Managing Opioid Use and PTSD After Service-Related Injuries

Key Takeaways

• Service-related injuries among veterans can lead to chronic conditions like PTSD and TBI, affecting their reintegration into civilian life.
• Musculoskeletal injuries are common in service members, leading to healthcare utilization, duty limitations, and disability.
• PTSD and chronic pain often coexist in service members, complicating recovery and potentially increasing opioid reliance.
• Opioid use among service members is linked to pain management and psychological trauma, with rising overdose mortality rates.
• Non-opioid pain management strategies, including medical and holistic approaches, are vital for service members to avoid opioid risks.
• Support systems and resources, such as the NIH HEAL Initiative and SAMHSA’s budget proposals, are available for service members struggling with opioid use.
• Rehabilitation programs, both inpatient and outpatient, provide tailored care for service members recovering from injuries.
• Mental health services play a crucial role in supporting service members’ recovery from opioid use.
• Policy recommendations for addressing opioid use in service members include education, treatment access, and regulatory updates.
• Prevention through education and early intervention is essential to combat opioid misuse among service members.

Comprehending the Impact of Service-Related Injuries on Veterans

Service-related injuries among military personnel are a significant concern, with a range of physical and psychological effects that can persist long after active duty. The prevalence of these injuries is highlighted by statistics indicating various types of harm that veterans may endure. Notably, conditions such as Post-traumatic Stress Disorder (PTSD) and Traumatic Brain Injury (TBI) are prevalent among those who have served, pointing to the profound psychological trauma that can accompany physical wounds. Statista provides data on the distribution of injuries, emphasizing the importance of understanding these issues.

Common Physical Injuries and Their Impacts on Service Members

Service members are at a heightened risk for various physical injuries due to the demanding nature of military duties. They fall into to two primary general categories:

• Musculoskeletal injuries (MSkIs) are particularly prevalent and represent a significant cause of healthcare utilization, duty limitations, and disability among armed forces personnel. Research has shown that the most common sites of injury include the lower back, knees, and lower legs, which are often linked to overuse and strain from physical activities such as carrying heavy equipment and prolonged marching. 
• Traumatic brain injuries (TBIs) also pose serious health concerns, with long-term consequences that can affect mental and physical health, as well as overall quality of life.

Complications of MSkIs and TBIs

MSkIs can lead to chronic pain, reduced mobility, and in some cases, medical discharge from service. The financial impact of these injuries is substantial, as they are the leading cause of outpatient medical encounters and contribute to a significant number of limited duty days. Additionally, service members with TBIs may experience persistent symptoms that can include cognitive decline, cardiovascular issues, and an increased risk for conditions like chronic traumatic encephalopathy (CTE) and Parkinson’s disease. These injuries not only affect the individual service member but can also have repercussions on family caregivers and the overall readiness of military units.

The Interplay of PTSD and Chronic Pain in Service Members

Service members frequently encounter psychological trauma, with Post-Traumatic Stress Disorder (PTSD) being a prevalent outcome of such experiences. Studies indicate that PTSD and chronic pain often coexist in this population, suggesting a complex relationship where each condition may exacerbate the other. For instance, research from the National Institutes of Health reveals that PTSD symptoms are significantly associated with increased pain intensity, pain interference, and reduced physical function among military service members.

The Prevalence of Service Members with PTSD and Chronic Pain

Furthermore, the prevalence of PTSD among individuals with chronic pain is alarmingly high, with estimates reaching up to 80% in certain subgroups. This comorbidity can have a substantial impact on social functioning and overall quality of life. The Veterans Metrics Initiative study highlights that the co-occurrence of PTSD with sleep disturbances and chronic pain can significantly impair social functioning among U.S. veterans transitioning to civilian life.

PTSD and the Perception of Pain in Service Members

The presence of PTSD can also intensify the perception of pain, creating a cycle that may lead to increased reliance on pain medications, such as opioids. Recognizing the intertwined nature of PTSD and chronic pain is crucial for developing effective treatment strategies. This includes integrated approaches that address both psychological and physical aspects of these conditions, thereby improving the overall well-being of affected service members.

Understanding Opioid Use Among Service Members

Service members often face unique challenges that can lead to the use of opioids, primarily for pain management and mental health issues. Opioids have historically been prescribed to manage pain effectively, and their use can be a critical component of recovery for service-related injuries. Research indicates that when used at appropriate doses, opioids can not only alleviate pain but also prevent its recurrence in long-term recovery scenarios.

Prevalence of Chronic Pain Among Service Members

However, the prevalence of chronic pain among active-duty service members is notably high, ranging from 31 to 44 percent. This chronic pain, often a result of physical injuries sustained during service, can lead to a reliance on opioid medications for relief. The psychological impact of service, including conditions like PTSD, further complicates the picture, as mental health issues can exacerbate chronic pain and create a cycle where opioids become a coping mechanism.

Increasing Overdose Mortality Among Service Members

Studies, such as the one published on PubMed, reveal that drug overdose mortality rates among U.S. military veterans increased by 53% from 2010 to 2019, underscoring the gravity of the opioid crisis in this population. The reasons behind opioid use among service members are complex and multifaceted, involving pain management challenges, mental health issues, and the potential for social isolation or stigma that may deter individuals from seeking help.

Understanding the Risks and Long-term Consequences of Opioid Use

Opioid use, particularly among service members, carries significant risks and long-term consequences that extend beyond the potential for addiction and overdose. One of the most concerning risks is the increased likelihood of serious falls, particularly in older adults. Research indicates that individuals aged 85 and over are six times more likely to experience a serious fall during periods of opioid use compared to younger adults, highlighting the dangers opioids pose to physical stability and safety.

Fentanyl and the ‘Fourth Wave’ of the Opioid Epidemic

The opioid crisis has evolved with the rise of synthetic opioids like fentanyl, which has led to a shift in the patterns of opioid use and overdose. Fentanyl, often mixed with other substances, has contributed to a ‘fourth wave’ of the epidemic, with a significant drop in heroin and prescribed opioid use detected in fentanyl-positive tests. Despite these shifts, the overall crisis has worsened, with overdose deaths reaching over 80,000 by 2021. This underscores the urgency of addressing opioid-related harms, including the underestimation of their mortality burden and the need for comprehensive interventions and policy changes.

Non-Opioid Pain Management for Service-Related Injuries

For service members dealing with pain from service-related injuries, non-opioid pain management strategies offer a vital alternative to opioid medications. These strategies encompass a variety of medical and holistic approaches designed to alleviate pain without the risks associated with opioid use:

• Transcutaneous Electrical Nerve Stimulation (TENS), despite mixed evidence, has been moderately recommended for neuropathic pain management. 
• Spinal Cord Stimulation (SCS) has shown high levels of evidence supporting its use in specific conditions like lumbar failed back surgery syndrome and Complex Regional Pain Syndrome (CRPS).
• Medications remain a cornerstone of non-opioid pain management, with various classes such as non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, steroids, antidepressants, anticonvulsants, and topical medications offering relief through diverse mechanisms. 
• Physical therapy is also emphasized as a transformative approach to pain management, according to the American Physical Therapy Association (APTA).
• Radiofrequency Ablation (RFA) and Sympathetic Nerve Blocks (SNBs) are interventional techniques used to manage chronic pain conditions, providing long-term pain reduction for certain conditions.
• For more acute interventions, epidural injections of lidocaine with or without steroids can alleviate pain associated with lumbar radiculopathy and spinal stenosis. 
• The use of antidepressants like Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs) and tricyclic antidepressants (TCAs) can also play a role in managing chronic neuropathic pain.

It is crucial for service members to explore these alternatives with healthcare professionals to find the most effective and safe pain management strategies that suit their individual needs and circumstances.

Potential Breakthroughs in Non-Opioid Treatments of Chronic Pain

Recent research has highlighted potential breakthroughs in non-opioid treatments for chronic pain: 

• Notably, a collaboration between The University of Texas at Austin, The University of Texas at Dallas, and the University of Miami has identified a molecule that significantly reduces hypersensitivity in animal trials. This discovery could pave the way for new medications that offer pain relief without the addiction risks posed by opioids. 
• In the realm of pharmaceuticals, companies like Vertex Pharmaceuticals are developing drugs like VX-548, which aim to block pain signals before reaching the brain, offering a potential new avenue for treating moderate to severe acute pain.

As the search for effective non-opioid pain management options continues, these emerging therapies and existing medical interventions provide hope for service members seeking alternatives to opioids for managing service-related injury pain.

Exploring Holistic Pain Management Techniques for Service-Related Injuries

For service members dealing with chronic pain from service-related injuries, holistic pain management approaches offer a range of non-pharmacological strategies. These methods focus on treating the whole person, addressing physical symptoms as well as emotional and psychological well-being. 

• Mindfulness meditation, yoga, and deep breathing exercises are pivotal techniques that foster relaxation and can significantly reduce the perception of pain. 
• Occupational therapy also plays a role in holistic pain management, introducing patients to relaxation techniques that go beyond traditional methods.
• Physical modalities such as massage therapy, acupuncture, and chiropractic care are commonly utilized to alleviate muscle tension, enhance circulation, and mitigate pain. The Cleveland Clinic‘s holistic pain management program is an example of integrating these treatments with conventional medical care. 
• The use of vitamin or herbal supplements and the application of aloe vera are explored for their potential pain-relieving properties.
• Engaging in regular exercise, particularly low-impact activities such as swimming and walking, is encouraged to promote overall health and pain relief. T

The emphasis on the mind-body connection is fundamental, acknowledging that mental health significantly influences physical symptoms. These holistic approaches offer service members a comprehensive strategy for managing chronic pain, potentially reducing the reliance on opioids and improving quality of life.

Support Systems and Resources for Service Members Struggling with Opioid Use

Service members have access to various support systems for opioid use recovery. Initiatives like the NIH HEAL Initiative and SAMHSA’s expanded budget proposals focus on improving behavioral health care and reducing stigma. Increasing naloxone availability and utilizing opioid settlement funds for public health efforts are crucial steps. These resources are essential for addressing the unique challenges faced by service members and providing consistent treatment access.

Rehabilitation Program Options for Service Members

Service members recovering from service-related injuries may have access to various rehabilitation programs tailored to meet their unique needs. These programs are crucial for facilitating recovery, promoting independence, and improving the quality of life. Rehabilitation programs for service members can be categorized into inpatient and outpatient options, each offering distinct approaches to care:

• Inpatient Rehabilitation: These programs provide intensive therapy and are suitable for individuals with severe injuries requiring round-the-clock care. Inpatient rehab often includes a multidisciplinary approach, with a team of healthcare professionals working collaboratively to address the physical, emotional, and psychological aspects of recovery. The recent CMS final rule indicates increased payment rates and updates to quality reporting for Inpatient Rehabilitation Facilities (IRFs), ensuring better resources and care.
• Outpatient Rehabilitation: Outpatient programs allow service members to live at home while attending scheduled therapy sessions. These programs are ideal for those with less severe injuries or as a step-down from inpatient care. The flexibility of outpatient care can be particularly beneficial for service members looking to reintegrate into their community and daily life while continuing their recovery.

Specialized Rehabilitation Programs

Additionally, specialized programs like the First Responders-Comprehensive Addiction and Recovery Act (FR-CARA) provide resources to support first responders, including service members, in dealing with substance abuse as part of their rehabilitation process. With the evolving landscape of rehabilitation services, as indicated by recent policy updates and funding adjustments, service members have access to a diverse range of programs that cater to their specific rehabilitation needs.

Supporting Service Members with Mental Health Services for Opioid Use Recovery

Service members dealing with opioid use have access to a variety of mental health services designed to support their recovery and overall well-being. 

• The Substance Abuse and Mental Health Services Administration (SAMHSA) has requested a substantial budget for FY 2024, emphasizing the expansion of mental health services. This includes a historic investment to transform the behavioral health crisis care system and the expansion of the 988 Suicide & Crisis Lifeline.
• Community Mental Health Centers (CMHCs) are set to increase access to comprehensive mental health services across the nation, with a focus on reducing the stigma associated with substance use disorders (SAMHSA).
• Recent regulatory changes have made permanent the COVID-19-related flexibilities, such as take-home doses of methadone and the ability to prescribe medication for opioid use disorder (OUD) via telehealth without an initial in-person physical evaluation, greatly improving access to treatment. 
• The Centers for Medicare & Medicaid Services (CMS) has also announced the Innovation in Behavioral Health (IBH) Model, aimed at improving care for Medicaid and Medicare populations with mental health conditions and substance use disorders.

For service members, these services are critical in addressing both the psychological and physical aspects of recovery from opioid use. The integration of mental health services with addiction treatment is essential to provide a holistic approach to recovery, ensuring that service members receive the support they need to overcome the challenges of opioid dependency.

Strategic Policy Recommendations for Addressing Opioid Use in Service Members

Combatting opioid use among service members requires a multifaceted policy approach that emphasizes prevention, treatment, and sustained support. Based on recent policy changes and expert analysis, several recommendations emerge as critical for addressing this issue effectively.

• Enhance Education and Prevention: Implement comprehensive education programs for service members about the risks of opioid use and effective pain management alternatives.
• Expand Access to Treatment: Increase access to evidence-based treatments like Medication-Assisted Treatment (MAT) and support the integration of telehealth services for initiating treatments like buprenorphine without in-person visits.
• Regulatory Updates: Continue to update regulations for Opioid Treatment Programs (OTPs) and leverage policy tools such as the removal of the X-waiver to allow more healthcare providers to prescribe necessary medications.
• Support Reentry Services: Approve policies like California’s Section 1115 request to cover reentry services for incarcerated individuals prior to release, to ensure continuity of care and reduce the risk of relapse.
• Address Racial Inequities: Develop targeted interventions to address disparities in care and ensure equitable access to treatment for all service members, including communities of color.
• Foster Collaboration: Encourage state and federal entities to collaborate on innovative strategies, including the use of opioid settlement funds for public health initiatives.
• Research and Data Collection: Support ongoing research to provide a robust evidence base for policy decisions and to understand the evolving nature of the opioid crisis.

These recommendations are informed by recent developments, such as the Biden-Harris Administration’s advancements in overdose prevention strategies and the American Medical Association’s national policy roadmap. By implementing these strategies, policymakers can better support service members in managing pain, overcoming addiction, and ultimately leading healthier lives post-service.

Strategies to Prevent Opioid Use Through Education and Early Intervention

Preventing opioid misuse among service members is a critical aspect of addressing opioid use after service-related injuries. Education and early intervention are key strategies that can be employed to prevent the initiation and escalation of opioid use. The U.S. Department of Education outlines the importance of schools, students, and families in preventing substance misuse, emphasizing the role of educational institutions in creating supportive environments that discourage drug use. Resources provided by the department can help guide these efforts.

• At a policy level, the Biden-Harris Administration’s Overdose Prevention Strategy highlights the importance of expanding access to life-saving medications for opioid use disorder and implementing evidence-based prevention strategies. 
• The Centers for Disease Control and Prevention (CDC) also offers a comprehensive guide on evidence-based practices for preventing opioid overdose, which includes establishing peer support services and promoting community-level interventions.
• Further, the National Institutes of Health (NIH) stresses the need for a viable prevention workforce and the utilization of national preventive intervention registries. These registries list evidence-based programs that have been evaluated for their effectiveness in reducing substance use and related issues. This approach underscores the necessity of a comprehensive prevention system that includes family, school, and community-level interventions.
• Lastly, the Addiction Policy Forum recommends strategies such as implementing student assistance programs in schools, expanding community prevention coalitions, and ensuring support group access, which are all vital in the fight against the opioid epidemic.

Enhancing Treatment and Support for Service Members with Opioid Use Issues

The Substance Abuse and Mental Health Services Administration (SAMHSA) has proposed updates to federal rules to improve access to opioid use disorder (OUD) treatment, aiming to make permanent the medication flexibilities introduced during the COVID-19 pandemic. These changes, which are the first significant amendments to Opioid Treatment Program (OTP) standards in over two decades, are designed to support recovery and provide greater autonomy to OTP practitioners. Recent studies indicate that such flexibilities have led to improved treatment retention and reduced illicit opioid use among patients.

A Whole-of-Government Approach to the Opioid Crisis

To address the opioid epidemic among service members effectively, it is essential to ensure that policies not only focus on treatment accessibility but also on providing comprehensive support systems. This includes robust funding for drug abuse treatment programs, especially for those transitioning out of incarceration, to reduce the risk of fatal overdose and recidivism. A whole-of-government approach that integrates prevention, treatment, harm reduction, and recovery support services is necessary to mitigate the opioid crisis and support service members in their recovery journey.

Addiction and Mental Health Treatment at The Recovery Village at Baptist Health

The Recovery Village at Baptist Health is an industry-leading treatment provider for addiction and co-occurring mental health disorders. Our clinicians are specially trained in trauma-informed care, military culture and treating veteran-specific addiction and mental health needs. We’re also proud members of the VA Community Care Network, so we can accept VA health benefits as payment at no cost to the veteran.

 If you’re a veteran struggling with alcohol or drug addiction, our physician-led, private rehab program could be your path to recovery. Call us today and request a specialized Veteran Advocate to assist you.