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

With this work, ISPR hopes to greatly inform the development of effective programs for preventing opioid misuse and opioid-related overdose among veterans by helping to identify the salient contexts for risky opioid use and gaining a better understanding of how even routine, adherent pain management behaviors sometimes lead to risky situations. This task is suited to both qualitative inquiry and survey research, and to that end, ISPR has conducted in-depth interviews with veterans who have experienced a PO-related overdose to gain a better understanding of proximal and distal antecedents of overdose. These interviews have helped ISPR to develop an Overdose Risk Behavior Scale, which is being administered to 250 veterans to monitor risk trajectories over a period of 2 years.

Preliminary results suggest that veterans are engaging in a variety of risky practices, such as off-label use of POs, mixing prescription opioids with other drugs and/or alcohol, and excessive opioid misuse without other people present. The research is also finding that these risky behaviors are deeply rooted in social factors (eg, unemployment, homelessness, and relationships) and mental health issues. Consistent with other research, we are finding that a large portion of veterans do not utilize or engage VA hospitals for a variety of reasons, including discharge status, confusion about eligibility, and a dissociation from military status, often due to experiences of trauma and/or moral injury.²¹

The ISPR has also convened focus groups involving homeless and female veterans to better understand the gendered dimensions of substance abuse challenges.⁴ In collaboration with the New York City Department of Health and Mental Hygiene (NYCDOHMH), ISPR is convening additional focus groups with male and female veterans currently using opioids to gain insights into ways to promote opioid safety and prevent overdose among the veteran population.

Policy and Outreach

Ongoing work indicates that there is a need for additional community-based approaches to reach this high-risk population. In this community and through this work, ISPR is finding that community-based, low-threshold approaches are paramount. For veterans who do not utilize the VA, the foundational principles of risk mitigation, which urge individuals to “come as you are” and service providers to meet clientele “where they are” in low-threshold settings, are essential guidelines for conducting effective outreach.²²

In New York City, for example, where the ISPR study is being conducted, the veteran community is served by a diverse network of veterans’ organizations, many of which serve specific veteran subpopulations, including the homeless (eg, Jericho Project), black/African American (eg, Black Vets for Social Justice), female (eg, Service Women’s Action Network), and substance-dependent veterans (eg, Reality House). The study has been working with these groups to develop strategies for overdose reduction. We are fortunate that the NYCDOHMH has been promoting overdose prevention and reversal within the community. They have collaborated with ISPR to support efforts to reach within the veteran population.

Although robust, collaborative community-based projects involving veteran populations have been slow to emerge, the ISPR findings indicate that by collaborating with veterans and supporting them with overdose prevention knowledge and skills, they can be better prepared to participate in peer outreach efforts and in some cases, even become community health providers to other veterans in need. As many veterans have suggested, the “battle-buddy” military model of support could be adapted and widely implemented for veterans. With these veterans and the organizations that support them, ISPR aims to further the overdose prevention and opioid safety prevention efforts and pioneer new prevention and information resources for PO-using veterans, their friends, and family members. This effort is also helping to construct valuable ties with veterans service organizations (VSOs) that will empower them in future outreach to localized veteran subpopulations.

This joint effort will provide the means to develop more creative and time-sensitive interventions that prevent or mitigate risky behaviors before they lead to negative health consequences, including overdose and even untimely death. Helping to understand how veterans conceptualize risk and draw on social and institutional supports will allow for greater refinement in future efforts to educate veterans and assist them in establishing meaningful institutional affiliations and social relationships that may serve as protective factors against opioid-related health risks.

The ongoing dialogue with many veterans and the organizations that serve them has yielded recommendations to help improve their transitions to civilian life. Many veterans suggested the need for a continuum of services and more frequent/robust outreach, such as support and referral programs at every stage of the military/veteran career through VSOs. Many veterans also suggested the need for increased access to a range of treatment options on demand, including traditional 12-step and faith-based programs, medically assisted maintenance and therapy programs (eg, methadone and buprenorphine), as well as complementary and alternative medical approaches (eg, acupuncture).