There is a time for everything. Now is the time for the Department of Veterans Affairs to go opioid-free.
When I first began practicing medicine at the VA, it was common to “prescribe” alcoholic beverages to veterans. Many VA hospitals even listed whiskey, wine, and beer on their formularies to make patients “more comfortable.” Although benzodiazepines were the recognized standard of care for alcohol withdrawal, some veterans preferred alcohol, and the VA accommodated them.
A 2006 survey revealed this practice persisted at many VA Medical Centers until it was finally prohibited around 2010.
We knew that alcohol-related illnesses were widespread among veterans. The National Health and Resilience Veterans Study, found 40.8 percent of U.S. veterans report lifetime Alcohol Use Disorder, and 10.5 percent meet criteria within the past year. Nationwide, alcohol-related disorders account for more than $250 billion in medical costs annually — with the VA’s share estimated at over $10 billion.
Years later, when I was leading the VA healthcare system, I discovered the VA still had no ban on smoking at its facilities. In fact, the VA maintained nearly 1,000 designated smoking areas. Veterans had a higher incidence of tobacco- and smoking-related illnesses than the general population. Yet it wasn’t until October 2019, that all VA healthcare facilities prohibited veterans from smoking, and not until January 2020, that the VA extended this ban to employees, creating a fully tobacco-free environment.
Opioid prescribing followed a similar trajectory. Like most physicians trained two decades ago, I was encouraged to use opioids liberally to ease suffering, and the VA was no exception. In 2012, opioids accounted for 21.2 percent of all prescriptions for veterans — nearly 900,000 patients.
Recognizing the dangers of opioid use disorder, the VA launched the Opioid Safety Initiative in 2013. This effort reduced prescription opioid use by 64 percent — from more than 679,000 veterans in 2012 to about 247,000 today. The program cut long-term opioid use by 70 percent and high-dose prescribing by 80 percent.
Still, opioid use disorder did not peak until 2017 and remains at unacceptably high levels. The consequences are devastating: veterans with opioid use disorder are more than six times as likely to report suicidal behavior. Thousands of veterans each year die by overdose, with women veterans facing twice the suicide risk of non-users. The economic impact is equally severe, exceeding $16,000 annually per veteran with opioid use disorder, not including overdose-related costs.
Despite progress, opioids remain common in acute pain management — particularly after surgery. More than half of veterans receive opioids upon surgical discharge, and roughly 10 percent of those patients later develop opioid addiction.
The real opportunity lies in preventing opioid initiation. The moment for this is here, becuse new non-opioid medications are providing viable alternatives.
This year, the FDA has approved the first selective sodium channel blocker for acute pain. Additional advances are emerging with different mechanisms of action, including drugs targeting peptide-receptors that appear to provide effective pain relief without the addictive risks of opioids.
The VA’s comprehensive, integrated system makes it uniquely positioned to lead the nation in eliminating opioid use and become the first opioid-free health system in the country. While it would be inappropriate to abruptly discontinue opioids for current chronic users, the VA could immediately begin limiting opioids for acute pain and adopt new alternatives. By combining these new non-addictive pharmacologic options with multimodal pain management, the VA can significantly reduce — and eventually eliminate — chronic opioid use.
With the right leadership and a thoughtful plan, the VA could be an opioid-free health system by 2030. Just as we no longer prescribe alcohol or allow tobacco on VA campuses, the day will come when we look back and wonder why opioids were ever part of routine care.
The precedent is clear. The tools are here and more are coming. The time is now.
The Honorable David Shulkin, MD, was the ninth secretary of the Department of Veterans Affairs in the Trump administration and VA’s Under Secretary of Health in the Obama administration.
