By Andrea Hellenthal, Ph.D.
Jan. 27, 2023

Photo by Senior Airman Hailey R. Staker

Opioid use disorder is a battle that takes more lives every year than the Vietnam War, the Korean War, or any armed conflict since the end of World War II.¹

In 2020, an estimated 2.7 million people in the United States had OUD in the past 12 months, which includes 2.3 million people with a prescription opioid disorder.² Opioid overdose reached an all-time high in the United States in 2021.³ Because opioids can slow or even stop breathing, OUD comes with a significant risk of overdose. Overdose deaths involving opioids increased from an estimated 70,029 in 2020 to 80,816 in 2021. Each day, 221 people died from overdoses involving prescription opioids.³ In 2017, opioid overdose was declared a national emergency in the United States.⁴ The opioid epidemic affects every demographic, but none as heavily as veterans. Research indicates that veterans die from opioid-related overdoses at roughly twice the rate of the general population.⁵

What can we do about OUD? Why are service members and veterans particularly affected?

What are opioids?

Opioids are a class of chemicals that are frequently prescribed to relieve pain. They are typically used following surgery, serious injury, or to manage long-term pain.¹ Opioids are available by prescription and include oxycodone, hydrocodone, fentanyl, and methadone. When opioids enter the body, they produce several physiological responses including pain relief. But they also stimulate the reward pathway in the brain, which can cause a feeling of well-being and happiness. Opioids can be habit forming and have a high risk of misuse because they activate the reward pathway.

What is OUD?

OUD is a chronic problem in which people continue to use opioids despite harm caused by their use.⁶ Patients with OUD can develop physical dependence and experience serious consequences. Physical dependence is characterized by developing tolerance and withdrawal. Tolerance occurs when increasingly larger quantities of opioids are required to attain the same effect. Withdrawal can be life threatening, symptoms include diarrhea, nausea, vomiting, pupil dilatation, and autonomic hyperactivity (i.e., fast heart rate, sweating, hypertension). Individuals can also feel like they have lost control over their use. Loss of control is characterized by an inability to quit or decrease opioid use, despite wanting to do so, or by taking opioids in greater quantities or for a longer time than was planned. The misuse of opioids can disrupt relationships with family and friends, harm performance at work or school, and can result in serious health and legal consequences.

Please note: Not everyone who uses opioids develops OUD, though some do. Even if you take the opioids only as prescribed by a physician, you can develop OUD. Warning signs for the opioid misuse could include taking opioids for reasons other than what they were originally prescribed. You may also spend time trying to obtain prescriptions through different physicians or from family or friends.

Why are service members and veterans particularly effected by OUD?

Combat operations in Iraq and Afghanistan have taken a unique physical and psychological toll on veterans and service members. Major innovations in battlefield medicine and protective equipment resulted in a higher survival rates than in previous conflicts⁵ and higher rates of chronic pain. Severe pain was reported by 9.1% of veterans and was 40% more common than in non-veterans.⁷ As in civilian healthcare settings, opioids were increasingly used in veterans’ healthcare settings for the treatment of chronic pain during the early part of this century.

Veterans exhibit high rates of mental health disorders and some may use opioids and other substances as a means of coping with emotional pain and trauma.⁵ Researchers have found that OUD often co-occurs with chronic pain and posttraumatic stress disorder (PTSD), a mental health condition that may develop following exposure to a traumatic event, such as a deployment-related trauma.⁸ The prevalence of OUD in chronic pain patients is higher among those with PTSD than among those without this disorder. Approximately 10% of patients who attended a pain care center also had PTSD, and the rate of PTSD was considerably higher when the onset of pain corresponded with a traumatic event. PTSD seems to be an important risk factor of developing OUD.

The overdose rate among veterans steadily climbed beginning in the late 1990s. From 2010 to 2019, the rate of drug overdose mortality among veterans increased by 93.4% for overdoses involving opioids.⁹ At the same time, data demonstrated that the majority of veterans diagnosed with OUD have at least one additional substance use disorder, especially alcohol. For many veterans, military service and recreational culture may involve moderate-to-heavy alcohol use, and the use of alcohol greatly elevates the risk of overdose when combined with opioids.

How is OUD treated?

First and most important to know: OUD is treatable. The goal of therapy is to minimize opioid use relapse, help to sustain recovery, and prevent or reduce opioid overdose.¹⁰ The VA/DOD Clinical Practice Guideline for the Management of Substance Use Disorders outlines the following treatments:

Opioid Dependence Medications: Buprenorphine, methadone, and naltrexone are approved by the Food and Drug Administration to treat OUD. These medications are safe to use for months, years, or even a lifetime.

Opioid substitution therapy involves replacing an opioid with a longer-acting but less euphoric and addicting opioid. Buprenorphine and methadone are opioids, but they block the effects of other opioids, lessen withdrawal symptoms, and reduce cravings. While methadone can only be obtained at special licensed treatment facilities, buprenorphine can be filled at regular pharmacies. Naltrexone is not an opioid. It blocks opioids from binding to receptors in the brain to stop producing the feeling of well-being. Therefore, an individual is less likely to continue opioid use or to relapse.

Opioid Overdose Prevention Medication: Naloxone can be used to treat an overdose in emergencies. Naloxone, combined with basic life support, can quickly reverse an opioid overdose. It is simple to use via nasal spray and causes no harm if given when not experiencing an overdose. This medication is available over the counter. Your healthcare provider can also prescribe it for you and provide instruction on administration.

Resources

To learn more about OUD visit:

National Institute on Drug Abuse: This site offers general information and related resources on opioids, opioid crisis, safe opioid prescribing, and overdose prevention. 

U.S. Department of Veterans Affairs: The VA’s opioid safety initiative toolkit contains documents and presentations that can aid in your clinical decisions about starting, continuing, or tapering opioid therapy—and other challenges related to safe opioid prescribing. 

Substance Abuse and Mental Health Services Administration (SAMHSA): Learn about the warning signs of opioid overdose and how medication-assisted treatment programs can help treat and prevent it. 

If you need help right now, reach out to:

• SAMHSA: Get treatment referrals and other information via this free, confidential helpline. It's available 24/7, 365 days a year.
  1-800-662-HELP (4357)
• Veterans Crisis Line: 24/7 crisis support for veterans and their loved ones. Dial 988 then press 1. Or text 838255. 

References

1. National Academies of Sciences, Engineering, and Medicine. (2017). Pain management and the opioid epidemic: Balancing societal and individual benefits and risks of prescription opioid use. The National Academies Press.
2. National Institute on Drug Abuse. (2021, December 2). Overview. National Institutes of Health, U.S. Department of Health and Human Services. https://nida.nih.gov/publications/research-reports/medications-to-treat-opioid-addiction/overview
3. Ahmad, F. B., Rossen, L. M., Sutton, P. (2022). Vital Statistics Rapid Release—Provisional Drug Overdose Data. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm.
4. Strang, J., Volkow, N. D., Degenhardt, L., Hickman, M., Johnson, K., Koob, G. F., Marshall, B., Tyndall, M., & Walsh, S. L. (2020). Opioid use disorder. Nature Reviews Disease Primers, 6(1), 3.
5. Bennett, A. S., Watford, J. A., Elliott, L., Wolfson-Stofko, B., & Guarino, H. (2019). Military veterans' overdose risk behavior: Demographic and biopsychosocial influences. Addictive Behaviors, 99, 106036.
6. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
7. Nahin, R.L. (2017). Severe pain in veterans: The effect of age and sex, and comparisons with the general population. The Journal of Pain, 18(3), 247-254.
8. López-Martínez, A. E., Reyes-Pérez, Á., Serrano-Ibáñez, E. R., Esteve, R., & Ramírez-Maestre, C. (2019). Chronic pain, posttraumatic stress disorder, and opioid intake: A systematic review. World Journal of Clinical Cases, 7(24), 4254–4269.
9. Begley, M. R., Ravindran, C., Peltzman, T., Morley, S. W., Stephens, B. M., Ashrafioun, L., & McCarthy, J. F. (2022). Veteran drug overdose mortality, 2010-2019. Drug and Alcohol Dependence, 233, 109296.
10. Veterans Affairs and Department of Defense. (2021). VA/DOD Clinical Practice Guideline for the Management of Substance Use Disorders. Version 4.0. p. 55-65. https://www.healthquality.va.gov/guidelines/MH/sud/VADoDSUDCPG.pdf

Andrea Hellenthal, Ph.D. is a psychologist specializing in clinical psychology. She works for the German Armed Forces and is employed there at the university. Additionally, she treats patients in her own practice. She is currently participating in a scientific exchange program with the U.S. Armed Forces and works for the Psychological Health Center of Excellence.