While much of private health care in the U.S. is only beginning to confront the burgeoning opioid epidemic, the VA has a long-standing commitment to providing treatment to veterans struggling with substance use disorders. To understand the scope of the challenge and the VA’s approach, Federal Practitioner Editor-in-Chief Cynthia M.A. Geppert, MD, talked with Karen Drexler, MD, national mental health program director, substance use disorders. Dr. Drexler served in the U.S. Air Force for 8 years before joining the Atlanta VAMC in Georgia, where she directed the substance abuse treatment program. She is an associate professor of psychiatry and behavioral sciences at Emory University. In 2014, Dr. Drexler was named deputy mental health program director, addictive disorders.
Editor-in-Chief Cynthia M.A. Geppert, MD. As national mental health program director for substance use disorders, what are the challenges facing VA substance use programs?
Karen Drexler, MD. The biggest challenge is the increasing demand for services. Veterans have been coming to the VA for mental health care in general and for substance use disorder treatment in particular. The most common substance use disorder that we treat in addition to tobacco is alcohol use disorder, and the demand for alcohol use disorder treatment continues to grow.
Also, with the opioid crisis, there’s increasing demand for opioid use disorder treatments, including what we recommend as first-line treatment, which is medication-assisted treatment using buprenorphine or methadone, or injectable naltrexone as a second-line treatment. Gearing up with medication-assisted treatment for both alcohol and opioid use disorders is probably our biggest challenge.
Dr. Geppert. What were the most important accomplishments of the VA substance abuse programs over the past 5 years?
Dr. Drexler. There have been a lot! First of all, one of the things I love about practicing within the VA is that we are an integrated health care system. When I talk with colleagues in the Emory system here in Atlanta and across the country, oftentimes mental health and substance use disorders are isolated. The funding streams through the public sector come in different ways. Third-party payers have carve-outs for behavioral health.
It’s really wonderful to be able to collaborate with my colleagues in primary care, medical specialty care, and general mental health care, to provide a holistic and team-based approach to our patients who have both medical and substance use disorder problems and often co-occurring mental illness. As we’ve moved from a hospital-based system to more outpatient [care], the VA continues to be able to collaborate through our electronic health records as well as just being able to pick up the phone or send a [Microsoft] Lync message or an Outlook encrypted e-mail to help facilitate that coordinated care.
Another accomplishment has been to [develop] policy. It’s one of our challenges, but it’s also an accomplishment even at this early stage. In 2008, we issued the Uniform Mental Health Services benefits package as part of VHA Handbook on Mental Health Services. From that very beginning, we have included medication-assisted therapy when indicated for veterans with substance use disorders.
Now, we also know there’s a lot of variability in the system, so not every facility is providing these indicated treatments yet; but at least it’s part of our policy, and it’s been a focus of ongoing quality improvement to make these treatments available for veterans when they need them.
Dr. Geppert. We’ve heard a lot lately about the CDC guidelines for prescribing opiates for chronic pain that were published earlier this year. How do you see these guidelines affecting the VA Opiate Safety Initiative? Do you see any important contradictions between current VA policy and these new guidelines?
Dr. Drexler. Yes—not necessarily with policy but with our VA/DoD Clinical Practice Guidelines from 2010 and the new CDC guidelines. There’s a shift in emphasis. The 2010 VA/DoD guidelines were maybe a little too optimistic about the safety of opioids for chronic, noncancer pain. As time goes on, more evidence is mounting of the potential harms, including from my perspective, the risk of developing an opioid use disorder when taking opioid analgesics as prescribed.
In the 1990s and the early 2000s, experts in the field reassured us. They told us all—patients and providers alike—that if opioid analgesics were taken as prescribed for legitimate pain by people who didn’t have a previous history of a substance use disorder, they could take them and would not be at risk for becoming addicted. We now know that’s simply not true. Patients who take these medicines as prescribed by their providers end up developing tolerance, developing hyperalgesia, needing more and more medication to get the desired effect, and crossing that line from just physiologic tolerance to developing an opioid use disorder.
We now have better guidelines about where that risk increases. We have some data from observational studies that patients who are maintained on opioid analgesics that are < 50 mg of daily morphine equivalent dose (MED) tend not to have as high a risk of overdose as those who are maintained on more, but the risk of developing an opioid use disorder actually is not insignificant even below 50 mg MED.
The key for developing an opioid use disorder is how long the patient is on the treatment. For patients who take opioid analgesics for < 90 days—again, these are observational studies—very few went on to develop opioid use disorder. However, those who took it for > 90 days, even those who were maintained on < 36 mg MED, had a significantly increased risk of developing an opioid use disorder. And for those who were on the higher dose, say, > 120 mg MED, the risk went up to 122-fold.
We just don’t see those kinds of odds ratios elsewhere in medicine. You know, we address risk factors when it increases the risk by 50%, but this is 122-fold.