By Michael Komorn
03/18/2018 08:01 am ET Updated 26 minutes ago
From America’s Warriors To Victims Of Its Opioid Epidemic
“All they want is pain relief.” By Erin Schumaker and Anna Almendrala JI SUB JEONG/HUFFPOST When Cpl. Darin Adams got back from serving in Iraq in 2009, he suffered from sharply painful back spasms ― a lingering symptom of an injury from falling off a ladder in the armory during his second deployment. After the fall, it didn’t occur to him to take off any time to rest, and he resumed carrying his 75-pound rucksack the next day.
By the time Adams, now 32, returned home, the pain was so bad that he sometimes couldn’t sleep at night or walk more than a few steps around the house. He took ibuprofen to ward off the pain, but his back spasms worsened until 2012, when the pain became so severe that he couldn’t get out of bed some mornings. Finally a doctor at the Veterans Administration put him on a low-dose opioid, which he began taking almost every day.
Adams worked as a manager at Walmart, which included lifting heavy boxes. He said if he hadn’t been taking opioids, it would have been impossible to do his job.
SCOTT OLSON VIA GETTY IMAGES Retired Army Sgt. Noah Galloway of Birmingham, Alabama, arrives at Afghanistan’s Bagram Airfield on March 12, 2014. Galloway lost an arm and a leg to an explosion in Iraq in 2005. He was one of five wounded soldiers visiting Afghanistan with the Troops First Operation Proper Exit program, which brings wounded servicemen back to Iraq and Afghanistan to help them come to terms with their injuries. Adams is one of the thousands of Iraq War vets who came home with chronic pain.
Saddled with injuries that veterans from previous wars would never have survived, 60 percent of military members who fought in the Middle East were returning with chronic pain, a significantly higher rate than older veterans getting care from the VA. And their timing couldn’t have been worse: By 2005, two years into the Iraq War, 10 million Americans were taking prescription opioids for long-term pain relief.
But as prescription rates grew, so too did rates of overdose, accidental death and use of illicit opioids.
A dangerous pattern of pain, prescription and misuse was emerging among veterans. They were encountering serious harm overseas, receiving liberal amounts of prescription painkillers for their injuries and then bringing dangerous coping strategies back home with them.
A 2013 study on veterans who served after 9/11 illustrates this cycle well. “Joel” suffered serious injuries after a roadside bomb exploded near his tank. During his recovery program, the doctor prescribed hundreds of pills at a time, even though Joel had serious risk factors for addiction.
“They were giving me pain pills, I was getting Percocet, Vicodin. I was getting fucking OxyContin, Oxycodone. If I fucking wanted it, they would give it to me, no doubt about it,” Joel told the study researchers.
“I used to get like 460 at a time!” Joel continued. “[I told my doctor,] `Look I’m a heavy drinker,′ and he was like, ’Well, just take one before you start drinking, about an hour before you start, and then don’t take anymore after that until the morning.”
Opioid prescription in the Veterans Administration health system skyrocketed 270 percent from 2001 to 2012. VA patients were twice as likely as other Americans to die of accidental opioid overdoses, according to a 2011 study, and another study found that 13 percent of all veterans taking opioids had an opioid-use disorder ― about 68,000 people.
By 2012, the VA had already started to look critically at their doctors who had been excessively prescribing opioids.
So by the time soldiers like Adams sought treatment, the VA was asking them to take mandatory classes at the VA pain clinic, and he spoke with a specialist about the dangers of opioid addiction. A year later, Adams appealed to the VA to approve surgery on his pinched nerve, which was causing his muscle spasms. But for the VA to sign off on the surgery, Adams had to do six months of physical therapy first.
In the end, physical therapy paid off. The more stretches and exercise Adams did, the less he needed his daily painkiller. By the end of the six-month waiting period, he had reduced his opioid use to one pill a month.
By medical standards, Adams’ decrease in the use of opioids is a success story. But his success was hard fought. For many other veterans who were prescribed opioids after returning from Iraq and Afghanistan, the daily pressure to live pain- and opioid-free is a continuing struggle.
“I guess I’m a unicorn,” Adams said, recounting that he just followed his doctor’s instructions closely. “It was successful for me, but it’s not successful, unfortunately, for everyone.”
DARIN ADAMS Darin Adams and future wife Laura Tull at her parents’ house in Waterloo, Iowa. (2006) By 2005, two years into the Iraq War, 10 million Americans were taking prescription opioids for long-term pain relief. From 1999 to 2010, prescription opioids sold to hospitals, pharmacies and doctors’ offices nearly quadrupled, according to the U.S. Centers for Disease Control and Prevention, while the amount of pain Americans reported stayed the same. So when vets started coming back complaining of chronic pain, their doctors ― largely employees of the Veterans Administration ― provided them with opioids just as they would any patient.
Opioid painkillers appeared to be effective at treating pain, were quick to prescribe and, unlike the morphine drips of yore, were simple to administer by pill. Best of all, according to pharmaceutical representatives, they weren’t addictive. Doctors’ beliefs about opioids’ efficacy were similarly misguided. Not only do opioids present serious risks, including addiction and overdose, they’re not even an effective medicine for chronic pain relief. A recent study by VA researchers in Minneapolis found that over-the-counter pain relievers like Tylenol and ibuprofen, neither of which contains opioids, are slightly more effective chronic pain treatments than opioids.
The medical community at large was lulled into a false sense of security about prescribing opioids until 2011, explained Louis Celli, the national director of veterans affairs and rehabilitation at the American Legion, a nonprofit veterans organization.
“This drug is extremely addictive,” Celli said. “There was less concern in the beginning, until this national epidemic took hold.”
Another constellation of factors made veterans more susceptible to opioid addiction. Men who enlist in the army are twice as likely as other Americans to have been sexually abused as children and to have grown up in an environment that included domestic violence and substance abuse. Moreover, 1 in 5 soldiers who volunteer to join the Army had disorders such as intermittent explosive disorder, post-traumatic stress disorder or attention deficit hyperactivity disorder before enlisting, which all increase one’s risk of addiction.
If the opioid epidemic were factored into the Iraq and Afghanistan body counts, that count would be staggeringly high. Many men and women who enlist are predisposed for substance abuse issues even before they’re issued uniforms. When soldiers from the Iraq and Afghanistan wars returned home, many had gruesome injuries that would have killed soldiers in past generations who didn’t have access to the same medical technologies. And now opioids were considered to be a safe and non-addictive first line treatment and were extensively prescribed to these returning soldiers.
Worst of all, insufficient research about treating veterans addicted to high-dose pills means that today’s best practices for treating veterans addicted to opioids are based on weak data. In this science-free environment, tapering off high-dosage opioids is akin to an act of faith.
THE WASHINGTON POST VIA GETTY IMAGES OxyContin is among the opioids often prescribed to veterans with long-term pain. In an effort to lower the risk of overdose and death among veterans taking opioids, the VA has taken incremental steps to lower new prescriptions, help veterans taper off existing medications, allow different centers within the VA to share data on opioid prescriptions for individual patients and be more transparent about how many opioids are being prescribed.
Consequently, change on opioids has come swiftly. From 2012 to 2017, opioid prescriptions are down 41 percent among patients, and the decrease is spread out across 99 percent of the VA’s facilities. Veterans who seek treatment after these shifts on opioids are benefiting from additional education on addiction risk, an emphasis on non-pharmaceutical or non-opioid therapies, and opioid prescriptions with lower doses.
In contrast, no other medical system in the U.S. releases comprehensive data on opioid prescriptions, and while almost all states now have databases that can track opioid prescriptions and flag patients for strange activity, most states don’t require doctors to check the database before issuing a prescription to a patient. VA doctors, on the other hand, are required to check the database before starting new patients on opioids.
Dr. Kenneth Goldberg, chief of staff and acting director of the Durham VA Healthcare System in North Carolina, is not Adams’ doctor, but he said that his story is an example of what the VA is doing right when it comes to opioid prescription.
“We want to get them on the lowest possible dose that we can,” Goldberg said. “One pill a month was his number. It’s not zero, but it’s definitely better than where it was.”
While the VA has continued to implement wide-ranging new policies that have resulted in steep cuts to their prescription rates, others who work closely with veterans say that these efforts have left some veterans scrambling for ways to manage their pain and may even be pushing them toward illicit drugs.
A 2017 study on Afghanistan and Iraq war veterans who had overdosed found that the transition to illicit, risky drugs like heroin was driven in part by the growing scarcity of prescription opioids, said Alex Bennett, a program director of the Opioid Overdose Prevention Program at National Development and Research Institutes who authored both this paper and the 2013 study that interviewed “Joel.” If veterans can’t stretch their limited opioid prescriptions until their next refill, some supplement that prescription with street drugs.
“In a place like New York City, it is roughly a dollar or two per milligram of Oxy, and a bundle of heroin can be purchased for $60, so people tend to do a cost-benefit analysis,” Bennett said. “Let’s say I have 60 Percs ― I can get rid of those, manage my pain and eat.”
For instance, “Barber,” a 54-year-old Army veteran featured in Bennett’s study, explained that when the prescribed Percocets weren’t enough to get him through to the next refill, he decided to sell the pills on the street and then use that money to buy heroin, which provided more relief for the two bulging vertebral discs in his spine.
“These are self-care and self-management strategies, in many ways,” Bennett said.
Because of this potential pipeline to illicit drugs, as well as other concerns, Dr. Stefan Kertesz, a frontline caregiver and long-term addiction researcher who teaches at the University of Alabama at Birmingham, isn’t convinced that everyone who takes high-dosage prescription opioids should be tapered off them as much as possible.
“If a patient is currently functioning OK from their point of view, [and then] if you change something that leaves them afraid they’ll function worse, that can be pretty violative,” Kertesz said.
Without scientific evidence, there’s no proof that weaning veterans off high doses of opioids protects their health. And without that scientific backing, some patients may be better off staying on opioids.
The existing data on tapering patients’ opioid doses is pretty bleak. A 2017 review of all tapering studies to date finds that among people who volunteer to have their opioid intake reduced, there is only low-quality evidence to suggest that their chronic pain levels and quality of life will improve once they decrease their opioid use. Keep in mind that these results are only for those who actually want to reduce their opioid consumption, said Kertesz, and doesn’t include participants like these veterans, who might feel like the VA is reducing their opioid intake against their will.
“Certainly we have no solid studies on involuntary mandatory dose reductions at all,” Kertesz said. “That should trouble you, because that means we’re flying blind.”
But scant high-quality evidence that tapering off opioids will make people safer doesn’t mean that we should accept the status quo, Goldberg explained.
“I don’t think any patient should take any medication that’s not really helping them,” Goldberg said.
This is especially because the status quo exposes veterans to opioid tolerance, overdose and death, said Dr. Chris Marx, who works alongside Goldberg as a psychiatrist at the Durham VA Medical Center.
“These are not medications without risk,” she said.
As for Adams, while he was skeptical about how physical therapy could help manage his back pain, he was pleasantly surprised by the results. By the end of the six-month waiting period, Adams’ back pain was so well-controlled that he decided to forgo the surgery altogether. Now he takes ibuprofen in addition to continuing his twice-a-day stretching routine. He still has an opioid prescription, but it’s for 25 pills a year — a far cry from his once-a-day routine — and he rarely uses them.
“The best advice I can give to a vet is if there is an alternative treatment, such as physical therapy, give it an honest shot,” he said. “There was a period of time that I didn’t think physical therapy was working, [and] I had to go a few times before I found a physical therapist that helped me see the light.”
Erin Schumaker Senior Reporter, HuffPost Anna Almendrala Senior Reporter, HuffPost https://www.huffingtonpost.com/entry/iraq-war-opioid-addiction-veterans_us_5aa17569e4b0d4f5b66eb332
Washington, D.C. -- State lawmakers are calling on the federal government to change its drug laws to let states experiment with marijuana and hemp policy.
The National Conference of State Legislatures, the de facto bipartisan group of lawmakers, passed a resolution at its annual meeting Thursday calling on the federal government to amend the Controlled Substances Act to authorize state marijuana laws and on the administration to keep its nose out of state pot policies.
CITY HALL — The city's first medical marijuana cultivation center is one step closer to operating.
The Zoning Board of Appeals took the first step toward approving a Chicago cultivation center for medical marijuana Friday, passing a proposal from a city trucking and strip-club magnate.
The board approved a special-use permit for a proposed cultivation center in Hegewisch put forward by Custom Strains, owned by Perry Mandera, who also owns the Custom Companies trucking and Cardinal Fitness firms, as well as VIP's, which touts itself as the city's only "full liquor and topless bar," at 1531 N. Kingsbury St.
In a marathon session that ran from the morning into the evening, the board also approved a permit for a Custom Strains dispensary for medical marijuana at 1105 W. Fulton Market, over some community resistance.
The two facilities still must earn state approval as Illinois implements the medical-marijuana law passed last year. The city will have a maximum of one cultivation center and 13 dispensaries.
The cultivation center was the first to earn a special-use permit. It would be located on an eight-acre site at 12233 S. Avenue O, between Wolf Lake and the Calumet River, but also near Interstates 90, 94 and 57. It would produce an estimated 4,500 pounds of medical marijuana a year, as well as processing it into topical oil and edible forms for ease of use by patients.
Mandera testified Friday that he was bringing in experts experienced in the field from Colorado and Michigan, where medical marijuana has long been legal, to run the center, and that his own background in trucking would aid in distribution to dispensaries.
The board was somewhat squeamish in approving its first permit for a cultivation center.
"If I had sticky fingers ... how does the system catch me?" Chairman Jonathan Swain said. "That's my largest concern."
Brett Roper, of Colorado's Medicine Man Technologies, testified that the Bio Track system follows plants from seedlings to finished product with weights down to the gram and beyond. "You typically know pretty quickly," Roper said, if there's any "pilferage."
Perry Mandera (center) listens to Hunter Sutterfield (l.) testify at Friday's Zoning Board of Appeals meeting.
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Robert Gedville, of Guardian Security Systems, said the facility would have 110 surveillance cameras, linked to the State Police and the state Department of Agriculture.
Earlier in the day, Mandera testified that he has run Custom Companies since 1986 and Cardinal Fitness 21 years. He acknowledged he owns a business with a liquor license and a public entertainment license, but never mentioned it was a strip club, and the board never raised the issue. He said he had never been arrested or convicted of a crime, and has never had a business fail or filed for bankruptcy for any business.
Mandera said that, if the dispensary were approved, he'd offer a 10 percent discount for veterans on all medical marijuana. Mandera said he served in the Marine Corps.
Hunter Sutterfield, who would be brought in from running a dispensary in Tempe, Ariz., to handle the operation, testified that prices were typically $50 for an eighth of an ounce or or 3.5 grams, $20-$30 for a gram, consistent with "street value" by state statute.
The "intent," they said, was to use the Custom Strains cultivation center if approved.
The cultivation center had the support of Ald. John Pope (10th), but the Fulton Market dispensary met some public resistance before it won approval from the board.
Six dispensaries' permits were approved Friday, including a permit for a Jefferson Park facility, as well as dispensaries at 4568 S. Archer Ave., 5648 S. Archer Ave., 2723 N. Elston Ave. and 500 W. 18th St. The board denied a permit for a Wicker Park dispensary at 1811 W. North Ave. after questioning the applicants on what Swain called "subjective" security arrangements.
Colorado's 40 casinos — and hundreds of others, including in the gaming mecca in Las Vegas — are bound by the same money-reporting rules that have made banks reluctant to let legal marijuana businesses open bank accounts, federal authorities now say.
That means casinos can keep anyone associated with legal weed enterprises — from dispensary to grow operations — away from gaming tables anywhere in the country.
And if they do allow them to play, casinos must file the same suspicious activity reports banks must file whenever they handle money derived from pot profits, according to the Financial Crimes Enforcement Network, a division of the U.S. Department of the Treasury.
"FinCEN's guidance applies to all financial institutions covered under FinCEN regulations, including casinos," FinCEN's public affairs director Stephen Hudak told The Denver Post.
Because the government says casinos are financial institutions, like banks, they must have stringent anti-money-laundering programs in place.
Filing suspicious activity reports, or SARs, to crack down on money laundering by criminal and terrorist organizations is not new for casinos.
What is new is that it now extends to the legal marijuana trade.
While FinCEN in February announced how banks could work with legal marijuana businesses, the government only now realized it extends to casinos.
That's in any casino in the country — whether in Colorado, Atlantic City or Las Vegas — on land, on water or on sovereign American-Indian soil. So a casino on the Las Vegas strip would, by law, have to pay attention to the owner of a marijuana dispensary in Colorado who heads there to gamble.
Currently, 22 states have legalized the sale of medical marijuana and two — Colorado and Washington — have legalized recreational sales. Colorado and 41 other states have some form of legal casino gambling.
The news — revealed June 12 at a Las Vegas conference directed at curtailing money laundering — has stopped state regulators and the casino industry in its tracks.
"The (Colorado) Division of Gaming was unaware of the FinCEN guidance," spokeswoman Cameron Lewis told The Post. "Division management will be taking this matter under discussion."
Similarly, the Colorado Gaming Association, the trade group that represents the state's casinos, was unaware of the requirement.
"To my knowledge, we have not been contacted by FinCEN regarding any issues dealing with ... marijuana suppliers," executive director Lois Rice said.
Like banks, casinos must "know their customer" and have some knowledge of their source of funds. The casino industry keeps close track of gamblers through a variety of methods including high-roller clubs, frequent-player programs and other in-house incentives.
"Casinos most comply with the government's guidance on filing suspicious-activity reports" said Jim Dowling, an anti-money-laundering consultant.
"Their alternative is to not conduct a financial transaction with these individuals who were involved directly, or indirectly in the MJ business," said Dowling, a former IRS agent who was also an adviser on money-laundering issues to the White House.
Because marijuana is illegal under federal law, FinCEN's requirements for doing business with the marijuana industry modified how financial institutions are to file SARs.
The reports must now reflect that clients are in states where marijuana sales are allowed.
Although the pot industry saw it as a first step in obtaining banking services — and more recent efforts have included the theoretical creation of a marijuana financial cooperative — Colorado banks have mostly shied from opening the door too widely.
The marijuana-specific reports would either identify the cannabis-related business or employee as legally operating under appropriate guidelines, identify them as one conducting suspicious activity, or as one where the casino has ended its banking relationship "in order to maintain an effective anti-money-laundering" compliance program.
The seven-page guidance also notes a number of "red-flag" scenarios that would require a bank or casino to file a SAR, including for a customer "depositing cash that smells like marijuana" who might be trying to conceal involvement in marijuana-related business activity.
"There are a number of ways money laundering can occur in a casino," Dowling said, "and keeping track of this is very labor-intensive."
FinCEN Director Jennifer Shasky Calvery told attendees at the Las Vegas conference that it's no secret casinos are targets of organized crime.
"Illicit actors are also looking to game the system so that they can move or hide funds among the many cash and non-cash transactions you conduct daily," she said. "Think about what happens each time a customer enters your casino. Often, the first thing a customer does is conduct a financial transaction — they buy chips. And the last action a customer takes is usually also a financial transaction — they cash out those chips."
Casinos, like banks, must know who is bringing them money, she said, and meeting that obligation relies on the casino's ability to understand with whom it is doing business.
"It's one thing when it's organized crime or terrorist money laundering, when the individuals might be unknown," Dowling said. "It's quite another matter when it's a licensed business and the individuals associated with it are indeed known."
With a dispensary's difficulty in obtaining a banking relationship, casinos could become an easy substitute.
For instance, "chip walking" — when chips are not redeemed — is a well-known problem at casinos. A marijuana business without a bank account could choose to pay its employees with casino chips, which are redeemed for cash, a transactions that is, by definition, now laundered.
Chips purchased with marijuana-derived funds also can be redeemed for cash or a casino's check, which could then be deposited into a personal bank account.
Though Colorado has a $100 limit on the size of a bet, there is no limit on how many chips a customer can purchase. FinCEN's rules require casinos to file SARs when it "knows, suspects, or has reason to suspect" a transaction is suspicious, but only when the amount of money involved — typically buy-ins or cash-outs — is at least $5,000, at once or in a single day.