Veterans’ Health and Opioid Safety–Contexts, Risks, and Outreach Implications

Strengthening partnerships between the VA, local health departments, and community-based groups may greatly benefit the vulnerable veteran population that is at disproportionate risk of prescription opioid misuse and overdose.

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America has been facing an epidemic of drug overdoses. Prescription opioid (PO) misuse has been a major driver of this phenomenon. According to the CDC, from 1999 to 2013 the drug poisoning death rate more than doubled from 6.1 to 13.8 people per 100,000, and the rate for drug poisoning deaths involving opioid analgesics nearly quadrupled from 1.4 to 5.1 people per 100,000.1

This epidemic has greatly impacted active-duty military personnel and veterans who face especially elevated risks of opioid misuse and overdose.2-4 The army has reported that among active-duty personnel, drug toxicity deaths more than doubled between 2006 and 2011, and overdose rates are greatly elevated among VA patients compared with the civilian population.3,5 A May 2014 VHA report indicated that 440,000 current patients were prescribed opioids, placing them at potential risk, and 55,000 veteran patients were diagnosed as having a current opioid use disorder, placing them at even greater risk.3,6

Military personnel and veterans who experience combat- or service-related injuries are frequently prescribed POs to manage pain.7,8 However, POs can be misused, and routine pain management can easily lead to risky behavior through common practices such as unmonitored dose escalation and the use of POs in combination with other drugs or alcohol. Some service members and veterans engage in unsupervised, nonmedical use of POs for a range of reasons, including self-management of physical pain, anxiety, or sleep disorders.

Veterans’ PO use can take place within the broader context of readjustment to civilian life and its numerous challenges, including unemployment, homelessness, social isolation, cognitive impairment (eg, traumatic brain injury [TBI]), and mental health concerns (eg, depression, posttraumatic stress disorder [PTSD]).2,3,8,9 All of these factors can intensify the negative health consequences associated with PO misuse and can greatly increase the chance for overdose and accidental injury. Accordingly, veterans represent a vulnerable population at disproportionate risk of PO misuse and overdose. As current research is demonstrating, these risks are potentially even higher for women, minority, homeless, and otherwise socially isolated veterans, as well as those with mental health concerns.10,11

Preventing Overdose Death

Overdose events are both preventable and reversible.12 One policy response has been to provide outreach education programs that distribute naloxone (commonly referred to by its trade name, Narcan), an opioid antagonist that can reverse opioid- involved overdose, and train PO users, their family, and friends in its use. In response to the rise of PO misuse and PO-related overdose, VA, DoD, public health departments, drug treatment programs, and community groups have implemented opioid safety and overdose prevention programs targeting prescription drug users, their families, and their peers. Typical programs provide information about preventing opioid misuse, identifying and preventing an overdose, understanding overdose risks (eg, tolerance, mixing drugs, using alone), and responding to an overdose (eg, calling 911, rescue breathing, naloxone administration). The effectiveness of these programs is well established.13-17

The army has been highly responsive to this problem. Following contact with a Wilkes County, North Carolina-based overdose prevention program, army medical personnel at Fort Bragg implemented Operation Opioid SAFE in 2011, which provided overdose prevention training and naloxone to active-duty soldiers at risk for opioid overdose in the course of routine pain management.18 This program represents a forward-looking intervention in keeping with the CDC’s recent call to public agencies to educate laypersons to administer naloxone to those in need.12 This initiative has great potential to reach active-duty soldiers. However, additional outreach programs are needed to reach the veteran population who face similar overdose risks but may not be served by the VA, which is now providing risk reduction information and naloxone through its Overdose Education and Naloxone Distribution Program.6,19

Another approach to preventing opioid overdose has been to restrict access to POs, including a reduction in prescribing POs and the use of prescription drug monitoring programs to combat diversion. These programs are raising awareness and reducing misuse (especially casual misuse) among many populations. However, patients dealing with chronic pain still need medications, and POs work for many of them. Unfortunately, with restricted access to POs, some veterans self-treat pain with diverted POs or even switch to illicit substances, such as heroin.20 Without medical oversight for their opioid use (and the standardized dosage and contraindication information that it involves), these veterans experience an even greater risk of opioid- related overdose.

Assessing the Problem

Despite findings about the clustering of opioid-related risks among particular veteran subpopulations, very little is currently known about how these risks emerge over time and what conditions and events precipitate them. The Institute for Special Populations Research (ISPR) of the National Development and Research Institutes, Inc. (NDRI), is conducting a project to address the emergence of opioid-related risk behaviors over time and to track the changing dimensions of veterans’ reintegration experiences that impact PO and other substance use patterns. This project examines opioid-using veterans’ substance use patterns alongside other physiologic, social, and psychological dimensions of their lives, ranging from PTSD symptoms, depression, and pain severity to social relationships and employment status. The goal is to provide critical biopsychosocial insights into the stressors, turning points, and substance use patterns that precede emergence of overdose risk behaviors and the protective factors that keep some opioid-using veterans safe, despite their struggles with pain and the psychosocial challenges of reintegration.

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