Culture Change Needed Around Addiction Treatment in the Military

More work is needed to address how addiction is handled both within the military and for veterans after they serve. Removing the stigma around addiction treatment is key to addressing the issue, Anthony Dekker, DO, Northern Arizona VA Healthcare System, said at the AMSUS annual meeting on December 4, 2019.

“When we are talking about treating addiction in the military and the VA, those are 2 different issues,” Dr. Dekker said. “In the VA, it should be understood this is a service that needs to be provided. In the military, it is highly dependent on command. Some commands are in favor of treatment. Some commands are in favor of separation.”

But that separation comes with a cost. Dr. Dekker noted that the military spends about $200,000 to get a person from recruitment to an E-5 pay grade and about $400,000 to an O-5 pay grade. That can be a huge investment loss considering the cost of treatment for someone who is suffering from a use disorder.

“Treatment is going to cost about $44,000,” he said. “That will be treatment in a residential center. That was a person who is serious enough to come into a residential center, follow up with a partial hospital program and continue with ongoing [treatment] that would last a year.”

He touted some of the successes addiction treatment programs have had, recalling data from 2008-2009 from 110 military active-duty service members treated across 5 residential treatment centers in the Washington, DC, area. Within a year, 91% had separated from the military either because of a command decision before treatment or because of loss of recover.

“We know what works in addiction,” he said, noting that program changes that involved using a combination of medication-assisted treatments with regular substance use screenings and medical practitioner follow-up has helped to reduce the rate of lost recovery to 12%. He also noted that in 2013-2014, 41 active military members who received treatment in the same centers were able to be redeployed to Afghanistan and had no relapses during that deployment. 

“We try to take the stigma away,” Dr. Dekker said. “So if you have leadership who has a stigma against addiction treatment, you are going to have a steep incline to work against, whereas if you have leadership that were, I would say, endowed with a different sense of knowledge and experience,” there is a much greater chance for helping both military service members and veterans alike.

He called on the US Department of Veterans Affairs (VA) to look more closely at how it is prescribing opioids. While acknowledging the opioid addiction epidemic, he noted that simply cutting back on prescribing may not be the right solution because it is having a ripple effect and causing other problems, namely that although the VA has written 60% fewer opioid prescriptions from 2012 to 2019, overdose rates have doubled as military members and veterans are seeking opioids from other sources outside of a controlled, safer medical environment.

It can be especially problematic for those who have a legitimate medical need for opioids but have a disqualifying event that causes the pain medication to be cut off.

“We need to have a different answer to this because termination of opioids because a patient is positive for marijuana or even positive for cocaine doesn’t mean you take services away. You ramp services up,” Dr. Dekker said. “If I have a patient who has a chronic pain syndrome, the only thing that is going to push him out of my system is if they threaten my staff.…The loss from recovery is not a reason to lose treatment. That is another concept that needs to be addressed and we need to really look at that.”

He also called on VA leadership to be more encouraging in prescribing buprenorphine, noting that many doctors and nurses have waivers to prescribe it, but there is a lot of reluctance to do so, even though there is a lot of success with that treatment.

More work is needed to address how addiction is handled both within the military and for veterans after they serve. Removing the stigma around addiction treatment is key to addressing the issue, Anthony Dekker, DO, Northern Arizona VA Healthcare System, said at the AMSUS annual meeting on December 4, 2019.

“When we are talking about treating addiction in the military and the VA, those are 2 different issues,” Dr. Dekker said. “In the VA, it should be understood this is a service that needs to be provided. In the military, it is highly dependent on command. Some commands are in favor of treatment. Some commands are in favor of separation.”

But that separation comes with a cost. Dr. Dekker noted that the military spends about $200,000 to get a person from recruitment to an E-5 pay grade and about $400,000 to an O-5 pay grade. That can be a huge investment loss considering the cost of treatment for someone who is suffering from a use disorder.

“Treatment is going to cost about $44,000,” he said. “That will be treatment in a residential center. That was a person who is serious enough to come into a residential center, follow up with a partial hospital program and continue with ongoing [treatment] that would last a year.”

He touted some of the successes addiction treatment programs have had, recalling data from 2008-2009 from 110 military active-duty service members treated across 5 residential treatment centers in the Washington, DC, area. Within a year, 91% had separated from the military either because of a command decision before treatment or because of loss of recover.

“We know what works in addiction,” he said, noting that program changes that involved using a combination of medication-assisted treatments with regular substance use screenings and medical practitioner follow-up has helped to reduce the rate of lost recovery to 12%. He also noted that in 2013-2014, 41 active military members who received treatment in the same centers were able to be redeployed to Afghanistan and had no relapses during that deployment. 

“We try to take the stigma away,” Dr. Dekker said. “So if you have leadership who has a stigma against addiction treatment, you are going to have a steep incline to work against, whereas if you have leadership that were, I would say, endowed with a different sense of knowledge and experience,” there is a much greater chance for helping both military service members and veterans alike.

He called on the US Department of Veterans Affairs (VA) to look more closely at how it is prescribing opioids. While acknowledging the opioid addiction epidemic, he noted that simply cutting back on prescribing may not be the right solution because it is having a ripple effect and causing other problems, namely that although the VA has written 60% fewer opioid prescriptions from 2012 to 2019, overdose rates have doubled as military members and veterans are seeking opioids from other sources outside of a controlled, safer medical environment.

It can be especially problematic for those who have a legitimate medical need for opioids but have a disqualifying event that causes the pain medication to be cut off.

“We need to have a different answer to this because termination of opioids because a patient is positive for marijuana or even positive for cocaine doesn’t mean you take services away. You ramp services up,” Dr. Dekker said. “If I have a patient who has a chronic pain syndrome, the only thing that is going to push him out of my system is if they threaten my staff.…The loss from recovery is not a reason to lose treatment. That is another concept that needs to be addressed and we need to really look at that.”

He also called on VA leadership to be more encouraging in prescribing buprenorphine, noting that many doctors and nurses have waivers to prescribe it, but there is a lot of reluctance to do so, even though there is a lot of success with that treatment.

More work is needed to address how addiction is handled both within the military and for veterans after they serve. Removing the stigma around addiction treatment is key to addressing the issue, Anthony Dekker, DO, Northern Arizona VA Healthcare System, said at the AMSUS annual meeting on December 4, 2019.

“When we are talking about treating addiction in the military and the VA, those are 2 different issues,” Dr. Dekker said. “In the VA, it should be understood this is a service that needs to be provided. In the military, it is highly dependent on command. Some commands are in favor of treatment. Some commands are in favor of separation.”

But that separation comes with a cost. Dr. Dekker noted that the military spends about $200,000 to get a person from recruitment to an E-5 pay grade and about $400,000 to an O-5 pay grade. That can be a huge investment loss considering the cost of treatment for someone who is suffering from a use disorder.

“Treatment is going to cost about $44,000,” he said. “That will be treatment in a residential center. That was a person who is serious enough to come into a residential center, follow up with a partial hospital program and continue with ongoing [treatment] that would last a year.”

He touted some of the successes addiction treatment programs have had, recalling data from 2008-2009 from 110 military active-duty service members treated across 5 residential treatment centers in the Washington, DC, area. Within a year, 91% had separated from the military either because of a command decision before treatment or because of loss of recover.

“We know what works in addiction,” he said, noting that program changes that involved using a combination of medication-assisted treatments with regular substance use screenings and medical practitioner follow-up has helped to reduce the rate of lost recovery to 12%. He also noted that in 2013-2014, 41 active military members who received treatment in the same centers were able to be redeployed to Afghanistan and had no relapses during that deployment. 

“We try to take the stigma away,” Dr. Dekker said. “So if you have leadership who has a stigma against addiction treatment, you are going to have a steep incline to work against, whereas if you have leadership that were, I would say, endowed with a different sense of knowledge and experience,” there is a much greater chance for helping both military service members and veterans alike.

He called on the US Department of Veterans Affairs (VA) to look more closely at how it is prescribing opioids. While acknowledging the opioid addiction epidemic, he noted that simply cutting back on prescribing may not be the right solution because it is having a ripple effect and causing other problems, namely that although the VA has written 60% fewer opioid prescriptions from 2012 to 2019, overdose rates have doubled as military members and veterans are seeking opioids from other sources outside of a controlled, safer medical environment.

It can be especially problematic for those who have a legitimate medical need for opioids but have a disqualifying event that causes the pain medication to be cut off.

“We need to have a different answer to this because termination of opioids because a patient is positive for marijuana or even positive for cocaine doesn’t mean you take services away. You ramp services up,” Dr. Dekker said. “If I have a patient who has a chronic pain syndrome, the only thing that is going to push him out of my system is if they threaten my staff.…The loss from recovery is not a reason to lose treatment. That is another concept that needs to be addressed and we need to really look at that.”

He also called on VA leadership to be more encouraging in prescribing buprenorphine, noting that many doctors and nurses have waivers to prescribe it, but there is a lot of reluctance to do so, even though there is a lot of success with that treatment.