Treating Opioid Use Disorder in Veterans With Chronic Pain

nurse with veteran with chronic pain

The relationship between chronic pain and opioid use is complex, and this dynamic has played a significant role in the way the opioid crisis developed in the U.S. The CDC indicates that overprescribing opioid pain medication drove the initial wave of the opioid crisis. Then, when the CDC introduced guidelines to reduce the number of opioid prescriptions, two things happened that directly impacted veterans with chronic pain.

First, many people who developed opioid use disorder (OUD) while using prescription opioids turned to illicit opioids such as heroin. Second, people in chronic pain – for whom only opioids worked sufficiently – experienced significant barriers to accessing the medication that made daily life possible.

Both those groups of people include veterans who experience chronic pain as a result of injuries sustained in combat or injuries related to their military service.

Here are some statistics that illustrate the experience of veterans during the opioid crisis:

  • Between 2010 and 2016, overdose deaths among veterans increased by 45%
  • Between 2010 and 2016, the number of veterans prescribed an opioid pain reliever within 90 days of their overdose death declined by 52%

This phenomenon is indeed complex. Researchers who conducted a study called “Effectiveness of a Substance Use Treatment Program For Veterans With Chronic Pain And Opioid Use Disorder” explain the apparent contradiction in this data this way:

“This trend may be related to increased use of illicit opioids and highlights the continued critical importance of VHA programs that provide treatment for veterans with chronic pain and OUD, or who are at substantial risk for developing OUD.”

The research team saw the data on increasing overdose deaths among veterans as valid impetus to conduct a study on the impact of medication-assisted treatment (MAT) on veterans with OUD and chronic pain.

About the Study: Veterans With Opioid Use and Chronic Pain

Researchers examined outcomes for participants in a substance use treatment program that included medication-assisted treatment (MAT) with medications for opioid use disorder (MOUD) in Veterans Health Administration (VHA) hospital located in a large metro area.

Participants included:

  • A treatment group:
    • 478 patients diagnosed with OUD in a VHA substance disorder treatment program using medication-assisted treatment (SUD-MAT)
    • These patients experienced chronic pain
  • A non-treatment group:
    • 647 patients who used opioids but did not participate in the SUD-MAT program
    • These patients also experienced chronic pain

Data Collection Method:

  • Researchers examined electronic medical records in what’s called a retrospective cohort study, wherein researchers choose groups of participants and compare the records for specific groups over time for specific measures.
  • Measures for these two cohorts – the experimental group and the control group – included the following:
    • Prescription opioid use
    • Prescription benzodiazepine use
    • Urine screens for illicit and prescription opioids
    • Pain, with a 1-10 numeric pain rating scale
    • Addiction/substance use disorder, with the Brief Addiction Monitor (BAM). BAM measures factors related to SUD and relapse, including relationships, finances, and related medical or psychological issues
    • Depression, with the Patient Health Questionnaire-9 (PHQ-9). PHQ-9 is a self-report measure of depression severity
    • Suicidal behavior: attempts or suicidal ideation
    • Treatment utilization
    • Overdose events
    • Emergency room visits
    • Mortality (death)
  • Researchers examined records for each patient beginning a year before treatment with MAT and ending a year after the beginning of treatment with MAT. Researchers compared outcomes over this time period between the treatment group (MAT with MOU) and the non-treatment group.

Let’s take a look at the results.

Veterans With Chronic Pain and Opioid Use: Does MAT With OUD Improve Outcomes?

Here’s how the research team describes the goal of their study:

“We examined the effectiveness of an intensive outpatient clinical program for substance abuse treatment as it relates to Veterans with opioid use disorder and chronic pain offered by the Veterans Health Administration in a large metro-area system.”

In other words, for veterans with chronic pain and problem opioid use, does MAT help?

We’ll offer the results from most of the metrics listed above for the MAT group and the non-MAT group. The final publication did not include detailed results for all the metrics. Therefore, we’ll present the results they provided, beginning with the first, and most significant metric: mortality.

Here’s what the researchers found:

  • Mortality (death):
    • MAT group: 14.2% died during the observation year
    • Non-MAT group: 20.4% died during the observation year
Participation in MAT reduced risk of mortality by 38%
  • Overdose:
    • MAT group: 6.5% reported overdose
    • Non-MAT group: 4.0% reported overdose
Any overdose increased risk of mortality by 39%
  • Opioid use:
    • MAT group: 207 used opioids less than 90 days in the observation year, while 271 used opioids on more than 90 days in the observation year
    • Non-MAT group: 281 used opioids less than 90 days in the observation year, while 378 used opioids on more than 90 days in the observation year
Presence of opioids was associated with a 10% decrease in mortality risk. In this context, the presence of opioids “likely reflects increased participation in treatment.”
  • Benzodiazepine use:
    • MAT group: 34.4% used benzodiazepines during the observation year
    • Non-MAT group: 31.8% used benzodiazepines during the observation year
Any prescription of benzodiazepines alongside prescription for opioids increased risk of mortality by 26%
  • Outpatient treatment utilization:
    • MAT group: 35.8 outpatient visits/average per participant
    • Non-MAT group: 26.5 outpatient visits/average per participant
Outpatient treatment utilization was not associated with increased mortality risk
  • Inpatient treatment utilization:
    • MAT group: 0.6 days/average per participant in observation year
    • Non-MAT group: 0.5 days/average per participant in observation year
Inpatient treatment utilization increased mortality risk by 40%. Inpatient treatment is an indicator of the severity of the OUD: the more severe the disorder, the higher the likelihood of mortality, with or without treatment
  • Emergency room visits:
    • MAT group: 2 visits/average per participant
    • Non-MAT group: 1 visit/average per participant
Emergency room visits were not associated with increased mortality risk
  • Chronic pain:
    • MAT group: 5.1/10 average
    • Non-MAT group: 4.9/10 average
Chronic pain severity was not associated with increased mortality risk
  • Depression:
    • Mild:
      • MAT group: 22.6%
      • Non-MAT group: 19.8%
    • Moderate:
      • MAT group: 34.5%
      • Non-MAT group: 28.6%
    • Severe:
      • MAT group: 2.1%
      • Non-MAT group: 3.9%
Diagnosis of severe depression was associated with a 27% decrease in mortality risk. Study authors indicate this represents an enhanced engagement in treatment, which improves outcomes for people with co-occurring disorders

We’ll discuss these results now.

What This Data Means

That data contains important information for us, as providers of substance use treatment for people with substance use disorders in general, and as providers of medication-assisted treatment (MAT) to veterans with opioid use disorder (OUD) specifically.

The topline takeaway from this study is that participation in medication-assisted treatment (MAT) with one of the Food and Drug Administration (FDA) approved medications for opioid use disorder (MOUD) decreases likelihood of mortality by 38 percent.

In other words, if you’re a veteran in chronic pain with OUD, participating in an MAT program increases your chance of staying alive, and if you’re a veteran who in chronic pain who uses opioids, declining to engage in an MAT program increases your likelihood of premature mortality.

That’s why MAT is called a lifesaving approach to OUD treatment: it does, in fact, save lives.

We’ll point out two additional facts in the data above. First, veterans in chronic pain who also use benzodiazepines had a 26 percent increased risk of mortality. That foregrounds the role of polysubstance misuse in the most recent phase of the overdose crisis. Second, the fact that the presence of severe depression reduced risk of mortality by 27 percent.

While that may seem counter-intuitive at first, look at it this way: the individuals with severe depression participated in more intensive treatment, therapy, and support than those with mild or moderate depression. This indicates that the more immersive the treatment, the more positive the outcome. That’s an important fact for people with co-occurring mental health and substance use disorders to understand: their additional diagnosis does not guarantee a negative outcome. In fact, if it leads to more immersive treatment, the additional diagnosis – as it did in this study on veterans – may lead to improved outcomes.

How This Study Helps Us Help Veterans with OUD

We can use the results of this study when we talk to veterans in chronic pain with OUD about their treatment options. If they’re resistant to MAT, then we can show them that if they participate in and MAT program, they reduce their likelihood of mortality.

That’s’ a compelling argument for participating in an MAT program.

Next, we can use the information in this study to reaffirm our commitment to the integrated treatment model, which begins with a comprehensive screening and assessment for co-occurring disorders and polysubstance misuse. The data tell us that polysubstance misuse increases risk of mortality, which means we need to address polysubstance misuse proactively with all of our patients, with a focus on veterans with chronic pain and OUD.

Our commitment to the integrated treatment model and comprehensive intake assessments means we can also identify any co-occurring mental health disorders, such as depression, sooner rather than later. The data shows us that patients with severe depression had a reduced likelihood of mortality, which can be explained by increased participation in all aspects of treatment and support. We can use this information to encourage patients with mild or moderate depression – or other mental health disorders that are mild or moderate – to fully engage in the complete continuum of support we offer in our MAT programs, with the idea that immersive treatment and an engaged patient leads to improved outcomes overall.

Treatment Saves Lives

In our final analysis, what this study tells us is that for veterans with OUD who are in chronic pain, participation in an MAT program – as compared to not participating in and MAT program – leads to improved outcomes. The fear that the combination of chronic pain and medications associated with MAT might increase mortality risk is not supported by the evidence. On the contrary, the data shows that for veterans with chronic pain and OUD, participation in a SUD program with a medication for opioid use disorder (MOUD) decreases mortality risk. In other words, in this context, MAT with MOUD can not only improve, but also save lives.