VA Working to Slash Opioid Use Amid New Research on Painkiller Alternatives

A pharmacy technician counts pills before filling a prescription. (U.S. Air Force/Bobby Jones)
A pharmacy technician counts pills before filling a prescription. (U.S. Air Force/Bobby Jones)

The VA’s efforts to cut prescription rates for opioids have been backed up by encouraging new research showing success for the use of non-opioid alternatives in the treatment of some types of chronic pain.

"Many people do have expectations that opioids are just amazingly effective for pain. You know, it turns out that's probably not true," said Dr. Erin Krebs, a general internist and researcher at the Minneapolis VA Center for Chronic Disease Outcomes Research.

"We found in this trial no evidence that opioids were doing a better job for chronic pain than the non-opioid medications we already have on hand," said Krebs, who also is an associate professor of medicine at the University of Minnesota.

The VA's efforts to cut opioid prescriptions began well before President Donald Trump last October declared the opioid epidemic a national public health emergency.

"Nobody has seen anything like what is going on now" but "we can be the generation that ends the opioid epidemic," Trump said at a White House East Room ceremony.

In line with the VA's commitment to curb opioid use, the VA in January became the only health care system nationwide to post prescription rates for opioids.

The data on opioids dispensed by VA pharmacies showed an overall and sometimes dramatic decrease in their use by veterans for treatment of chronic pain from 2012 to 2018.

At the Manhattan VA Medical Center in New York, the rate was cut in half, from eight percent to four percent; at the Fargo VA Medical Center in North Dakota, the rate went down from 11 percent to five percent; at the C.W. Bill Young VA Medical Center in Florida from 15 to 6 percent; and at the West Los Angeles VA Medical Center in California from 16 to 7 percent.

According to the National Center for Health Statistics at the Centers for Disease Control and Prevention, more than 72,000 drug overdose deaths attributable to opioids occurred in 2017.

Of that total, the sharpest increase resulted from the use of fentanyl and fentanyl analogs (synthetic opioids), with nearly 30,000 deaths recorded, the CDC said.

The number of troops and veterans who succumbed to overdoses is difficult to determine, since the CDC and healthcare systems have different accounting methods, Krebs said in an interview last week. However, VA case studies indicate that veterans are twice as likely to die from an accidental opioid overdose compared to the general population.

The National Institutes of Health reached the same conclusion in a study on veterans' death rates from opioid "poisonings" in 2005 when the scope of the epidemic began to take shape in the national consciousness.

The objective of the study was "to describe the rate of accidental poisoning mortality in the Veterans Health Administration (VHA) during fiscal year 2005" and "assess differences with rates observed in the general U.S. population," NIH said.

"After accounting for gender and age distribution, VHA patients had nearly twice the rate of fatal accidental poisoning compared with adults in the general U.S. population," the study found. "Opioid medications and cocaine were frequently mentioned as the agents causing poisoning on death records."

To gauge the comparative effectiveness of opioids and non-opioids in pain treatment, Krebs oversaw a study on long-term results.

Her work, called the Strategies for Prescribing Analgesics Comparative Effectiveness (SPACE) study, was funded by the National Institutes of Health and the Patient-Centered Outcomes Research Institute.

"I wouldn't have been willing to bet much money on the outcome of this trial. This was a study where we really did not know how it was going to come out," Krebs said.

The study involved 240 patients, including 120 who received opioids, and 120 who were treated with non-opioids. She said 234 completed the year-long testing and follow-ups.

The test participants were experiencing chronic lower back and hip pain, and knee arthritis pain, which Krebs said were "the two most common reasons people take opioids long-term."

The non-opioids used in the study were individualized for each patient in the therapy that involved three stages for back, knee and hip pain, Krebs said.

The first step involved the use of acetaminophen and anti-inflammatories such as ibuprofen, she said. The next two steps involved a mix of non-opioids including topical Diclofenac, topical Lidocaine, Gabapentin, and Nortriptyline.

In a follow-up email, Krebs said "most patients in the non-opioid treatment group received treatment with medications in step two or three because acetaminophen and anti-inflammatories didn't work well enough."

"We found in this trial no evidence that opioids were doing a better job for chronic pain than the non-opioid medications we already have on hand," Krebs continued.

The official conclusion of the study was that "treatment with opioids was not superior to treatment with non-opioid medications for improving pain-related function over 12 months ... Results do not support initiation of opioid therapy for moderate to severe chronic back pain or hip or knee osteoarthritis pain."

Krebs said high expectations for the effectiveness of opioid drugs are common across the general population, not just among veterans.

"So getting that word out is important," she said. "And not just getting the word out, but saying, 'hey, we do have effective existing treatments for pain and we have a lot of other options that certainly are safer and mostly, probably, work better as well.'"

These alternative treatments, she said, include exercise plans and other complementary therapies such as yoga and tai chi to work in combination with non-opioids for pain treatment.

According to the Department of Health and Human Services (HHS), the factors that led to the opioid epidemic are clear.

"In the late 1990s, pharmaceutical companies re-assured the medical community that patients would not become addicted to opioid pain relievers and healthcare providers began to prescribe them at greater rates," HHS said. "Increased prescription of opioid medications led to widespread misuse of both prescription and non-prescription opioids before it became clear that these medications could indeed be highly addictive."

When asked if she agreed with the HHS assessment, Krebs said it was complicated.

"There's a lot of blame to go around, but I think that's kind of the generally accepted narrative," she said.

Editor's note: This story has been updated to clarify the steps taken in the non-opioid trial.

-- Richard Sisk can be reached at Richard.Sisk@Military.com.

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