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Breaking It Down: The Hard Stuff

Be sure to read our feature story on vets in pain, Breaking It Down.

The prescription of first resort for doctors in the military and the VA is acetaminophen, but that over-the-counter painkiller brings its own risks. As with many of their age in the general population, soldiers are often heavy and/or binge drinkers, and acetaminophen coupled with alcohol brings a high risk of irreparable liver damage.

What's more, many veterans and active-duty personnel suffer levels of pain exceeding acetaminophen's palliative effects. That's when doctors resort to the harder stuff: opioid painkillers such as OxyContin and Vicodin.

It overstates the matter somewhat to say that military doctors have been handing these powerful, highly addictive drugs out like Skittles to trick-or-treaters, but since about 1990 — mirroring pain-management protocols in society at large — the numbers are undoubtedly very high.

The VA itself seems to be only now discovering the extent of the problem. Last year, a study was conducted with the following stated objectives: "Little is known about the treatment Operation Enduring Freedom/Operation Iraqi Freedom veterans receive for chronic noncancer pain. We sought to describe the prevalence of prescription opioid use, types and doses of opioids received and to identify correlates of receiving prescription opioids for CNCP among OEF/OIF veterans."

The study examined 762 Operation Enduring Freedom and Operation Iraqi Freedom veterans suffering from chronic pain and found that 64 percent were prescribed at least one opioid in the year after they started suffering from pain. Of that number, 41 percent were given a long-term prescription with an average dosage of 40.8 milligrams. One third of those prescribed long-term were also given sedative hypnotics. ("Low back pain" was cited first in the list of maladies these prescriptions were meant to treat. The list also included migraines, PTSD and "nicotine use disorder.") The study concluded that "prescription opioid use is common among OEF/OIF veterans with CNCP [chronic non-cancer pain] and is associated with several pain diagnoses and medical conditions."

Zooming out from the sample set to a broader shot, according to Defense Department statistics, military doctors scratched out nearly 3.8 million prescriptions for pain medications in 2009, up from 2001's number of 866,773. It's as if every person in the city of Houston got a prescription for heavy pain meds in a single year.

"The ideal is that people will take these medicines to help them do the things they need to do to try to help them get their lives better," says Dr. Jodie Trafton. Based in Menlo Park, California, she is the director of the VA's Program Evaluation and Resource Center and a research scientist at the Center for Health Care Evaluation. "If they are having really bad pain, they can do the work they need to do, they can engage with their family, they can do whatever it is they need to do."

Trafton says that successful treatment of pain with these drugs is a very tricky process. The line between ameliorative use and recreational and/or escapist misuse is blurry in the extreme.

"People think there's this line in the sand where on one side you have the people who are using these drugs the correct way, and on the other side you have these crazy party people who just can't control their desire for euphoria," she says. "That's not really what it looks like."

It's a continuum, she says. On the far end, after years of misuse, abusers eventually fall into a place where they are "doing all these wacky things around [their] medications."

With a number of people getting opioid prescriptions as large as today's military tally, there are bound to be problems among a vulnerable subset, and stats bear out this assessment. Painkiller addiction is one of the largest and fastest-growing problems among today's younger veterans. A study cited by VA addiction expert Dr. Andrew Saxon found that 2 percent of military personnel treated with opioids became addicted, often predicted by the fact that the patient also has a psychiatric disorder such as PTSD.

While that number might sound insignificant, looked at another way, it seems enormous. In a detailed 2010 United States Army report on mental health and suicide prevention, 18 percent of Army personnel were found to be abusers of prescription drugs. (Other studies pegged the percentage of Army pain-med abusers at 25 percent and 20 percent of Marines.) The 2010 Army report also found that pain medications played a role in one third of the active-duty suicides that occurred between 2006 and 2009 and 72 percent of the accidental or undetermined deaths over the same time period.

And according to VA data, 35,240 patients were found to be addicted and/or abusers of opioids in 2008. The number rose to 39,020 in 2009 and 43,332 in 2010. According to Pentagon records, prescription drugs are abused by the military at a rate more than double that of civilians, but Trafton warns against making too much of that statistic.

"Our data would say it's a problem for the military the way it's a problem for people," she says, and points out that the use and abuse of opioid painkillers has increased greatly in society at large over the past ten to 15 years. She thinks measuring the military versus the general population is a faulty metric. "The veteran population and the U.S. population are not age-matched, gender-matched or any of the other very salient factors that play in for substance-abuse problems."

For the most part veterans are young men, she points out, and young men in the general population tend to have higher rates of substance abuse in general.

"That being said, it's a big problem," she adds. "Let's face it, this is a high-exposure population. The military are more likely to get injured than average folk. They are getting more exposure to these things and may be at higher risk."

"This is a problem that is likely to grow rather than shrink," she adds.

That risk of addiction skyrockets when you add in a PTSD dual-diagnosis.

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Dr. Andrew Saxon, director of the VA's Addiction Treatment Center in Seattle, say the two conditions feed off each other. "It just becomes this vicious circle that they can't get out of," he says. "A lot of them get emotional relief or sedation from using opioid drugs, so certainly that's kind of a setup for them, because they get the opioids for pain and then they find that the drugs also work for their mental disorder," he says. Then, he adds, they frequently begin telling themselves that they are in physical pain when they are not, all so they can keep the prescriptions coming.

It's a dilemma for medical professionals. Which do you treat first? Saxon says that in some cases, taking away patients' chemical crutches has allowed their PTSD to become unmanageable. Others can't begin to address their nightmares and flashbacks until they are clean and sober.

In some cases, the drugs make them think that other forms of therapy are not necessary, he adds. Why submit to the pain of remembering your worst experiences and talking through your fears again and again — in his view, one of the most effective treatments for PTSD — when a little white pill can carry you away from all of that in mere minutes?

Trafton says a good portion of her work lies in retraining doctors on how to talk and listen to their patients, especially those in the middle ground of the pain continuum. "[Those patients] say things like 'Oh, I take it when I feel like I can't cope with my pain.' And that's kind of along that line where you're thinking maybe it's not such a good idea, but it's also where a typical MD would prescribe medication and say to take them when you need 'em. That's not that specific enough.' A lot of what we are trying to do is fix what the doctors are saying and help the patients understand that this isn't a way to manage your mood, this is a way to help you do something."

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