Symposium Focuses on Substance Use Disorder, Alternative Therapies, Military Readiness

SUD Symposium 2019

Symposium Focuses on Substance Use Disorder, Alternative Therapies, Military Readiness
By Bernard S. Little
WRNMMC Command Communications

“Opioid withdrawal is the single worst thing I’ve ever been through in my life, and that includes having my foot torn apart,” said Travis Rieder, a medical bioethicist with Johns Hopkins’ Berman Institute of Bioethics.

“Every minute of opioid withdrawal is excruciating,” he added. “It can turn your body…upside down, and just pull you apart from the inside out.”

Rieder served as guest speaker during the Annual Substance Use Disorder Symposium, hosted by the National Capital Region-Walter Reed Bethesda at the National Institutes of Health on Sept. 11. The symposium included a number of speakers and workshops focused on pain, dependency, addiction, and alternative therapies for treating all.

The author of “In Pain: A Bioethicist’s Personal Struggle with Opioids,” Rieder described his 2015 motorcycle accident which nearly claimed his left foot and resulted in numerous surgeries. He explained the good news is that he didn’t lose his foot, but the downside was in the struggle to save his foot, which included six different surgeries in three different hospitals and numerous teams of health professionals, he became dependent on pain medication. “It was horribly, horribly painful for a very long time because the doctors had to keep cutting on my foot,” he said. 

“Pain is suspicious,” Rieder continued. “It’s suspicious because it’s unverifiable, and you have to trust the patient’s testimony.” He added that when he sought medication for his pain, he began hearing words such as “drug seeker” and “malingering” from health-care providers. “We should retire that language because it’s not helpful,” he said. “I was really ashamed.” He added that this language helps stigmatize those seeking pain relief.

Clinicians are basically taught to be on the lookout for “drug seekers because it’s one of the worst things to be had…to have someone come in and complain of pain, for it not to be real, and you give them drugs anyway; so [providers become] cynical and suspicious,” Rieder furthered.

Eventually, doctors did prescribe Rieder various medication for his pain, but along with it he describes inadequate monitoring and follow-up by pain management teams. “I had a bunch of non-specialists picking up the protocol. It never occurred to me to ask about dependency, addiction, withdrawal [and] the struggles getting off the medication.”

Rieder said it got to a point at which he contemplated suicide. He described his experiences trying to get off prescription pain meds and the support he received from others, as being like a “hot potato…prescribers sent me to pain management, pain management sent me to the addiction clinic, the addiction clinic sent me to prescribers, and no one seemed to see routine withdrawal maintenance as their job.” 

Despite the challenges, Rieder weaned himself off pain meds.

“So how did we get to this point?,” asked Rieder.

He explained the nation’s first opioid epidemic can be traced back to the Civil War, when Soldiers were prescribed morphine to alleviate their pain from war injuries and developed dependencies and addictions to the drug.

“That was enough to scare politicians, policy makers and the public so much that we started the pharmaceutical arms race, continuing today, with companies trying to develop more potent and safer opioids,” Rieder said. He added heroin was later introduced on the scene with the claim as being less habit-forming than morphine, but both can be highly addictive. Heroin is more potent than morphine, and it’s easier and cheaper to get than morphine in most cases. Oxycodone was later introduced on the market, also with claims that it was safer and more effective, attributing to the rise in the number of people who developed dependencies and addictions.

“We’ve been here before,” Rieder said. “We’ve been to the place where a glut in the supply combined with the message that these are safe and effective drugs led to an epidemic, and we’ve seen the response before…we got terrified.”


“We have to stop the pendulum swing,” Rieder continued. “Opioids are really complex drugs and we still haven’t been teaching doctors how to use them.” He explained many clinicians don’t get a lot of pain education in medical school, so there’s a knowledge gap. He encouraged aspiring doctors to seek advanced training in addiction medicine.

Rieder also encouraged “ethically responsible prescribing,” which includes “appropriate initiation, appropriate management and appropriate discontinuation.” He explained a concern is pain meds being prescribed to patients for too long, leading to dependencies and addictions. “The longer you’re on opioids, the more it hurts to get off. I know what it felt like to get off of opioids after two months, and it was excruciating. Dependence starts in the first couple of days if you’re on opioids around the clock.”

He added responsible prescribing includes education, management of the patient, counseling, long-term following and having an exit strategy. “’De-prescribing’ is part of prescribing, and that’s never been a part of the pain management culture in the United States or at large.”

“The opioid crisis is really driven by the number of overdose deaths,” said Jane Acri, chief of the Medications Discovery and Toxicology Branch of the National Institute on Drug Abuse and another symposium presenter. She added that in 2017, there were 70,237 overdose deaths, 9.6 percent higher than 2016.

According to the Centers for Disease Control and Prevention, from 2013 through 2017, more than 67,000 people died of synthetic-opioid-related overdoses, most from fentanyl, which is more potent than heroin. In 2018, another approximate 31,500 Americans died, according CDC figures.

Acri discussed the evolution of the current opioid crisis, explaining that since 2005, overdose fatalities from fentanyl and heroin have overtaken overdose deaths attributed to prescription opioids. She agreed with Rieder, stating, “the increase in opioid prescribing is really behind the opioid epidemic from the starting 1996 [with the marketing of] oxycodone.”

Some providers spoke of pain as “the fifth vital sign,” a measure of health included with blood pressure, pulse, temperature and respiration, Acri explained. Therefore, many accepted pain relief as a fundamental human right, which may have also contributing to the over prescribing of pain medicine leading to dependency and addiction.


“Addiction is a brain disease,” Acri stated, explaining that “drugs hijack the brain. When you take drugs, they influence the brain and cause certain changes.” She added when the drugs are removed, those changes and effects generally continue. “In that sense, the brain is altered. You don’t just wake up with brain disease; it happens as the use of drugs causes changes we can characterize as brain disease.”  

“Medication-assisted treatment saves lives,” she added. 

U.S. Public Health Service Vice Adm. (Dr.) Jerome Adams, the 20th U.S. Surgeon General, has urged more Americans to carry the overdose antidote naloxone to help combat the country’s opioid crisis and save lives. 

“You decrease mortality by treating people with the available medications,” Acri said. “The problem is we don’t have very many places where people can get medication-assisted treatment [for opioid use disorder].”

Acri, Rieder and Adams emphasize that naloxone alone will not solve the opioid crisis, and should instead be used in conjunction with expanded access to evidence-based treatment. Acri explained evidence-based interventions for opioid use disorder include vaccines under development to target drugs in the bloodstream and prevent them from reaching the brain and exerting euphoric effects; transcranial magnetic stimulation (TMS); and buprenorphine, methadone and naltrexone. Providers stress that medications should be combined with behavioral counseling for a holistic approach to care.

Alternative treatments for pain include acupuncture, meditation, exercise, TMS, hypnosis, sleep therapy, spirituality, therapeutic movement (tai chi), yoga, as well as nutrition and herbal therapies.


Navy Capt. Eric Welsh, director of the Department of Defense Office of Drug Demand Reduction Program, stressed that the office he oversees “enables operational readiness, safety, and security of the Total Force by deterring illicit and prescription drug abuse through robust and dynamic drug testing; emerging drug threat surveillance; prevention, education, and outreach efforts; and development of new testing procedures.

“Drug use is incompatible with operational readiness,” he added.

Welsh stated that prescription drug abuse/misuse crosses all age groups and military personnel. He added that the bottom line goal of the ODDR include providing a safe, secure, mission ready Total Force,” which require an effective program for deterring and detecting drug abuse through frequent random testing. The office is also focused on educating service members on the adverse consequences of drug use.

“Drug testing is a proven means to enable commander to objectively assess readiness, safety and security,” Welsh explained. “Trends are in the right direction, but we need to remain vigilant and agile to address emerging drug threats,” he said.

“One of the big things that we have learned is that social support and social influence play a big role in prevention of substance use disorders, as well as in support of people who are working through substance use disorders,” said Navy Capt. Kimberly Elenberg, program manager for the Defense Health Agency Population Health Program. 

Elenberg added that DoD has a multi-pronged approach to address substance misuse and increase readiness among service members, including health education, campaigns, policy initiatives and service-level program. “It takes a lot to serve, and it takes a lot of strength,” she said.

In addition, “the DoD counter-marketing campaigns are a critical element in support of the Secretary of Defense’s line of effort to increase force lethality and improve readiness, the 2009 National Defense Authorization Act that mandates smoking cessation programs in the DoD, as well as the NDAA 2017 requirement to prevent, educate and treat prescription opioid drug abuse,” Elenberg explained. “Without a preventive initiative to address and combat this issue, these factors will continue to negatively impact readiness and resilience,” she added.

For more information about the You Can Quit 2 campaign, focused on tobacco cessation, visit

For information regarding the Own Your Limits campaign, which offers responsible drinking information, visit

For information concerning the Substance Abuse and Mental Health Services Administration, visit

The Center for Substance Abuse Treatment (CSAT) can be reached 24/7 at 1-800-662-HELP (4357).

The National Suicide Prevention Lifeline is at 1-800-273-TALK (8255) and offers free and confidential support for people in distress, 24/7.


Article 5/16/2019 A change of address may mean new TRICARE health options

A change of address, such as moving to a new country, city, region, or ZIP+4 code is a TRICARE Qualifying Life Event (QLE). This QLE means you have 90 days from the date of your address change to enroll in or change your TRICARE Prime or TRICARE Select health plan based on your eligibility or plan availability in the new location. (U.S. Navy photo)


Article 4/24/2020 Be Cyber Aware: COVID-19 Myths vs. Facts

While your attention is focused on staying safe and healthy at this time, don’t take your eye off cybersecurity measures. Whether you’re working from home or browsing social media sites, you’re a target for scammers taking advantage of the COVID-19 national health emergency.



Article 2/4/2020 DoD releases guidance to protect forces from novel coronavirus

Acting Undersecretary of Defense for Personnel and Readiness Matthew P. Donovan released a guidance letter for force health protection specifically relating to the novel coronavirus. In it, Donovan states that DoD will follow guidance by the Centers of Disease Control and Prevention.


Article 4/16/2020 Get Familiar with Your Emergency and Urgent Care Options

During the COVID-19 crisis, you may have more questions than usual about where to seek care or even the level of care you need. Now is the time to learn the difference between emergency and urgent care, and the rules for your TRICARE health plan. That way, you can get the appropriate treatment you need.

Article 2/27/2020 Got Feedback About TRICARE Publications? Take the Survey

Do you love TRICARE newsletters, or are fact sheets answering your questions? TRICARE wants to hear your feedback. Your comments, suggestions, and questions help to create better content and improve your TRICARE benefit resources.


Article 4/16/2020 How to Help: Delay Routine and Elective Medical and Dental Procedures

To keep up with self-distancing practices due to COVID-19, you should strongly consider rescheduling certain medical and dental appointments. Your health care provider may have already contacted you to reschedule your appointment. Be sure to check on the availability of telehealth and teledentistry appointments as an option to address your health care.


Article 2/20/2020 Join Feb. 27 TRICARE Webinar on TRICARE For Life

Do you have questions about TRICARE For Life (TFL)? Not sure if you’re eligible for TFL, or how TFL coverage works? Join the “What is TRICARE For Life?” webinar on Feb. 27, from 1 to 2 p.m. ET to get your TFL questions answered.




Article 4/2/2020 Possible Military Pharmacy Changes Due to COVID-19

Do you use a military pharmacy? If so, there may be temporary limitations that result in a decrease in service or closure at your pharmacy due to COVID-19. To maintain patient and personnel safety, you may have to temporarily switch your prescription to TRICARE Pharmacy Home Delivery or to a TRICARE retail network pharmacy.


Article 4/2/2020 Staying Mentally Fit During Social Distancing

Are you experiencing cabin fever? If so, you’re not alone. Sudden lifestyle changes and extended time at home is a reality for many during the COVID-19 outbreak.


Article 3/12/2020 Tracking COVID-19: Know the Symptoms and How to Get Care

Take action and stay informed about the new coronavirus, also known as COVID-19. Simple measures can protect you and your community. It’s also important to identify the symptoms of COVID-19 and know when to seek help.

Article 7/11/2019 Traveling Overseas? Know How to Get Care With TRICARE

If you’re planning to travel overseas this summer, your TRICARE coverage goes with you. However, the rules vary based on your sponsor status, your location, and your health plan. Familiarize yourself with your plan’s rules and these tips so you know what to do if you have health issues while traveling overseas.

Article 3/27/2020 TRICARE Covers Certain Telemedicine Services in the U.S.

TRICARE covers certain telemedicine services. You may be able to see a TRICARE-authorized provider without leaving your home. Using a computer or smartphone, you connect with your provider by secure video conferencing.

Article 2/20/2020 TRICARE Dental Coverage Options Keep Your Smile Healthy

Let’s kickoff National Children’s Dental Health Month by looking at how you can keep your and your family’s smile healthy with TRICARE dental options. If you’re new to TRICARE dental or need a refresher, there are three dental options. These options are separate from TRICARE health care options

Article 12/12/2019 TRICARE Expands Care With New Policy Changes

TRICARE recently expanded coverage for beneficiaries who meet certain criteria. Coverage now includes: concurrent pediatric hospice and curative care, portable continuous positive airway pressure (CPAP) machine, and platelet rich plasma injections.

Article 4/2/2020 TRICARE Extends Temporary Telehealth Support for Applied Behavior Analysis Services

TRICARE is taking new steps to support family members in the Autism Care Demonstration (ACD). From March 31 to May 31, TRICARE will temporarily cover telehealth support for applied behavior analysis (ABA) parent or caregiver guidance services. This is to help support ACD beneficiaries during social distancing and the COVID-19 respons

Article 4/24/2020 TRICARE Offers Telehealth Services for Mental Health Care

The Military Health System is working to provide you with health options while you practice social distancing to combat the coronavirus pandemic. TRICARE covers telehealth services to include otherwise-covered mental health services.

Article 3/27/2020 TRICARE Pharmacy Home Delivery Brings Your Prescriptions to Your Door

When practicing social distancing, you may want an alternative to having to travel to the pharmacy. Now is a good time to ensure you have adequate medication on hand to cut down on leaving the house. The TRICARE Pharmacy Program gives you three ways to get up to a 90-day supply of your covered prescriptions, including delivery right to your door.


Article 1/15/2020 What You Need to Know if You’re New to TRICARE

If you’re newly enrolled in TRICARE health or dental coverage, you’re in good company. You now have access to a global network of military and civilian providers. Learning about your health care coverage now will help you maximize your benefit and take command of your health in 2020.

Article 4/24/2020 With TRICARE, Help From a Nurse is Just a Call Away

With TRICARE and the Military Health System (MHS) Nurse Advice Line, you can. Whether you’re dealing with an ankle sprain or a sore throat, you can use the MHS Nurse Advice Line and get health advice from a registered nurse anytime, at no cost, from the comfort of your home.


Last Updated 5/13/2020