The Veterans Administration in Roseburg is cracking down on its issuance of opioids and encouraging patients to reduce their use of them for anything other than cancer pain or palliative and end-of-life care.
The VA is among many organizations caught up in the opioid abuse, addiction and overdose crisis across America, primarily because of the number of veterans it serves who are in chronic pain due injuries incurred in the line of duty.
And local veterans, who comprise more than 25 percent of the county’s population, have been for years among those most readily prescribed opiates, state studies have repeatedly shown.
The new VA criteria
According to Todd Quier, the chief of primary doctors for the VA hospital in Roseburg, the VA has now crafted 18 recommendations for the prescribing, monitoring and use of opioids.
“Thirty years ago, we didn’t get trained (about opioids) in medical school, in medical residency,” Quier told a group of about 20 veterans at a town hall in Brookings Monday evening. “It was one of those things you pick up here and there. It’s not a good way to do medicine.”
The new recommendations clarify when opioids should be used, which kind should be prescribed and advise doctors to address a risk-to-benefit analysis before considering them over other over-the-counter pain relievers, such as ibuprofen or Tylenol.
The first recommendation to doctors is to avoid jumping right to opioids for pain relief and instead consider other options such as over-the-counter medications, yoga, chiropractor, tai-chi, massage therapy and acupuncture, many of which can at least make the pain tolerable.
“There are a lot of alternatives out there the VA is starting to recognize — and the VA is paying for,” Quier said. “They’ve come a long way, because we know prescriptions don’t fix things.”
Doctors are also advised not to prescribe opioids for a chronic condition. That merely promotes tolerance of the drug that results in demand for more and culminates in addiction — the VA now calls it “opioid use disorder.”
“That’s what doctors did,” Quier said of the practice.. “And what do you do with someone who’s on high-dose morphine and they’re still in the same pain two years later?”
Doctors are encouraged to reduce the number of days painkillers are prescribed to be taken, as well.
“Often, people would walk into the emergency room with a broken finger and walk out with a 30-day Vicodin prescription,” Quier said. “No more. Now, most states, the maximum is five days — and some, it’s three days. We gave out too many drugs.”
They should also consider each patient’s medical and mental status — and, if they have a history of depression, suicidal thoughts, Post Traumatic Stress Disorder or alcohol abuse, avoid opioids altogether.
Numerous variations must be considered, as well, because every patient is different, from how well their bodies will tolerate even the most innocuous of medicine to how much will relieve the pain.
Many of the new recommendations require better communication between providers and their veteran patients, Quier noted.
“I was crappy about communicating with my patients,” he said. “We’re learning by our mistakes. We’ve asked providers to do something (prescribe opiates) and we’re (only) now providing them with information about it.”
Veterans under the age of 30 shouldn’t be prescribed opioids, either, as they have many more decades ahead of them in which to become addicted. To reduce the risk of abuse, physicians should inform their patients of all the risks involved and for those on the drugs for a long time, require urine tests to ensure they’re in compliance with their dosages.
Databases also now exist to ensure a patient isn’t “doctor shopping” — and getting the same prescriptions from different providers.
And physicians should also reevaluate their patients every three months to ensure the opioid prescription is relieving enough of their pain so they can continue some semblance of the life they want.
“If they’re sitting on the couch all day doing nothing, they’re not enjoying life,” Quier said. “Most have found if you reduce the opiods, the overall quality of life improves.”
Doctors considering an opioid regimen should start at the lowest dose and monitor it if it has to be increased, the new advice reads.
“There is no safe opioid dose, just like there’s no safe smoking dose,” Quier said.
Interim Director Dave Whitmer, who also attended the town hall Monday, said that at one point, Roseburg had more people on opioids than any other healthcare system. But, he noted, all the patients were on smaller doses than those in other systems.
“There has been a pendulum swing,” Whitmer said. “At one point, the VA was contributing to the opioid crisis. Now we’re leading a very safe way to deliver opioids for the short-term and alternatives for long-term pain.”
If someone is already suffering from an opioid use disorder, a pain management team comprised of medical, addictions and behavioral health providers can be included in the discussion.
“We cannot treat your pain,” Quier said. “Our job is to give you the tools to manage it in your own direction. For chronic management of pain, opioids don’t do a lot of good.”
Some asked about the alternative of using marijuana or CBDs, an element in weed that reduces pain without the high.
The VA’s not sold, Whitmer and Quier said.
“I could show you studies of people who use too much alcohol and their use of opioids decreased,” Quier said. “It doesn’t mean (the alcohol use) is safe.”
He said it really is up to the provider and the patient, but the VA’s stance is that marijuana should not be used.
“Each provider has to balance it out for themselves,” Quier said. “What is the standard of care in most communities on marijuana and pain? Most pain clinics do not allow the use of marijuana.”
In the minds of federal officials — Whitmer says his board of directors is the U.S. Congress and his job is to carry out their orders — marijuana is still a dangerous drug, on par with heroin and methamphetamine. That might be changing, the VA staff Monday admitted, but it’s not there yet.
“I can’t presume it’s safe,” Quier said. “And it’s my medical license, my 30 years of doing my job.”
Reach Jane Stebbins at firstname.lastname@example.org .