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

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.”

STOPPING THE PENDULUM SWING

“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

“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.

THE MILITARY

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 https://www.ycq2.org.

For information regarding the Own Your Limits campaign, which offers responsible drinking information, visit https://www.ownyourlimits.org.

For information concerning the Substance Abuse and Mental Health Services Administration, visit https://www.samhsa.gov.

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.


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