buffer-overrun

On Sunday, I heard another NPR piece about super high rates of opiate prescriptions to veterans by the VA (this seems to be the text of what I heard), and there were a lot of things that didn’t quite fit together in the story, and I am looking for someone who knows more about the situation.

I should preface this by saying that I think that the US has problems with both underprescribing and overprescribing of opiates.  Research has shown that some kinds of pain respond well to physical therapy.  But good physical therapy is expensive, and a lot of times insurance doesn’t cover enough PT for it to actually be useful.  So people are given opiates long term even though they aren’t the best treatment.  I would guess that something similar is happening with the VA – veterans need treatments, for PTSD and/or physical injuries, that are expensive and labor intensive, and the VA is overwhelmed and is using opiates as a stop gap measure, and apparently not giving people good overdose prevention tools (i.e. education and narcan).  There is also an issue of managing prescriptions. Is someone escalating their use of opiates as they develop tolerance?  Would a different opiate work better? Is someone being prescribed both opiates and sedatives in a way that is putting them at higher risk for overdose? But some people also have a lot of problems accessing humane pain medication and humane opiate substitution therapy.

The story made a really big deal about veterans being given opiates when they didn’t have physical injuries, and so I’m wondering if the VA is intentionally prescribing opiates for PTSD.  Which might actually be a good treatment – the scientific research is kind of a mess in this area.  Also, apparently, people with PTSD can experience pain more intensely, so higher doses of painkillers might be necessary.

There were also a lot of people saying that known addicts were being given opiates.  But it wasn’t clear what people meant by addiction – physical dependency? DSM definition (use that is detrimental to family, intimate relationships and work responsibilities)?  Is opiate maintenance or opiate substitution being lumped into “giving opiates to addicts”?

Clearly the VA is prescribing high dose opiates and people are ODing on them, but how much of this is a failure to give narcan and eduction?  Is the VA detoxing people without appropriate overdose education?  Would some people be better off on buprenorphine, which has a lower risk of overdose? 

There were so many questions that the reporters didn’t address, that it left me really confused about what is actually happening.