- Kimberly Boyles / Shutterstock.com
In 1978, when she was 21, Lisa Gray was serving in the Air Force at Lackland Air Force Base in Texas. She suffered nerve damage after a botched fistula surgery, leaving her with chronic pain in her pelvic region and weakness in her lower extremities that requires her to wear leg braces. Now an Aurora resident, she describes her pain experience as "like falling on the bar of a boys bicycle."
Gray was medically retired after the surgery, which also left her unable to bear children. She was considered "unemployable" and has received 100 percent disability ever since. For her ongoing pain, Department of Veteran's Affairs (VA) physicians prescribed opioid painkillers.
"They told me to take as much Percodan as needed to stop pain," she says, referring to a brand of medication that contains aspirin and oxycodone hydrochloride, the latter an opioid. After Gray expressed concerns over potential liver damage from the Percodan, she was prescribed another opioid, Vicodin (hydrocodone and acetaminophen) in 1982.
She's taken three pills a day for the last 36 years.
In July, her primary care doctor began weaning her off the painkiller she had been taking for over two-thirds of her life. "My pain is a lot worse, there are a lot of days when I just stay in bed now," she says. "They're sending me to acupuncture right now. I haven't noticed an effect [on pain] yet, but I'm giving it a try."
Gray's sudden medication changes are part of a trend within the VA as well as Medicare, Medicaid and the American health care system in general. In response to what has been dubbed the "opioid crisis" or "opioid epidemic" — which refers to the national rise in rates of abuse of opioid drugs and overdose deaths from opioids since the 1990s — along with a push from the Centers for Disease Control and Prevention and the Food and Drug Administration, the VA stands among the major players taking steps to reduce the number of opioid prescriptions its providers are writing. Since 2012, the VA reports that its Denver Medical Center has reduced its opioid prescribing rate by 43 percent.
Last year, the CDC reports more than 72,000 people in the U.S. died from opioid overdoses. Of those, the Coroner's Office confirms that 102 occurred in El Paso County.
The steady up-tick in deaths has led to outcry from everyone from leaders of small communities to President Donald Trump. In September, Colorado Attorney General Cynthia Coffman joined a class action suit against Purdue Pharma, alleging that the company "misled health care providers and consumers about the addiction risks associated with its painkillers." Coffman joins a plethora of other states and local governments suing Big Pharma for the impacts of the opioid epidemic.
The focus on reducing prescription rates would seem to be a logical first step — one of the oft-cited contributing factors to the current epidemic is unscrupulous marketing practices by pharmaceutical companies and manufacturers of opioid medication, and irresponsible prescription practices by medical providers. Take the case of Wheat Ridge's Dr. Kevin Clemmer. In 2013, he pleaded guilty to illegally distributing OxyContin. His practice was tied to at least three overdoses.
The VA has issued its own guidelines as part of its "Opioid Safety Initiative." In 2017, as part of the initiative, the VA and Department of Defense released clinical practice guidelines for the management of opioid therapy. According to the VA's website, "The guideline describes the critical decision points in the Management of Opioid Therapy (OT) for Chronic Pain and provides clear and comprehensive evidence based recommendations incorporating current information and practices for practitioners throughout the DoD and VA Health Care systems."
These guidelines are focused on addressing and preventing what the VA calls "opioid use disorder (OUD)," but which most people simply call addiction. The implementation of these guidelines is causing long-term opioid patients, like Gray, to be re-evaluated, and in many cases to have their medications adjusted. Providers are feeling pressure to ensure that opioid prescriptions are medically justified, and many are taking a conservative approach to pain management. According to Gray, her provider told her, "I'm not going to lose my license for any patients."
The medical community appears divided on how to best address these concerns. The prevailing medical opinion says the adverse effects of long-term opioid therapy outweigh the benefits. An article published in 2012 in the medical journal Primary Care Companion for CNS Disorders warns that "Through a variety of mechanisms, opioids cause adverse events in several organ systems. Evidence shows that chronic opioid therapy is associated with constipation, sleep-disordered breathing, fractures, hypothalamic-pituitary-adrenal dysregulation, and overdose. However, significant gaps remain regarding the spectrum of potentially opioid-related adverse effects. Opioid-related adverse effects can cause significant declines in health-related quality of life and increased health care costs."
But some providers disagree, and feel opioid therapy has a place in the treatment of chronic pain conditions such as nerve damage. In September 2018, over 100 medical professionals signed an open letter to the U.S. Department of Health and Human Services Pain Management Task Force over their concerns regarding "Forced Opioid Tapering," like the kind experienced by Gray.
"Rapid forced tapering can destabilize these patients, precipitating severe opioid withdrawal accompanied by worsening pain and profound loss of function. To escape the resultant suffering, some patients may seek relief from illicit (and inherently more dangerous) sources of opioids, while others may become acutely suicidal," the letter reads, emphasizing concern over "an alarming increase in reports of patient suffering and suicides within and outside of the Veterans Affairs Healthcare System in the U.S."
Considering those risks and consequences of the VA's new opioid guidelines, Gray offers the portrait of a model patient. She claims her opioid therapy isn't complicated by any co-morbid, trauma-induced psychological conditions like PTSD, or a history of substance abuse conditions, and she questions her recent decision to try CBD oil for her pain, saying, "I've never used an illegal drug in my life, and now I have to do this." (Though legal in Colorado, CBD is of questionable legality across the country.)
However, most of the VA's patients are more complicated than Gray. The recent wars in Iraq and Afghanistan have strained the resources of the VA, resulting in criticism and cries for reform from politicians. The veterans of the "Global War on Terror" are often dealing with behavioral health issues like PTSD in addition to any physical disabilities. Many veterans develop substance abuse disorder, which includes Opiate Use Disorder, in an attempt to manage their psychological pain. As the VA implements new guidelines to combat the opioid epidemic, many vulnerable combat veterans are finding themselves caught in the middle of a complicated conflict between medical professionals, politicians and the law enforcement community.