A three-time Purple Heart recipient, Vietnam veteran Donald Elverd spent two years in Army hospitals, recovering from shrapnel wounds that ravaged his body. One bullet had pierced a lung; another, his arm. Bone splinters filled his chest.
When Sergeant Elverd of the 25th Infantry Division was discharged in 1970, he walked out of the Army “with a lifetime prescription from the VA.” From there, he dove headfirst into a downward spiral of drug addiction.
“If someone had said to me, 'If you take these drugs, you could become addicted,' I'd say to them, 'Give it to me [anyway]. I hurt,' ” he recalls.
So Elverd intimately understands the struggles of military officers who come to the Hazelden Betty Ford Foundation in St. Paul, Minn., for opioid-addiction treatment. Now a senior psychologist at Hazelden, he has helped veterans overcome addiction and mental health issues for 24 years. He sees everyone from junior officers to generals and admirals. They want to live without pain, and they see opioids - natural or man-made chemicals that can reduce pain - as the only way to manage it, he says.
Washington takes note
In July, lawmakers and health care professionals met in Washington, D.C., to discuss how the country's opioid epidemic affects the military community. Veterans are twice as likely to die from an accidental opioid overdose compared to the general population, according to a 2011 study of the VA health system. Active duty military personnel have a lower level of illicit drug use than civilians, but their abuse of prescription drugs is higher - and on the rise. In 2008, 11 percent of servicemembers reported misusing prescription drugs, up from 2 percent in 2002 and 4 percent in 2005. Most drugs that are abused are opioid medications.
This year across the U.S., there will be more deaths tied to drug overdoses than there are names on the Vietnam Veterans Memorial - more than 58,000 - according to Rep. Tim Murphy, a commander in the Navy Reserve who practices psychology at Walter Reed National Military Medical Center in Bethesda, Md., and spoke at the July meeting.
As veterans come home with wounds and disabilities from far-flung conflicts, they join the ranks of the nationwide opioid epidemic. Whether from bouncing around in a Humvee, walking long patrols, or standing guard duty, many servicemembers and veterans experience chronic pain, a debilitating condition that often is difficult to treat. A 2014 study in JAMA Internal Medicine examined the prevalence of chronic pain and opioid use among 2,500 soldiers following deployment. Forty-four percent had chronic pain, and 15 percent regularly used opioids - rates much higher than the general population.
“In the veteran population, we have a lot of people with neck and back injuries,” Murphy said. “Just about anyone who carried around a backpack of 100 pounds [or] 120 pounds ended up with arthritis or some other pain - and there's a big push for opioids.”
Murphy said the drugs were “everywhere he landed” after he was injured in a rollover accident in Iraq in November 2005. Unlike other health vitals, pain levels aren't measured by machines. Instead, troops and veterans are told to describe their pain based on a subjective scale from one to 10.
“ 'Here's some morphine, here's some fentanyl, here's something else,' ” he said. “That's the way it's done.”
Too many servicemembers are returning from overseas missions addicted to opioids, said Sen. Joe Manchin, who serves on the Senate Committee on Veterans' Affairs and also spoke at the July event.
“They can get a concoction of anything they want just to get through the day,” he said. “There have got to be better ways of treating this.”
When some of those servicemembers return home, they hit up VA clinics to try to get access to the same medications they were able to get “free rein on for so long,” Manchin said. “If they don't get it, then they call the senator or the congressman's office raising Cain about not getting good treatment from the VA, so we put pressure on the VA,” he said. “It's just a conglomeration of things that we've got to get through.”
Pleasure versus pain
Prescription opioids attach to parts of the brain called pleasure centers, creating a feeling of happiness or well-being. The drug makes the sensation of pleasure stronger than pain. Some common prescription opioids include Vicodin, Percocet, OxyContin, and morphine.
“Most people, if they have to choose between pain and being numb, they go with numb,” Elverd explains. “I see them here every day. These aren't dopers, addicts, or criminals. They just hurt.”
Most people who become addicted to opioids have had surgery or a serious injury, says Dr. A.J. Marsden, a former Army sergeant and surgical nurse who now is an assistant professor of human services and psychology at Beacon College in Leesburg, Fla.
“The doctor gives them painkillers, and they slowly keep taking it, and it escalates out of control,” Marsden says.
Marsden, who was stationed as a reservist at the 325th Combat Support Hospital in St. Louis from 2002-06, witnessed veterans battling opioid addiction.
“Opioid addiction is sneaky. It's slow. It takes over your life without you realizing it,” Marsden says.
Veterans with chronic pain experience much higher rates of comorbidities such as post-traumatic stress and traumatic brain injury, which may contribute to pain-management challenges. The addiction can hit veterans especially hard as they process traumatic experiences connected to their injuries. This trauma can exacerbate their ability to cope with physical discomfort, says anesthesiologist Dr. Peter Abaci, the medical director of Bay Area Pain and Wellness Center in Los Gatos, Calif., and author of Conquer Your Chronic Pain: A Life-Changing Drug-Free Approach for Relief, Recovery, and Restoration (New Page Books, 2016).
Furthermore, emotions tied to an event that led to surgery or injury can affect one's ability to manage pain, Abaci says. For example, suppose a lawyer gets into a car accident. Across town the same day, a businessman is beaten and robbed in a parking lot after work. Despite similar injuries, the businessman might have more trouble with the pain during recovery due to the trauma of being assaulted. If trauma is not well-managed, addiction may ensue.
“The opioids help ameliorate that anxiety,” Abaci says. “It takes over everything - the decision making and how they feel - and they latch onto that. It's the only thing to calm them down, and they can potentially develop addiction from there.”
Anesthesiologist Dr. Christopher Spevak notes our perceptions are linked to centers in the brain that regulate pain. He is the director of the National Capital Region Opioid Safety Program at Walter Reed.
“With a traumatic event, the pain will proceed differently than, for example, an elective surgery. We can address all the underlying issues and take those into account. It's important, because people get better faster and back to health when this is addressed,” Spevak explains.
To avoid dependence on opioids before addiction can even take hold, Abaci and Spevak recommend holistic treatment, or treating the whole person. This might mean bringing in counselors or psychologists, dieticians, physical therapists, and other professionals in addition to a surgeon.
Spevak says troops at Walter Reed have clamored for nonmedicated ways to combat pain, and he and his team have encouraged them to take up yoga, physical therapy, meditation, tai chi, and other behavior-based practices.
“During this last conflict, we've really … advanced our understanding of pain and also the treatment of substance use disorder,” Spevak says. “We're making progress.”
How to help
It can be especially difficult for military officers in leadership positions to admit they have an addiction problem. And for those concerned about troop readiness, spotting signs of opioid addiction among their peers or enlisted troops is challenging, too.
As a psychologist at Betty Ford, Elverd has worked with many officers seeking help for opioid addiction. He has one consistent message for them: “You understand suffering and sacrifice. We want you to use the same skills you learned for the battlefield here. You're in another war. This is also life and death.”
Family members who want to get help for a loved one should educate themselves about addiction before confronting them, Marsden says. (See “5 Ways to Support a Loved One's Recovery,” www.moaa.org/recoverysupport, for more information.)
“Don't ever offer an addict an ultimatum. Don't ever say, 'It's the drugs or me.' It tells them you don't take it seriously, that they can choose it cold turkey,” Marsden says. “Approach them with compassion [and] empathy and try to get them to understand you're not blaming them for anything - that you're there to listen and want to do what's best for them.”
Officers in a position to counsel troops should know addicts are less likely to report their problem to a superior or someone in their direct chain of command because of perceived negative consequences, Marsden says.
“They're more likely to tell friends and coworkers,” Marsden says. “So the officer needs to make it comfortable for the friends and coworkers to talk to superiors.”
“If they think you'll kick the person out, tell them that's not true,” Marsden continues. “The military has lots of programs. [See “Resources,” at right.] Make sure everyone in your chain of command knows the resources. And you may think opioid addiction is not an issue for your own troops. But have a general meeting where you let them know that you know it's a problem and that there will be a compassionate and empathetic response, and that you will help them.”
Active duty officers and retirees must keep a close eye on their servicemembers and other veterans to spot prescription drug abuse, says Maj. Jim Wiggs, ANG (Ret). Wiggs, a MOAA member, is a prior-enlisted airman who retired from the Air National Guard in 2006 and now works at Cigna, a global health insurance provider on a quest to curb opioid abuse by 25 percent over the next year-and-a-half.
“The senior enlisted and officers need to be very in tune with the men and women serving underneath them and with them,” says Wiggs, who coleads Cigna's veteran colleague resource group.
It's important for officers to encourage their troops to be open about that kind of pain without fear of it negatively impacting their careers. If troops do require medication to treat their pain, Wiggs says officers should encourage them to stay away from addictive narcotics.
Preventing addiction in the ranks makes it less likely for veterans to abuse opioids. That's an important step in preventing accidental overdoses or suicides.
“I don't want to see them find the bottom of the bottle,” Wiggs says.