Given the recently concluded election season, it may seem that there are few things Americans have in common or can agree on. And although I did not conduct a poll or hold a debate, I suspect that a majority of those who work in the VA, DoD, or PHS would agree that one of the most serious and prevalent public health problems facing those in federal service and in the country at large is the epidemic of substance use disorders (SUDs).
In 2013 the National Institute on Drug Abuse reported that “members of the armed forces are not immune to the substance use problems that affect the rest of society.”1 Although active-duty service members use illicit drugs less frequently, as would be expected given the potential disciplinary consequences, the prevalence of problematic use of the legal ones—tobacco, alcohol, and particularly prescription medications—is greater among individuals in the military.
Substance use disorders affect every sector of federal health care practice from military pediatrics and VA pathology to PHS primary care. Reflecting this ubiquity, in this special substance use disorders issue of Federal Practitioner we focus on several distinctive and significant efforts of health care practitioners who care for patients with SUDs. All of medicine is becoming more interdisciplinary, multidisciplinary, and team-based, but perhaps no other area has as long a legacy or as intrinsic a need for team approaches to care than does the diagnosis and treatment of SUDs. We see this need reflected in this issue’s articles authored by clinical pharmacists, nurse practitioners, physicians, and physicians in training, among others.
Prescription opioids are the subject of 3 articles from VA practitioners: a look at primary, secondary, and tertiary forms of prevention of morbidity and mortality from substance use. Pharmacists at the Salt Lake City VAMC studied the epidemiology of veterans seen in emergency departments who were given naloxone for unintentional opioid overdoses. A second article reviews the distribution of naloxone at a VA facility, providing an example of a successful implementation of the VA Overdose Education and Naloxone Distribution network (OEND)—the only national naloxone program in any health care system.
Even farther upstream in the effort to reduce the large doses of opioids that are directly related to overdose deaths is an article on an outpatient opioid-monitoring clinic that uses evidence-based medicine to diagnose patients with opioid use disorder. Research in the VHA showed that in a 4-year period of study, “the risk of overdose deaths was directly related to the maximum prescribed daily dose of opioid medication.”2
Our colleagues in active duty underscore the challenge that new and emerging substances present not only to federal regulatory agencies like the Drug Enforcement Agency, but also to state and local law enforcement agencies. When spice (synthetic cannabinoids) and bath salts (synthetic cathinones) first appeared, no drug tests were available to detect them. Technically not illegal in the early phase of their use, they became the perfect and popular drugs of young service men and women.3
Tragically, history has shown 2 truths about humans and the use of psychoactive products. The first is that as soon as one product is outlawed, creative chemists invent another mind-altering product. Practical education regarding the latest of these underground drugs, kratom, which threatens our service members, is introduced in this issue.
The second truth is that nearly every drug that is originally prescribed for legitimate medical reasons is eventually misused for a nonmedical purpose and can lead to SUDs. By the time the medical community realizes the dark side of the medication, many individuals have already developed a disorder, and sadly some have died.
One of the oldest classes of drugs that brings both relief and torment to human culture—opioid medication—is now the scourge of postmodern society. Our well-intentioned efforts to succor real pain for patients using prescription opioids have paved a road to hellish suffering for others. A recent study examined whether a resurgence of heroin use among veterans—the likes of which has not been seen since the Vietnam era—was associated with the nonmedical use of yes, prescribed narcotics. The same study found that solely having chronic pain was not correlated with the use of heroin.4 This finding offers the hope that practitioners and patients together can learn to treat chronic pain with opioids in selected patients, which can be life-restoring in appropriate cases for limited duration, safely and responsibly while avoiding and minimizing the death dealing blow of opioid use disorders.
In this issue, we also feature a discussion with Karen Drexler, MD, the newly appointed Mental Health Program Director, Addictive Disorders. Dr. Drexler expertly discusses a wide array of SUD subjects relevant to Federal Practitioner readers, including the approach to patients using medical marijuana in the VA, the 2016 VA/DoD Clinical Practice Guidelines, and an inside view of the challenges and successes of VA SUD programs, from the vantage point of the new leader of these critical initiatives.
Finally, astute readers may notice the editorial attempts to avoid use of the value-laden terms addiction and substance abuse. Instead, the less stigmatizing terminology of DSM-5 is employed, which jettisons the problematic abuse and dependence distinction for the unitary domain of SUDs. This approach is not just a change in semantics but as thought leaders have shown, a real and meaningful comprehension of the role of words in shaping culture.5 The VA as a health care entity is moving to adopt better scientific framing of SUDs as a salient step toward a recovery-oriented program.
In the coming months, we intend to expand our coverage of this public health crisis, and we invite readers who care every day for patients wrestling with SUDs for control of their health and very lives, to educate, advocate for resources for active-duty service personnel and veterans, and share innovative efforts to turn the tide toward recovery.