VA turns to alternative pain treatments amid opioid crisis
WHITE RIVER JUNCTION, Vt. — Navy veteran Jake O'Neill turned to opioids — some prescribed, some illicit — to ease the lower-back pain that left him in near-constant agony.
O'Neill's degenerative arthritis became so bad that just leaning over to pull on a pair of socks could put him in traction. The opioids Vicodin and OxyContin helped him cope, but at a heavy cost. He became dependent on them and eventually addicted several years ago.
"It became less about the pain," said O'Neill, 47, of Springfield, Vt.
Now, O'Neill is clean. Physical therapy and acupuncture, among other alternative pain treatments at the veterans hospital here, have replaced the stream of opioids that had hijacked his life.
O'Neill's experience is part of a dramatic shift at the US Department of Veterans Affairs, which has sharply reduced the use of opioids to treat chronic pain in favor of once-unlikely alternatives such as yoga and tai chi.
In the vanguard of that movement is the White River Junction VA Medical Center, whose pain clinic has cut opioid prescriptions by 42 percent, particularly among veterans who had been receiving the heaviest dangerous doses.
"It used to be most patients would be on opioids," said Dr. Julie Franklin, who supervises the hospital's pain clinic. "That's not the case any longer."
The decline has been striking. The total number of VA patients at White River Junction that received opioids for chronic pain plummeted from 2,088 in early 2014 to 1,221 late last year.
The change has been even more dramatic among veterans who receive the highest doses, the equivalent of more than 400 milligrams of morphine a day. The number of those patients has shrunk from 26 in early 2014 to only four in late 2017.
For veterans who receive the equivalent of 300 to 399 milligrams of morphine a day, the total has sunk from 34 to two.
With the opioid crisis still raging, this embrace of holistic treatments is designed to help prevent veterans from developing addictions and allowing others to recover from theirs, specialists said.
"We've definitely saved some lives. We've helped a lot of veterans," Franklin said.
Pain is rampant among veterans. Nearly 60 percent of Iraq and Afghanistan veterans are afflicted by chronic pain, as are more than 50 percent of older veterans. Many have returned home with battlefield injuries, but even more suffer back ailments, nerve damage, headaches, and other forms of severe pain that come with age and inadequate treatment.
The VA and many of America's physicians, aggressively encouraged by drug makers, once dispensed opioids as the default remedy for pain. From 2001 to 2013, opioid prescriptions in the VA system increased 270 percent while the number of patients rose less than 40 percent, according to the Center for Investigative Reporting.
"Because of their aggressive use of opioids, they wound up with an enormous problem," said Dr. Andrew Kolodny, co-director of the Opioid Policy Research Collaborative at Brandeis University. "Tens of thousands of veterans ended up addicted."
Over the last several years, opioid prescriptions have fallen across the VA system. But what helps set White River Junction apart is its pain clinic, which pays extensive, detailed attention to veterans on the highest doses of opioids, Franklin said.
The clinic manages their pain and opioid use separately from the primary-care treatment veterans receive at the VA, allowing specialists to focus exclusively on that front.
As a result, high-risk patients are seen "as often as needed for safety and support," Franklin said. "We don't tell our patients that they need to reduce opioid doses and see them six months later. We're there with them every step of the way."
Many patients referred to the clinic have never been on opioids but instead have avoided their use because of the multidisciplinary treatment. But for high-risk veterans with chronic pain, tapering off large amounts of opioids can be grueling and complicated.
"Just because we're now figuring out that opioids are not good drugs for the vast majority of people with chronic pain, that doesn't mean that people who are on opioids can come off easily," Kolodny said.
But by embracing alternative treatments, offering options that include acupuncture and pool therapy to reduce opioid use, the clinic is gaining wider attention. US Representative Annie Kuster, a Democrat from New Hampshire, is preparing legislation on VA pain care that would draw from White River Junction's work.
Under that plan, at least six veterans hospitals around the country would be designated a "center of excellence," where an integrated team of specialists would manage and develop pain care, much like the system used in Vermont. A national pain-care coordinator would be established within the VA.
At White River Junction, the pain-management team includes physicians, a nurse practitioner, a pharmacist, and the help of a psychologist. Together, they coordinate care for individual veterans and often refer them to chiropractic services, physical therapy, and classes about coping with pain.
Kuster and other officials hope the centers will benefit other VA hospitals by sharing expertise and lessons learned with the nationwide system.
She sees broad promise in the approach at White River Junction, which cares for veterans in Vermont and four New Hampshire counties that border the state.
"Dr. Franklin's focus on developing unique pain-management plans for each individual recognizes that pain management cannot be one-size-fits-all," Kuster said. "Dr. Franklin's work has the potential to serve as a model throughout the VA and civilian medical community."
Last year, the pain clinic and rehabilitation services were placed in a joint unit that Franklin oversees. Dr. Derek Golley, a chiropractor, said that the staffs are in regular communication and that he often treats veterans from the clinic.
Baron Tang, a physical therapist at White River Junction, credited the hospital's holistic approach with giving veterans a renewed sense of control over their lives.
"We give them coping strategies to address specific needs," Tang said. "And if we can give them strategies that are active, rather than looking at pills, then that patient will be empowered."
O'Neill, the Navy veteran, said his treatment at White River Junction — including a procedure called radio frequency ablation, which blocks pain signals from nerve fibers — has significantly reduced his pain, and with it the temptation to turn to drugs.
Without regular attention at the clinic, O'Neill said, he would be hunting for opioids, legal or not. "They're doing anything and everything to keep me from failing," O'Neill said. "I'm not being dropped like a hot potato at the side of the road."
Franklin said she worries that fewer opioids at the VA could send veterans searching for street drugs. But the clinic rarely cuts off patients against their will, she said, and there is little evidence veterans look elsewhere.
Instead, many of them are looking to the clinic, where healthier options are available.
"I feel that we do help people feel better," Franklin said.