The time for the Department of Veterans Affairs to move away from opioids is now.
When I began practicing medicine with the VA, it was not unusual to see prescriptions for alcoholic beverages granted to veterans. Many hospitals openly included whiskey, wine, and beer on their lists to “enhance patient comfort.” Benzodiazepines were standard for alcohol withdrawal, but some veterans simply preferred alcohol, and the VA accommodated them.
A survey from 2006 showed that this practice continued in several VA medical centers until it was put to an end around 2010.
We were aware of the rising incidence of alcohol-related health issues among veterans. According to the Veterans’ Research into National Health and Resilience, nearly 41% of U.S. veterans reported having alcohol use disorders in their lifetime, with about 10.5% meeting the criteria in the past year. Nationwide, alcohol-related issues represent approximately $250 billion in medical costs each year, with the VA’s share estimated at over $10 billion.
Years later, while leading the VA Healthcare system, I learned that smoking had not been banned within the facilities. The VA had around 1,000 designated smoking areas, and veterans incurred smoking-related health issues at a higher rate compared to the general population. It wasn’t until October 2019 that the VA banned smoking altogether, extending the prohibition to employees by January 2020, achieving a completely smoke-free environment.
The trajectory of opioid prescriptions mirrored this situation. Like many medical professionals of my time, I was taught to use opioids for pain relief, and the VA was no exception. By 2012, opioids comprised about 21.2% of all prescriptions for veterans, affecting roughly 900,000 patients.
In 2013, recognizing the dangers of opioid dependency, the VA launched the Opioid Safety Initiative. This effort, rather significantly, contributed to reducing opioid prescriptions by 64% — from over 679,000 veterans in 2012 to around 247,000 now. The program cut long-term opioid use by 70% and decreased high-dose prescriptions by 80%.
Still, opioid use disorders peaked around 2017 and have remained distressingly high. The consequences are tragic: veterans with opioid use disorders are more than six times likely to report suicidal thoughts. Each year, thousands of veterans succumb to overdoses, with female veterans facing double the suicide risk compared to non-users. Economically, the impact is severe, surpassing $16,000 per veteran annually—excluding costs related to overdose incidents.
Despite some improvements, opioids remain prevalent in managing acute pain, especially post-surgery. Reports indicate that more than half of veterans receive opioids at surgical discharge, and about 10% of those subsequently develop an addiction.
The crucial opportunity lies in preventing initial opioid use. That opportunity is now, as new non-opioid medications offer promising alternatives.
This year, the FDA approved the first selective sodium channel blocker for acute pain relief, alongside other innovative drugs targeting various pain relief mechanisms without the inherent risks of addiction.
The VA’s comprehensive system has the unique capacity to eliminate opioids entirely, potentially positioning itself as the nation’s first opioid-free healthcare institution. While abruptly stopping opioids for existing users isn’t advisable, the VA could soon start limiting opioid prescriptions for acute pain and pursue new treatment options. By integrating these novel pharmacological alternatives with a multi-faceted approach to pain management, the VA could vastly reduce and ultimately phase out chronic opioid use.
Through effective leadership and careful planning, the VA has the potential to achieve an opioid-free healthcare system by 2030. Just as we once wondered about prescribing alcohol or allowing smoking on VA grounds, we may soon look back and question why opioids were ever part of standard care.
The path ahead is clear. The resources are available, and there are even more innovations on the horizon. The time has come.
David Shulkin served as the ninth secretary of the Veterans Affairs Bureau during the Trump administration and was also part of the Obama administration’s health team.
