Ironic Partners: Suicide Prevention and Pain Awareness Month

By Dr. Lynn Webster, PNN Columnist

September is National Suicide Prevention Month. It is also Pain Awareness Month. It may appear coincidental or ironic that we recognize suicide and pain during the same month. However, there is an unfortunate association between the two: pain -- either emotional or physical -- too often leads to suicide. Conversely, awareness and treatment of either type of pain, can often prevent suicide.

According to the World Health Organization, 800,000 people worldwide take their own lives each year. The number of suicide attempts is many times greater. Suicide is a serious problem globally and it is often linked to mental health problems.

Many military veterans, like civilians, suffer from both physical and emotional pain. This can lead to substance abuse and increased suicide risk. Veterans frequently experience post-traumatic stress disorder (PTSD) as a result of their military service, but they often don’t get the help they need because the military's mental health system may not take their struggles seriously. The Pentagon has even refused to award Purple Hearts to veterans with PTSD because it is not considered a physical wound.

Transitioning to civilian life after leaving the military can be stressful due to disruptions in social support, financial strain and changes in access to health care. Between 6 and 12 months after they separate from the military, veterans are at the highest risk of suicide.

Suicides associated with serving in the military are at a crisis level -- perhaps because of a lack of pain awareness and cuts in funding to suicide prevention programs. The Department of Veterans Affairs estimates 17 veterans commit suicide every day. Veterans' suicides account for 18% of all suicides in the U.S., even though veterans only make up 8.5 percent of the adult population.

More People at Risk

It’s not just veterans at risk. Over 48,000 Americans took their own lives in 2018. The suicide rate in the U.S. has increased by about 1.8% annually since the year 2000 and is one of the highest among wealthy nations.

The coronavirus pandemic may be adding to the problem. According to the Centers for Disease Control and Prevention, adults have recently reported considerably increased adverse mental health conditions associated with COVID-19. The CDC says groups that are suffering the greatest numbers of COVID-19 cases, including minorities, essential workers and caregivers, have experienced “disproportionately worse mental health outcomes, increased substance use, and elevated suicidal ideation."

People with substance use disorders are also more likely to contract the coronavirus. Those who do become infected bear the double burden of COVID-19 and addiction.

All suicides are tragic, and the losses affect families and entire communities. But suicides can be prevented by understanding the warning signs. Aggression, mood changes, relationship problems, prolonged stress, another person's suicide, and access to firearms or lethal drugs are all risk factors. Intractable pain, too, is a red flag.

According to the American Foundation for Suicide Prevention, depression, substance use disorders, bipolar disorder, and schizophrenia all elevate the possibility of suicide.

Suicidality has become omnipresent in our society. We probably all know of someone who has committed suicide. Even worse, we may have lost a family member or loved one due to suicide. It affects people of all socio-economic levels.

The National Suicide Prevention Lifeline (1-800-273-8255) provides a hotline for anyone who is having a mental health crisis or suicidal thoughts. Free, confidential help for a loved one, or for you, is only a phone call — or online chat — away. 

We may not always know who is struggling with emotional pain, but it is generally apparent when someone experiences insufferable physical pain. The partnership between suicide ideation and severe untreated pain can be mitigated if society will see people in pain as deserving of treatment. 

Lynn R. Webster, MD, is a vice president of scientific affairs for PRA Health Sciences and consults with the pharmaceutical industry. He is author of the award-winning book The Painful Truth, and co-producer of the documentary It Hurts Until You Die. Opinions expressed here are those of the author alone and do not reflect the views or policy of PRA Health Sciences. You can find him on Twitter: @LynnRWebsterMD.

VA Studying Laughing Gas as Treatment for Veterans With PTSD

By Pat Anson, PNN Editor

The U.S. Department of Veterans Affairs is sponsoring a small study to see if nitrous oxide – commonly known as laughing gas – could be used as a treatment for veterans suffering from post-traumatic stress disorder (PTSD), pain and depression.

The placebo-controlled Phase 2 study will be held at the VA Palo Alto Health Care System in California this fall. Investigators plan to recruit 104 veterans with PTSD to participate. Half would inhale a gaseous mix of nitrous oxide and oxygen, while the other half would be given a placebo.

Although PTSD is the primary focus of the study, researchers also hope to learn if nitrous oxide could be used to treat pain and other symptoms.

“Specifically, the investigators will first assess whether nitrous oxide treatment improves PTSD symptoms within 1 week. In parallel, the investigators will explore whether the treatment improves co-existing depression and pain,” researchers said. “In addition, the investigators will explore nitrous oxide's effects on a PTSD-associated impairment that is often overlooked - disruption in cognitive control, a core neurobiological process critical for regulating thoughts and for successful daily functioning.”

Military veterans suffering from PTSD often experience pain, anxiety, anger and depression. About one in five veterans who served in the Iraq or Afghanistan wars developed PTSD within a year of coming home.

In a small pilot study funded by the VA, three veterans with PTSD inhaled a single one-hour dose of nitrous oxide through a face mask. Within hours, two of the patients reported a marked improvement in their symptoms. The improvement lasted one week for one patient, while the second patient's symptoms gradually returned over the week. The third patient reported an improvement two hours after his treatment, but his symptoms returned the next day.

"While small in scale, this study shows the early promise of using nitrous oxide to quickly relieve symptoms of PTSD," said anesthesiologist Peter Nagele, MD, chair of the Department of Anesthesia & Critical Care at University of Chicago Medicine and co-author of a study recently published in the Journal of Clinical Psychiatry.

Nitrous oxide is a colorless and odorless gas that is commonly used by dentists to manage pain and anxiety in patients. It was once widely used in American hospitals to relieve labor pain, but fell out of favor as more Caesarean sections were performed and women opted for epidural injections and spinal blocks.

Some hospitals are now reintroducing nitrous oxide as a safer and less invasive option. The gas makes patients less aware of their pain, but does not completely eliminate it.  Recent studies have shown that about 70% of women who receive nitrous oxide during labor wind up using another analgesic due to inadequate pain relief.

"Like many other treatments, nitrous oxide appears to be effective for some patients but not for others," explained Nagele. "Often drugs work only on a subset of patients, while others do not respond. It's our role to determine who may benefit from this treatment, and who won't."

If findings from the VA’s pilot study are replicated in further research, it may be feasible to use nitrous oxide for rapid relief from PTSD, while longer-term treatments like psychotherapy and pharmaceutical drugs are also implemented.

Honoring Our Veterans on Memorial Day

By Dr. Lynn Webster, PNN Columnist

On Memorial Day, we honor those who lost their lives while serving in the United States military. It is a time when we should also acknowledge the sacrifices all veterans have made, and continue to make, for our country.

Physical and mental trauma are some of the most devastating consequences veterans suffer as a result of their sacrifices. Opioid drug use in military populations is nearly triple that of civilian populations.

A 2014 JAMA study reported that more than 44 percent of active-duty U.S. infantry soldiers suffered from chronic pain. Other reports state that combat injuries cause most of the chronic pain.  

That doesn't surprise me. I've received many emails from veterans who describe their struggles to find treatment for the pain they acquired during their military service.

Here are three typical stories from veterans:

A Persian Gulf veteran, John, is being forced to slowly taper from a combination of opioids that he claims worked for him. His dose of medication is being tapered because his physician feels pressured to comply with recommendations of the CDC Opioid Prescribing Guideline.  

John is afraid that the new limit will be inadequate to treat his pain.  

"I am VERY upset with my government, as their draconian 'solutions' to the perceived 'drug problem' will only exacerbate pain issues with legitimate chronic pain patients. I don't think their efforts will have ANY effect on the illegal drug problems that plague the U.S.," John wrote me.  

He may be more fortunate than others. At the time John contacted me, he had a pain specialist who was still able and willing to support his need for treatment. 

Others have not been as lucky. Mark is a 100% disabled veteran with post-traumatic stress disorder (PTSD), severe lower back pain and severe knee problems. After surgery, Mark was only able to get a two week supply of pain medicine. For two and a half months, he suffered without any medication until he was able to go outside the VA system to obtain oxycodone.  

Then there is Jason. He is a young American hero who used opioids to self-medicate his PTSD and chronic pain. His story may help people understand why there are approximately 20 suicides each day by America's veterans.  

Although firearms are a common method of suicide with veterans, the use of prescription medication has also been implicated. Having access to opioids gives veterans a less violent way to end their lives. 

Unfortunately, the number of veteran suicides may even be underreported. As many as 45 percent of drug overdoses -- including those of military members -- might be related to suicide, according to a former past president of the American Psychiatric Association. 

Veterans' suicides make up 18% of all suicides in the U.S. The suicide rate among members of the military is nearly 3 times that of civilians.  In 2012, for the first time in a generation, the number of active duty soldiers who killed themselves exceeded the number of soldiers who were killed in battles.

Approximately 20% of recent war veterans suffer from PTSD, in addition to chronic pain. PTSD was the most common mental health condition for almost 1 million soldiers who served between 2001 and 2014. Nearly one in four of those who served during those years developed PTSD within a year of coming back home. 

Much of the general public and many mental health professionals have doubted that PTSD was a true disorder until recently. Even now, soldiers with symptoms of PTSD face rejection by their military peers and are often feared by society as potentially dangerous. Movies ranging from "American Sniper" to "Thank You for Your Service" frequently depict characters with PTSD struggling to fit into society.  

In real life, those with PTSD symptoms are often labeled as “weak” and removed from combat zones, and sometimes they are involuntarily discharged from military service. 

These disturbing trends are difficult to read anytime, but they seem especially troubling as we commemorate Memorial Day. This is the time for us to acknowledge that those who have served our country deserve the best medical care available.  

Five years ago, retired Gens. Wayne Jonas, MD, and Eric Schoomaker, MD, wrote a commentary in JAMA titled “Pain and Opioids in the Military: We Must Do Better.” Recognizing that veterans often misuse opioids to self-medicate mental health disorders, they proposed teaching members of the military a greater degree of self-management skills such as problem-solving and goal setting.   

Of course, self-management would be preferable to using opioids if it were sufficient to afford veterans a quality of life they deserve. However, teaching self-management skills is often insufficient. That is clear in the cases of John, Mark and Jason. 

On Memorial Day, I hope we can take a moment to think about the men and women who have fought -- and sometimes died -- for a country they believed in.  

I also hope we honor the living by showing them that they deserve treatment for their chronic pain, PTSD, addiction and any other health care issues they may have. We owe it to them. 

Lynn R. Webster, MD, is a vice president of scientific affairs for PRA Health Sciences and consults with the pharmaceutical industry. He is a former president of the American Academy of Pain Medicine and is author of the award-winning book “The Painful Truth” and co-producer of the documentary “It Hurts Until You Die.”

You can find him on Twitter: @LynnRWebsterMD.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Waiting for Effective Pain Care at the VA

By Steve Pitkin, Guest Columnist

As a veteran of Vietnam and as a chronic pain sufferer, I am so glad that Pain News Network has been a consistent voice for 100 million Americans who are basically being told to "go off and die somewhere" by the DEA, CDC and other government agencies who are supposed to be protecting us.

I started on morphine, clonazepam and temazepam in 2001, and was constantly monitored by a team of psychiatrists, psychologists and my primary care physician at the VA Medical Center in West Palm Beach, Florida. I did not get "high" from the treatment, but it gave me a quality of life that I could not have with other medications.

I was in a car wreck after I retired from the military in 1997. In September of that year, I was taking my youngest daughter to an orthodontist appointment when our vehicle was hit by a truck right after a rain storm.

The crash seriously injured my daughter, who was clinically dead for over 6 minutes before being brought back to life by a helicopter rescue team. She still suffers from a traumatic brain injury, as well as pain issues herself.

The accident worsened the already extensive injuries to my cervical spine and lower back area. I started to lose strength in both arms, and a civilian doctor attempted an ulnar nerve release. That worked for about a week, before the pain and numbness came back.

STEVE PITKIN

I eventually moved to Montana and was treated by a new primary care physician at the VA clinic in Missoula. He and his nursing team were not very helpful, so I asked to be transferred to a new doctor last year.

I was called back to the clinic and was introduced to my new physician. He took one look at my medical records and said, “The amount of painkillers you are on is borderline medical malpractice and we're going to have to get you off of them as soon as possible."

I nearly hit the roof when he said that. I had three failed right knee procedures, my cervical and spinal pain had grown worse, and here he's telling me that I was a victim of too many painkillers?

I have been pretty much bedridden since my dosage of morphine and the other medications were reduced. I have also been told I need to have both knees and both shoulders replaced. However, I was refused surgery on my neck by a neurologist who said, “If I were to operate on you, the amount of painkillers you’d need would kill you. You need to get off the morphine and benzodiazepines first, then come see me."

I told the neurosurgeon that I was an ex-Green Beret medic and had already gone through surgery several times with no serious side effects. But I was talking to a blank wall.

I went to see another primary care physician about the problems I was having with the lower dosage. He laughed at me when I asked if he could raise the dose. “You signed this paper saying you agreed to it," he said while waving the paper at me.

I didn't have any choice in the matter. I was told either to sign it or be cut off altogether.

I have written to both the House and the Senate Veterans Affairs Committees and was told there was nothing they could do to help me. When I found out that Montana Sen. John Tester was on the Senate Committee that helped the VA pass these measures, I was livid and told him so.

I even emailed President Obama and received a reply from him, saying something to the effect that it was important to keep heroin off the streets and to stop illegal sales of prescription pain meds.

There’s no doubt about that, but we who need those medications are being lumped into the same pile with drug abusers. The veteran suicide rate is estimated 20 a day and many vets, as well as civilian chronic pain patients, have been forced into buying illegal drugs and are dying from them.

I have always been a patriotic American and didn't hesitate to volunteer for the draft when I was 18. But if I knew that the government I served for so long would declare me an enemy, I think I never would have gone into the military. If not for my strong faith as a Christian, I would have killed myself long before writing this.

I can only hope that President Trump realizes that waiting in line for healthcare is not the only problem with the VA, and that wars injure and maim people for life.

Was it all really for nothing?

Steven Pitkin lives in Montana.

Pain News Network invites other readers to share their stories with us.  Send them to:  editor@PainNewsNetwork.org. 

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Do Opioids Raise or Lower Risk of Suicide?

By Pat Anson, Editor

Robert Rose has little doubt what the fallout will be from tougher guidelines for opioid pain medication being adopted by the Departments of Defense and Veterans Affairs. The 50-year old Marine Corps veteran calls the guidelines a “death sentence” for thousands of sick and wounded veterans like himself.

“Suicides are going to increase. No doubt about it. Alcoholism is going to increase. Veterans dying from accidental overdoses are going to increase. Deaths caused by veterans turning to street drugs are going to increase,” says Rose.

The VA and the Pentagon released the new opioid guidelines for veterans and active duty service members last month. (See “Tougher Opioid Guidelines for U.S. Military and Veterans”). It urges VA and military doctors to taper or discontinue opioids for patients on high doses, and strongly recommends that no opioids be prescribed for chronic pain patients under the age of 30.

Some VA doctors didn’t wait for the new guideline to be released. Rose, who suffers from chronic back pain due to service related injuries, was on a relatively high dose of morphine for 15 years before he was abruptly taken off opioid medication by his doctor last December.

Rose is in so much pain now that he rarely leaves the house.

“People cannot live in the amount of pain that I’m doing. They can’t do it. It’s just unimaginable to think that people can survive at this level for any length of time and be denied pain care,” Rose told PNN.

“Many, many, many days I was asking God to take me home because I couldn’t deal with the pain anymore.”

robert rose

Suicidal thoughts are not uncommon in the veteran community. Over half the veterans being treated at VA facilities suffer from chronic pain, as well as high rates of depression and post-traumatic stress disorder.  A recent study by the VA estimated that 20 veterans killed themselves each day in 2014.

Some have associated the high rate of suicide with opioid pain medication. The new VA guideline recommends that patients be closely monitored for suicide risk during opioid therapy, especially if they have a history of depression or bipolar disorder.

But there is no mention in the 192-page guideline that undertreated or untreated pain can also be a risk for suicide. The guideline is actually dismissive of suicide risk in patients being weaned off opioids:

“Some patients on LOT (long term opioid therapy) who suffer from chronic pain and co-occurring OUD (opioid use disorder), depression, and/or personality disorders may threaten suicide when providers recommend discontinuation of opioids. However, continuing LOT to ‘prevent suicide’ in someone with chronic pain is not recommended as an appropriate response if suicide risk is high or increases.”

Do Opioids Raise Risk of Suicide?

Are suicidal patients better off without opioids, as the guideline suggests?

“When I’m doing clinical work, that’s a question that I face on almost a daily basis,” says Mark Edlund, MD, a Utah psychiatrist who treats patients with chronic pain, mental health and substance abuse problems. “If people are being prescribed opioids, does that increase their risk for suicide?”

Edlund co-authored a recent study published in the American Journal of Public Health, which found that the number of suicides involving opioids more than doubled from 1999 to 2014, a period when opioid prescribing sharply increased.     

“There’s a good theoretical reason to think they are linked. Opioids can easily cause death. We know that opioid prescriptions have been going up,” says Edlund. “To me the results make complete sense. And they fit within a model you could make of increased access to opioids would increase suicide.”

Edlund, who is a research scientist with RTI International, co-authored the study with Jennifer Braden, MD, and Mark Sullivan, MD, both researchers at the University of Washington. Sullivan is a longtime critic of opioid prescribing practices and a board member of Physicians for Responsible Opioid Prescribing (PROP), an anti-opioid activist group.

Edlund is not a member of PROP, but has participated in some PROP research studies and says he is "largely in agreement" with the group's goals.

While his study found an association between opioid medication and suicides, Edlund admits it failed to prove causation – definitive proof that opioids contribute to suicidal thoughts or actions. In fact, recent research indicates that less than 5 percent of the attempted suicides in the U.S. involve opioids.  

“If you really wanted to get into causality, that would be very difficult to assess,” he said.  “I think there are competing explanations. What may be true for one person may not be true for another. Maybe for some people opioids are not helping with their pain and they’re worsening depression. But on the other hand, I’m sure there are some people that are using opioids and it improves their functioning and decreasing their pain. That part is hard to disentangle.”

The United States has seen a disturbing increase in suicides for over a decade. In 2014, nearly 43,000 Americans committed suicide, over twice the number of deaths linked to accidental opioid overdoses.

Most often suicides are blamed on depression, mental illness, financial problems, or drug and alcohol abuse. No statistics are kept on how many Americans kill themselves due to untreated or poorly treated pain, but there are a growing number of anecdotal reports of patients killing themselves after having their opioids reduced or eliminated (see “Chronic Pain Patient Abandoned by Doctor Dies”).

“I can't go on like this,” Bianca recently wrote to PNN. “They've cut my medicine to less than half of what I was taking.  I also have had suicidal thoughts, but pray to God that I don't.”

“I think of killing myself every day since… my doctors stopped prescribing (opioids). Why have they not been looking at this very issue, which is pain?” asked Tom.

“I will kill myself if they take me off it. Barely helps my pain anyways. The new anti-opiate laws by the government will cause my death,” wrote another pain patient. “I am certain many others will commit suicide.”

“I have suicidal thoughts every day since being taken off opioids. Life was bad before, now it is hell,” said Thomas. “Let’s place an ice pick in these doctors’ spines and see how long they last 24 hours per day, seven days a week. These ivory tower idiots would have a quick change of mind.”

Those are the patients that Mark Edlund worries about.

“That’s the personal clinical issue that I wrestle with. Which of those patients that I see will the opioid increase risk of suicide or decrease it? If it’s a legitimate pain patient who benefits from opioids, then yeah, it’s going to decrease the risk,” he said.

Do Opioids Lower Risk of Suicide?

Researchers in Israel recently found that very low doses of an opioid actually reduce suicidal thoughts. Patients in four Israeli hospitals – most of whom had a history of suicide attempts – had a significant decline in suicidal ideation after being given tiny doses of buprenorphine (Suboxone), a medication widely used to treat addiction.

“The study could not prove that opioids treat mental pain—it wasn’t designed to do so—but it did show that buprenorphine decreases suicidal ideation.  Perhaps the study’s most important contribution is its implication that treatments that help us withstand mental pain may prevent suicide,” psychiatrist Anne Skomorowsky wrote in Scientific American.

“(The) study provides a rationale for thinking about opioids in a new way. More than that, it suggests that interventions that increase our capacity to tolerate mental anguish may have a powerful role in suicide prevention.”

Suicide is a topic that is rarely addressed in the national debate over the so-called opioid epidemic. But as efforts continue to restrict or even eliminate opioid prescribing, patients like Robert Rose warn that we could be exchanging one epidemic for another.

“Them taking the pain meds away (from me) was God kicking me in the ass and telling me to get back into the world of the living. Now I have something to fight for,” says Rose, who bombards politicians, government officials and regulators with a steady stream of emails warning of the harm opioid guidelines are causing.

“Unfortunately since the VA adopted the CDC guidelines this is exactly what many veterans have done… turned to suicide. And with Medicare/Medicaid considering adopting the same policies, those suicides, your families, friends and neighbors, will spill over into the civilian populace with staggering implications for many,” Rose said in a recent email.

“Instead of tens of thousands of veterans being affected, it’s going to be tens of millions. And the loss of life is going to be devastating to families, communities and to the workforce.” 

Tougher Opioid Guidelines for U.S. Military and Veterans

By Pat Anson, Editor

It’s going to be even harder for U.S. military service members and veterans – especially younger ones -- to obtain opioid pain medication.

The Department of Veterans Affairs and the Department of Defense have released a new clinical practice guideline for VA and military doctors that strongly recommends against prescribing opioids for long-term chronic pain – pain that lasts longer than 90 days.

The new guideline is even more stringent than the one released last year by the Centers for Disease Control and Prevention (CDC).

It specifically recommends against long-term opioid therapy for patients under the age of 30.  And it urges VA and military doctors to taper or discontinue opioids for patients currently receiving high doses.

The 192-page guideline (which you can download by clicking here) is careful to note that the recommendations are voluntary and “not intended as a standard of care” that physicians are required to follow.

But critics worry they will be implemented and rigidly followed by military and VA doctors, just as the CDC guidelines were by many civilian doctors.

“I am concerned that many of these veterans with moderate to severe pain who may be well-maintained on long-term opioid therapy as part of a multidisciplinary approach or whom have already tried non-pharmacological and non-opioid therapies and found them insufficient will be tapered off their medication for no good reason except that their physicians will be fearful to run afoul of these new guidelines,” says Cindy Steinberg, National Director of Policy and Advocacy for the U.S. Pain Foundation, a patient advocacy group.

Although much of the research and clinical evidence used to support the new guideline was considered “low or very low” quality, a panel of experts found “mounting evidence” that the risk of harm from opioids -- such as addiction and overdose – “far outweighed the potential benefits.”

“There is a lack of high-quality evidence that LOT (long term opioid therapy) improves pain, function, and/or quality of life. The literature review conducted for this CPG (clinical practice guideline) identified no studies evaluating the effectiveness of LOT for outcomes lasting longer than 16 weeks. Given the lack of evidence showing sustained functional benefit of LOT and moderate evidence outlining harms, non-opioid treatments are preferred for chronic pain.”

The panel of experts was comprised of a diverse group of doctors, nurses and pharmacists within the Departments of Defense and Veterans Affairs, including specialists in pain management and addiction treatment. 

“We recommend against initiation of long-term opioid therapy for chronic pain,” reads the first of 18 recommendations of the expert panel, which said that only “a rare subset of individuals” should be prescribed opioids long term.

Instead of opioids, the panel recommends exercises such as yoga and psychological therapies such as cognitive behavioral therapy to treat chronic pain, along with non-opioid drugs such as gabapentin (Neurontin).

“In light of the low harms associated with exercise and psychological therapies when compared with LOT these treatments are preferred over LOT, and should be offered to all patients with chronic pain including those currently receiving LOT.”

Another strong recommendation of the panel is that opioids not be prescribed long-term to anyone under the age of 30, because of the damage opioids can cause to developing brains. 

“Some may interpret the recommendation to limit opioid use by age as arbitrary and potentially discriminatory when taken out of context; however, there is good neurophysiologic rationale explaining the relationship between age and OUD (opioid use disorder) and overdose.”

Of the seven studies used to support this claim, four were rated as “fair quality” and three were considered “poor quality.”

“That strikes me as an extremely weak evidence base for such a sweeping recommendation,” said Steinberg. “There is no mention of severity of pain condition which is extremely relevant in this population, many of whom sustained devastating and gruesome battlefield injuries such as blown off limbs.”

The panel recommends alternatives to opioids for mild-to-moderate acute pain. If opioids are prescribed temporarily for acute short-term pain, immediate release opioids are preferred.

Risk of Suicide Discounted

Pain is a serious problem for both active duty service members and veterans. A study found that nearly half the service members returning from Afghanistan have chronic pain and 15 percent reported using opioids – rates much higher than the civilian population.

The incidence of pain is even higher among veterans being treated at VA facilities. Over half suffer from chronic pain, as well as other conditions that contribute to it, such as depression and post-traumatic stress disorder. Even more alarming is a recent VA study that found an average of 22 veterans committing suicide each day.

The new guideline recommends that patients be monitored for suicide risk before and during opioid therapy, but curiously there is no mention that undertreated or untreated pain is also a risk for suicide. For patients being tapered or taken off opioids, doctors are advised not to take a threat of suicide too seriously.

“Some patients on LOT who suffer from chronic pain and co-occurring OUD, depression, and/or personality disorders may threaten suicide when providers recommend discontinuation of opioids. However, continuing LOT to ‘prevent suicide’ in someone with chronic pain is not recommended as an appropriate response if suicide risk is high or increases. In such cases, it is essential to involve behavioral health to assess, monitor, and treat a patient who becomes destabilized as a result of a medically appropriate decision to taper or cease LOT.”

Many patients could find themselves being tapered or taken off opioids if the guideline is taken literally by their doctors. The expert panel strongly recommends against opioid doses greater than a 90 mg morphine equivalent (MME) daily dose and urges caution for doses as low as 20 MME. 

“This again fails to recognize that patients differ widely in severity of pain, individual response to medication, body size and weight and tolerance for pain,” says Steinberg.

“I worry that, as we have seen with the CDC guidelines, clinicians will begin tapering patients who may be well-maintained on stable does of medication for fear of running afoul of sanctioned limitations rather than being guided by what is best for their patients. These limitations are in direct conflict with FDA approved labeling which is based on safety and efficacy trials and does not include dose thresholds.”

The VA and Department of Defense opioid guideline will affect millions of service members, veterans and their families. Nearly 1.5 million Americans currently serve in the armed forces and over 800,000 in the National Guard and Reserves.  The Veterans Administration provides health services to another 6 million veterans and their families.

The guideline is the second major initiative by the federal government so far this year aimed at reducing opioid prescribing. As Pain News Network has reported, the Centers for Medicare and Medicaid Services (CMS) has announced plans to fully implement the CDC’s opioid prescribing guidelines.

CMS is taking those voluntary guidelines a step further by mandating them as official Medicare policy and taking punitive action against doctors and patients who don’t follow them. CMS provides health insurance to about 54 million Americans through Medicare and nearly 70 million through Medicaid.

Veterans More Likely to Have Chronic Pain

By Pat Anson, Editor

Nearly one out of ten U.S. military veterans suffers from chronic severe pain, according to an extensive new survey that found the prevalence of pain higher in veterans than nonveterans, particularly in veterans who served during recent armed conflicts.

The survey by the National Institutes of Health provides the first national estimate of severe pain in both veterans and nonveterans.

The prevalence of severe pain – defined as pain that occurs "most days" or "every day" and bothers the individual "a lot" – was 9.1% for veterans and 6.4% for nonveterans.

“Our analysis showed that veterans were about 40 percent more likely to experience severe pain than nonveterans,” said Richard Nahin, PhD, lead author of the analysis.

“Younger veterans were substantially more likely to report suffering from severe pain than nonveterans, even after controlling for underlying demographic characteristics. These findings suggest that more attention should be paid to helping veterans manage the impact of severe pain and related disability on daily activities.”

The study is based on data from a survey of over 67,000 adults (6,647 veterans and 61,049 nonveterans) who responded to questions about the persistence and intensity of their pain. The vast majority of veterans were men (92%), while most of the nonveterans were women (56%). The survey did not identify any specific aspects of military service, including branch of the armed forces, years of service, or whether the veteran served in a combat role.

More veterans (65%) than nonveterans (56%) reported having some type of pain in the previous three months.  They were also more likely to have severe pain from back pain, joint pain, migraine, neck pain, sciatica and jaw pain.

Younger veterans (8%) were substantially more likely to suffer from severe pain than nonveterans (3%) of similar ages.

“These findings show that we still have much more to do to help our veterans who are suffering from pain,” said Josephine Briggs, MD, director of the National Center for Complementary and Integrative Health (NCCIH). “This new knowledge can help inform effective health care strategies for veterans of all ages. More research is needed to generate additional evidence-based options for veterans managing pain.”

Veterans Complain About VA Pain Care

The survey adds to the growing body of evidence that military veterans are more likely to suffer from physical and mental health issues, and that their problems are not being adequately addressed by the Veterans Administration, which provides health services to 6 million veterans and their families. According to a recent VA study, an average of 22 veterans commit suicide each day.

One of them was Peter Kaisen. In August, the 76-year old Navy veteran committed suicide outside a VA Medical Center in Northport, New York.  Kaisen’s widow told Newsday that her husband had chronic back pain, but VA doctors had told him there was nothing more they could do to ease his suffering.

According to a 2014 Inspector General’s study, more than half of the veterans being treated at the VA have chronic pain, as well as other conditions that contribute to it, such as depression and post-traumatic stress disorder.

In recent months, dozens of veterans have complained to Pain News Network that their treatment grew worse after the VA adopted the Centers for Disease Control and Prevention’s opioid prescribing guidelines, which discourage doctors from prescribing opioids for chronic pain.

“I am a Vietnam era veteran who has had testicular cancer, prostate cancer, hip joint cancer, and have been living with an inoperable spinal cord tumor,” wrote Tommy Garrett. “I cannot get the VA to prescribe OxyContin that civilian doctors have had me on for 17 years.”

“I received epidurals for 10 years and also I received pain medication for 6 years. The VA quit giving me epidurals and also took me off Vicodin,” said Mitch Kepner. “(Before) I was active and now I just lay around and do nothing wishing I was dead. I have no life, everything I do is a struggle. I don't want pity. I don't want compassion. I don't want (anything) from anybody. I just want Vicodin back so I can function.”

After several years of taking morphine to relieve pain from chronic arthritis, Vietnam veteran Ron Pence had his dosage cut in half by VA doctors – who want him to take Cymbalta, a non-opioid originally developed to treat anxiety. After reading about Cymbalta's side effects, Pence refused to take it.

“Why start something like that when what I was taking had no side effects for me and was working fine? I am sure the pills they are pushing will end in a lot more deaths and terrible disabilities and suffering,” wrote Pence in a PNN guest column.

“We are in one of the most advanced countries in the world medically, yet the doctors and politicians will not use that knowledge to ease pain and suffering. We have to find a solution.”