percent of the new heroin users seeking treatment said they had first become addicted to prescription painkillers.

According to the CDC, West Virginia has the highest rate of drug overdose deaths in the nation. In 2014, there were 627 deaths in the state, which works out to about 36 per 100,000 population. In 2015, drug-related deaths rose to 725, or 42 for every 100,000 people.

The CDC estimates that Huntington, W.V., a small city of 49,000 which sits on the Ohio River bordering Kentucky, has a rate of drug-overdose deaths about 10 times the national average. According to the Pew Charitable Trusts, about 8,000 residents (16 percent of its population) are addicted to drugs, primarily to opioids and heroin.

Last year, the city made national news when it recorded 26 drug overdose calls within a single day, a situation which prosecutors say was caused by a drug dealer selling heroin laced with another drug used to tranquilize elephants.

The CERL report said that between 1.9 million and 2.1 million Americans are addicted to opioids and that nearly 19,000 deaths a year result from opioid addiction. An estimated 34.5 percent of civilian males and 26.9 percent of civilian females who suffer from post-traumatic stress injury (PTSI) also abuse drugs or are dependent on them, according to the center.

“Individuals who abuse opioids are 19 times more likely than the general population to end up abusing heroin as well,” said the CERL report.

In 2016, the CDC concluded that there has never been any significant evidence that opioids are safe and effective for alleviating pain, and it reduced new guidelines for the prescription of opioid painkillers that recommended significant reductions in the quantity and duration of opioid use.

So having seen what opioids has done to the civilian population, let’s take a look at what it is doing to our nation’s vets.