{"id":1253,"title":{"rendered":"The Fifth Vital Sign: An Overview of the Opioid Crisis and Its Effects on Veterans"},"content":{"rendered":"

\r\nJeremiah Fues\u200a1<\/a>\u200a<\/span><\/sup> That is 3,675 American being lost every three weeks. To add perspective, the terrorist attacks on September 11, 2001, claimed 2,997 lives compared to the 3,675 lives lost every three weeks to opioid addiction. It is because of data like this, and the countless stories of how opioid addiction has destroyed lives and families, that on October 26, 2017, President Donald Trump declared the opioid crisis a national public health emergency.\u200a4<\/a>\u200a<\/span><\/sup> The significance of this letter is that it helped to alleviate medical providers\u2019 doubts about prescribing opioids, as an alternative therapy, for fear that patients may become addicted. After the letter mentioned above, more articles\/studies were published attesting to the same general theme that analgesics could be used as an alternative form of therapy and to reduce patients\u2019 pain without a realistic fear of addiction.\r\n<\/p>\r\n

\r\nFor example, in 1986, a study published by the Journal of Pain stated that analgesics can be safely and effectively prescribed to selected patients with relatively little risk of producing the maladaptive behaviors which define opioid abuse.<\/q> The study went on to state that [w]e conclude that opioid maintenance therapy can be a safe, salutary and more humane alternative to the options of surgery or no treatment in those patients with intractable non-malignant pain and no history of drug abuse.<\/q>\u200a7<\/a>\u200a<\/span><\/sup> To the authors\u2019 credit, they mention the need for long-term studies on the use of analgesics to treat chronic pain \u2014 something that has yet to be done. This article represented a growing shift in the medical community \u2014 that chronic pain is something that can be safely treated, should be thought of as a non-invasive alternative therapy, and should be something that doctors try to alleviate. \r\n<\/p>\r\n

\r\nThis is where Dr. James Campbell stepped into the light to advocate for doctors to treat a patient\u2019s pain and see pain as a fifth vital sign. Dr. Campbell was the president of the American Pain Society and, back in 1996, Dr. Campbell gave a keynote speech advocating greater awareness about pain and trying to change medical providers\u2019 philosophy regarding pain treatment. Dr. Campbell stated in his 1996 speech, If pain were assessed with the same zeal as other vital signs are, it would have a much better chance of being treated properly.<\/q> While Dr. Campbell advocated for medical providers to be trained in treating pain generally, he also advocated for a shift in treating chronic pain with opioids. Around the same time as Dr. Campbell\u2019s speech, prescription opioids were just hitting the market for the treatment of pain. Dr. Campbell\u2019s speech not only highlighted a problem, but also shed light on the recent pharmaceutical developments that offered a solution. In fact, OxyContin, a powerful prescription opioid, had been released on the market in 1996 \u2014 the same year as Dr. Campbell\u2019s speech. An even further coincidence is that during Dr. Campbell\u2019s presidency of the American Pain Society, the organization received funding from Purdue Pharmaceutical \u2014 the manufacturer of OxyContin.\u200a8<\/a>\u200a<\/span><\/sup> It should be noted that this is neither the first nor the last time a pharmaceutical company has funded movements, launched advertising campaigns, or created educational<\/q> events for medical providers just to market their pharmaceuticals \u2014 but, the ethics of Big Pharma is a topic for another paper.\r\n<\/p>\r\n

\r\nAfter Dr. Campbell\u2019s speech, the Fifth Vital Sign Movement was born. Dr. Campbell\u2019s speech illuminated an unnecessary epidemic of doctors\u2019 undertreatment of pain. It was unnecessary,<\/q> because medical providers now had prescription opioids. Government officials soon joined the fray advocating for medical providers to do more to treat patients\u2019 pain. Specifically, the Veterans Health Administration (VHA) stepped in to bridge the gap and to make pain the fifth vital sign. According to Vox, an online investigative journalism site, In November 1998, the Veterans Health Administration sent a memo to its 1,200 clinics requiring clinicians to ask patients\u2019 about their pain level at each visit. The initiative was called Pain as the 5th Vital Sign.<\/q> A pain score above 4 was meant to trigger a comprehensive pain assessment and prompt intervention.<\/q><\/q>\u200a9<\/a>\u200a<\/span><\/sup> The memo has since been taken down from the VA\u2019s website. It is with this back drop that we take a closer look at the VA\u2019s implementation of pain assessment and management through the Fifth Vital Sign.<\/q> It\u2019s clear that the VHA wanted to bring a prompt response to the under treatment of pain, but the VHA\u2019s plan was premature and its execution led to unforeseen consequences for veterans at VA hospitals.\r\n<\/p>\r\n

\r\n<\/a>III. The VA and The Fifth Vital Sign\r\n<\/h2>\r\n

\r\nWhen the VA implemented assessment plans for medical providers to use to treat patients\u2019 pain its actions provided an example to the rest of the American healthcare community to follow. For the first time, the VA was receiving praise for being at the forefront of patient care. To say that the VA was not influential in promoting the Fifth Vital Sign philosophy is an understatement. Around the time that the VA was implementing the Fifth Vital Sign project, it was the largest trainer of healthcare professionals and treated around 3.5 million patients a year. At the beginning of March 1999, veterans began to be assessed for the pain they were experiencing. A Washington Post article at the time discussed the VA\u2019s Fifth Vital Sign Movement project in assessing patient pain stating, VA officials said the change in routine is designed to call physicians\u2019 attention to what is widely considered one of the most unrecognized and untreated symptoms in American health care. In a study of 10,000 dying patients published in 1995 in the Journal of the American Medical Association, for instance, researchers found that almost half died in severe pain; other studies report that as many as three-quarters of advanced cancer patients are in pain.<\/q> The article discusses many reasons why the VHA project was needed and how patients, up to that point, did not discuss pain with doctors for fear it was either a worsening of the condition or distracted the doctor from the real issues.<\/q>\u200a10<\/a>\u200a<\/span><\/sup> Some veterans were suffering from PTSD and already had substance abuse disorders, yet the VA still prescribed them opioids, essentially feeding their addictions. While an entire book could be written on the shortcomings of the VA in treating veterans with mental health disorders, the fact that veterans suffering from PTSD were being prescribed not only psychotropic drugs and sedatives but also opioids illustrates another way opioids affected veterans \u2014 it led to overdoses. The over-prescribing of opioids is merely a symptom of the larger problem, which is that the VA haphazardly prescribes multiple drug cocktails without knowing how they work in concert to one another. \r\n<\/p>\r\n

\r\nA study done in 2011, by Amy Bohnert, a VA researcher at the University of Michigan, illustrates the VA\u2019s overdose problem. According to the study, Ms. Bohnert found that veterans were more likely to die from accidental overdoses than from suicides.\u200a18<\/a>\u200a<\/span><\/sup> On top of that, many facilities do not offer a variety of alternative therapies. In 2014, one in ten VA hospitals offered at least one form of alternative therapy ranging from things like yoga and meditation to acupuncture.\u200a26<\/a>\u200a<\/span>\u200a26\u200a<\/span>Mitch Mirkin, Complementary and Alternative Medicine: yoga, acupuncture and more<\/cite>, Blogs.va.gov<\/a><\/span> (2014).<\/span><\/sup> There remains hope for change in this area, though. In June 2017, a bill was introduced into the House of Congress in response to many insurance companies not covering accupuncture treatment, called the Acupuncture for Our Heroes Act,<\/q> which would provide veterans with the options to receive acupuncture. \u200a27<\/a>\u200a<\/span>\u200a27\u200a<\/span>H.R. 2838, 115th Cong. (2017)<\/a>.<\/span><\/sup> Why is the lack of alternative therapies a problem? The VHA has advocated for years for alternative therapies to be used to treat chronic pain, yet the VA facilities have not caught up and are not able to provide what the VHA is asking. More importantly, if insurance companies do not respond by covering alternative therapies, it makes no difference for the VHA to promote alternatives, because it is not possible for veterans to receive them. \r\n<\/p>\r\n

\r\nAlso, the VHA and the government in general are trying to combat the opioid issue from the clinician\u2019s perspective. The idea being that if they educate doctors more on the safe way to use opioid therapy, or avoid it altogether, they can reduce addiction and abuse. However, attacking the opioid crisis from one side is short-sighted and fails to reflect reality. As mentioned previously, doctors often deal with patients who ask for certain prescriptions drugs. This is because in the United States, it is legal for pharmaceutical companies to provide Direct to Consumer (DTC) advertising. Interestingly, only two countries in the entire world allow DTC advertising for pharmaceuticals that promote a product\u2019s claim \u2014 the United States and New Zealand.\u200a28<\/a>\u200a<\/span>\u200a28\u200a<\/span>C. Lee Ventola, Direct-to-Consumer Pharmaceutical Advertising: Therapeutic or Toxic?<\/cite>, 36 Pharmacy and Therapeutics 669\u2013684<\/a><\/span> (2011). <\/span><\/sup> The reason why DTC for pharmaceuticals is not allowed in most other countries is because advertising works too well. Almost every pharmaceutical commercial or advertisement says the phrase, ask your doctor,<\/q> and patients do ask their doctors. DTC advertising puts additional pressure on medical providers because they must worry about their patients demanding certain drugs or going to someone else if they do not give the patient what they want.\r\n<\/p>\r\n

\r\nTo be fair, there are some benefits to DTC pharmaceutical advertising. One benefit is that it educates patients about certain illnesses or diseases that they have but did not realize they have. For example, many commercials that advertise treatment for Chrons disease often start out by educating audiences about the symptoms of Chrons. Thus someone could see the commercial, see that they have the same symptoms, and go to a doctor to receive treatment. One critique on DTC for pharmaceutical advertising is that they can be misleading. For example, some critics argue that the advertisements give false expectations by showing actors who are allegedly suffering from the illness smiling and happy after taking the advertised drug. A more relevant example is Purdue Pharmaceutical\u2019s 1998 OxyContin promotional video. It features a doctor by the name of Alan Spanos stating that opioids are the best form of treatment for chronic pain. He cites the same article mentioned in the beginning of this paper, which discusses how addiction for pain patients is less than one percent and that opioid treatment is the most effective treatment for pain suffers.\u200a29<\/a>\u200a<\/span>\u200a29\u200a<\/span>Purdue Pharma OxyContin Commercial<\/cite>, Youtube.com<\/a><\/span>.<\/span><\/sup> This is very similar to what big tobacco used to do when they had medical doctors state that smoking cigarettes was safe. We know now that opioids drugs are highly addictive, but for patients, including veterans, such statements from a medical doctor influence them into believing that opioid therapy is safe and encourages them to ask their doctor about opioid drug therapy, which was a factor contributing to the opioid crisis. There was a demand for opioids created by pharmaceutical advertising and doctors fulfilled the demand.\r\n<\/p>\r\n

\r\nThe federal government, specifically the FDA, should promote stricter regulation on pharmaceutical advertising by requiring that statements made by any medical professional in an advertisement be supported by scientific evidence that has not been funded by a pharmaceutical company. Also, advertisements should reflect more of the realities of illness and not present images of actors returning to normal<\/q> after taking a medication. Additionally, advertisements should educate consumers and patients that medication alone may not be enough to treat their symptoms so as not to down-play the benefits of healthy nutrition and exercise. While the VHA is not directly responsible for the accountability of ethical pharmaceutical advertising, as one of the largest providers in the healthcare system, it should use its influence, and coordinate with other governmental agencies, so they can promote more ethical regulation on pharmaceutical advertising. By stopping misleading information at the consumer\/patient level, the VHA and healthcare system in general may see a downturn in patients asking doctors for opioid therapy. \r\n<\/p>\r\n

\r\n<\/a>VIII. The Consequences\r\n<\/h2>\r\n

\r\nThe government\u2019s response to the opioid crisis had a large effect on opioid therapy, but its lack of foresight has left many patients, including veterans, worse off. To understand why this is the case, some context of the government\u2019s actions is needed. One of the biggest actions the government has made to curtail the opioid crisis is to cut back on the production of opioids. For many years now, the Drug Enforcement Agency (DEA) has issued production quotas for prescription drugs. Essentially, the DEA has hoped that by reducing the supply of prescription opioids, we will see a decline in opioid addiction and opioid related deaths, at least for prescription opioids. The DEA has recently added a new proposal to the Federal Registrar on August 7, 2017, that reduces the production of opioids by twenty percent in 2018.\u200a30<\/a>\u200a<\/span>\u200a30\u200a<\/span>Proposed Aggregate Production for Schedule I and II Controlled Substances and Assessment of Annual Needs for the List I Chemicals Ephedrine Pseudoephedrine, and Phenylpropanolamine for 2018<\/cite>, 82 Fed. Reg. 36830\u201336831<\/a><\/span> (2017).<\/span><\/sup> This is after the DEA already reduced opioid production by twenty-five percent in 2017.\u200a31<\/a>\u200a<\/span>\u200a31\u200a<\/span>Alicia Ault, DEA Proposes Significant Cuts to Opioid Production in 2018<\/cite>, Medscape.com<\/a><\/span> (2017). <\/span><\/sup> Not only has the DEA reduced the supply of prescription opioids, but the VA has also reduced the prescribing of opioids.\r\n<\/p>\r\n

\r\nPreviously we discussed the VHA\/DoD\u2019s new 2017 guidelines for treating chronic pain and while it remains to be seen what the effects will be, the current trend is that the VA has reduced its prescribing of opioids. According to the VA\u2019s own data, the number of veterans prescribed opioids fell by 25%, and the number of veterans receiving concomitant opioids and benzodiazepines fell by 47%.\u200a32<\/a>\u200a<\/span>\u200a32\u200a<\/span>Julianne Himstreet, et al., Transforming the Treatment of Chronic Pain Moving Beyond Opioids, a Clinicians Guide<\/span>, Pbm.Va.gov<\/a><\/span> (2017) (citing Walid F. Gellad, Chester B. Good & David J. Shulkin, Addressing the Opioid Epidemic in the United States: Lessons from the Department of Veteran Affairs<\/cite>, 177 J. Am. Med. Assoc'n 611\u2013612<\/a> (2017)). <\/span><\/sup> These numbers seem promising, but it does not consider what percentage of those veterans suffered from opioid addiction and abuse or reflect the percentage of veterans who have resorted to heroin or prescription narcotics from off the street. \r\n<\/p>\r\n

\r\nThe government\u2019s reduction in the supply of opioids, along with the reduction in prescribing opioids, has left some veterans with no real treatment alternatives, has led to some veterans seeking the prescription drugs illegally on the street, and has left others purchasing heroin as a substitute.\r\n<\/p>\r\n

\r\nFirst, let\u2019s start with the premise that the government\u2019s and VA\u2019s response has resulted in no real alternatives for veterans and patients who do suffer from chronic pain. Earlier, we discussed the how VHA\u2019s policies promoted opioid therapy alternatives and doctors starting opioid therapy. The problem with the VHA\u2019s policies is that many VA facilities do not carry more than one form of alternative therapy, and Tricare doesn\u2019t always cover alternative therapies like acupuncture. The government\u2019s continuous reduction in opioids has further hindered patients with real chronic pain from getting any treatment. To put it concisely, the government reacted with no foresight. The government cutback the supply of opioids, but has not put any real alternatives in place for patients or veterans to use. While this is really a restatement of what has already been discussed previously. Restating it here briefly adds to the logical steps that eventually led veterans and patients alike to pursue opioids illegally.\r\n<\/p>\r\n

\r\nWithout a ready alternative to opioid therapy, some veterans\/patients have resorted to pursuing prescription opioids on the street illegally or using heroin. As prescription rates and the supply of prescription opioids have decreased, heroin overdoses have increased.\u200a33<\/a>\u200a<\/span>\u200a33\u200a<\/span>Jeffery A. Singer, In the Opioid Crisis, Keep Your Eyes on Heroin and Fentanyl<\/cite>, Nationreview.com<\/a><\/span> (2017). <\/span><\/sup> Another contributing factor was found in a study conducted in June of 2017, which concluded that OxyContin\u2019s abuse-deterrent<\/q> (abuse-deterrent<\/q> opioids will be discussed more in-depth later) reformulation led to consumers and patients substituting OxyContin with heroin.\u200a34<\/a>\u200a<\/span>\u200a34\u200a<\/span>William N. Evans, et al., How the Reformulation of OxyContin Ignited the Heroin Epidemic<\/cite>, 12 J. Econ. Lit. 1<\/a><\/span> (2017).<\/span><\/sup> This seems like a logical conclusion. The government cuts back on opioid production and prescribing and those who are either addicted or in actual need seek alternatives on the illegal market. To be fair, one study has concluded that veterans\u2019 heroin use is associated with the non-medical use of prescription opioids.\u200a35<\/a>\u200a<\/span>\u200a35\u200a<\/span>Edelman G. Banerjee, et. al., Non-medical use of prescription opioids is associated with heroin initiation among US veterans: a prospective cohort study<\/cite>, 111 Addiction 2021\u20132031<\/a><\/span> (2016).<\/span><\/sup> But to say that veterans do not resort to using heroin when denied prescription opioids, like the civilian population, would be inaccurate. Ryan Trunzo was an Army veteran who was given painkillers by the VA for his back injuries. However, because of a history of addiction while in the service, the VA did not prescribe anything stronger than Ibuprofen. Because of Mr. Trunzo\u2019s pain and lack of treatment by the VA, he started using illegal narcotics. Mr. Trunzo tragically passed away from heroin toxicity.\u200a36<\/a>\u200a<\/span>\u200a36\u200a<\/span>Mark Brunswick, VA doctors freely handed out pain medications to veterans for years. Then they stopped. The results have sometimes turned tragic<\/cite>, Star Trib.<\/a><\/span> (2015).<\/span><\/sup> Unfortunately, Mr. Trunzo\u2019s story is most likely not the only one. For other veterans, the result of battling addiction is jail time.\r\n<\/p>\r\n

\r\nOne natural consequence of seeking prescription medication illegally or using cheaper narcotics like heroin is jail time. Some of these veterans have either built up a tolerance to what they have been prescribed, cannot afford what is prescribed, or are no longer getting prescribed any pain medication. But remember that not all veterans have a drug addiction and for these veterans, they are simply trying to self-medicate, because of either the costs involved or the lack of treatment from the VA. Back in 2013, in Muskogee, Oklahoma, the Jack C. Montgomery VA Medical Center prescribed 1.6 opiates per veteran, and it was said that it was reflected in the city\u2019s jail along with its courthouse.\u200a37<\/a>\u200a<\/span>\u200a37\u200a<\/span>Aaron Glantz, Center for Investigative Reporting, VA increases opiate prescriptions for veterans<\/cite>, The Oklahoman<\/a><\/span> (2013).<\/span><\/sup> \r\n<\/p>\r\n

\r\nLuckily, many states like Oklahoma have Veteran Treatment Courts where veterans are given more tailored treatment versus simply going through the criminal justice system. Veteran Treatment Courts often provide a variety of resources that assist veterans in getting the treatment they need by connecting them with local VA facilities. One upswing to this is that Veteran Treatment Courts also provide resources for veterans suffering from addiction, such as prescription opioid addiction. The good news for veterans suffering from opioid addiction is that the Department of Justice, on September 22, 2017, awarded $58.8 million dollars to combat the opioid epidemic. Some of the $58.8 million dollars will go to jurisdictions to support the creation of diversion\/alternative incarceration programs. Specifically, for veterans, $22.2 million dollars will be used to support the implementation and enhancement of drug courts and Veteran Treatment Courts.\u200a38<\/a>\u200a<\/span>\u200a38\u200a<\/span>Dep\u2019t of Justice, Off. Pub. Aff., Department of Justice Awards Nearly $59 Million to Combat Opioid Epidemic, Fund Drug Courts<\/cite>, Dep't. of Justice<\/a><\/span> (2017). <\/span><\/sup>\r\n<\/p>\r\n

\r\nAlthough the government\u2019s quick reduction in the supply and prescription of opioids has left some veterans worse off, there is at least hope that those suffering from opioid abuse will receive the help they need through Veteran Treatment Courts. In a way, the government is obligated to help veterans because the situation is at least partly the government\u2019s fault. As we have seen, the government encouraged the treatment of pain and supported the use of prescription opioids. Then, when the government discovered that opioid therapy was not supported by leading medical evidence, they tried to pull the rug out from under veterans by reducing the supply of opioids, and law enforcement\u2019s response to those who obtained opioids illegally was to throw them in jail. Arguably, many patients, specifically veterans, would not have developed an opioid addiction, but for the government\u2019s na\u00efve endorsement of opioids. At the very least, the government is taking steps in the right direction by providing veterans with treatment courts to help fight opioid addiction.\r\n<\/p>\r\n

\r\n<\/a>IX. Abuse-Deterrent<\/q> Opioids\r\n<\/h2>\r\n

\r\nAnother response to the opioid crisis is that the FDA has encouraged the production of abuse-deterrent<\/q> formulations for prescription opioids. Abuse-deterrent opioids receive their name because the new formulations make it difficult for the pills to be crushed, injected, or snorted. However, the abuse-deterrent is somewhat of a mislabel, as it does not prevent the most common form of abuse, which is simply swallowing the pill. However, in 2010, Purdue Pharmaceutical created an abuse-deterrent formulation for OxyContin. The FDA was intrigued by the prospect and subsequently ordered Purdue Pharmaceutical to conduct further research on abuse-deterrent medications \u2014 eventually a few manufacturers have started producing abuse-deterrent<\/q> opioids at the FDA\u2019s encouragement. It sounds like a promising alternative to an outright ban to prescription opioids and would help those veterans\/patients who really do need some form of treatment for chronic pain. However, according to an article by STAT,<\/q> there is little evidence that abuse-deterrent<\/q> opioids actually deter abuse and reduce chances of opioid addiction.\u200a39<\/a>\u200a<\/span>\u200a39\u200a<\/span>C. Bernie Good, et al., There\u2019s little evidence abuse-deterrent opioids work. Why should we use them?<\/cite>, Statnews.com<\/a><\/span> (2017). <\/span><\/sup>\r\n<\/p>\r\n

\r\nWhile it is not this paper\u2019s direct goal to expose pharmaceutical companies, it is worth noting why pharmaceutical companies are interested in producing abuse-deterrent<\/q> opioids. According to the same STAT<\/q> article, a major incentive to produce abuse-deterrent opioids is because the companies can charge more money for them and the fact that their new formula alleges that it deters abuse means that it can 1) have a patent that protects its formulations for five years; and 2) they can compete directly with generic opioid medications that are far cheaper because society is currently trying to deter and reduce opioid abuse.\u200a40<\/a>\u200a<\/span>\u200a40\u200a<\/span>C. Bernie Good, et al., There\u2019s little evidence abuse-deterrent opioids work. Why should we use them?<\/cite>, Statnews.com<\/a><\/span> (2017). <\/span><\/sup> Pharmaceutical companies would stand to make a huge profit if the FDA, and the medical community, started pushing abuse-deterrent opioids as an alternative to current opioids on the market. The STAT<\/q> article provided an eerie example:\r\n<\/p>\r\n

\r\nA mandate to use abuse-deterrent opioids at an up to twentyfold increase in cost would be staggering to health care systems. For example, the Department of Veterans Affairs spent nearly $100 million in fiscal year 2016 on opioids for 1.2 million patients with at least one opioid prescription. Only 1.9 percent of the opioids dispensed were for an abuse-deterrent product, but they accounted for 37 percent of overall opioid spending. Long-acting abuse deterrent opioids were approximately 10 times the cost of long-acting opioids without abuse-deterrent properties. \r\n<\/blockquote>\r\n
\r\nApplying a conservative tenfold increase in price for abuse-deterrent opioids would increase the VA\u2019s expenditures for opioids to approximately $1 billion a year, and could represent as much as 20 percent of the entire VA pharmacy budget. Such an increase would also compete against funding of other important opioid use disorder treatments, such as medication-assisted treatment and rehabilitation programs.\u200a41<\/a>\u200a<\/span>\u200a41\u200a<\/span>C. Bernie Good, et al., There\u2019s little evidence abuse-Deterrent opioids work. Why should we use them?<\/cite>, Statnews.com<\/a><\/span> (2017). <\/span><\/sup>\r\n<\/blockquote>\r\n

\r\nThe promotion of abuse-deterrent drugs has made veterans worse off because once again, veterans and doctors are being misled to believe that somehow these drugs are less addictive and prone to abuse,when there is no credible evidence to substantiate the claims. What is worse about this development is it reveals pharmaceutical companies\u2019 profit motive that, at least in this instance, trumps the well-being of patients. As of June 2017, the FDA has started to take a closer look at the efficacy of abuse-deterrent opioids and one can only hope that the government, especially the VA, does not mandate or encourage the use of abuse-deterrent opioids when there is no evidence they do deter abuse.\u200a42<\/a>\u200a<\/span>\u200a42\u200a<\/span>Michael Mezher, FDA to Take Closer Look at Abuse-Deterrent Opioids, Regulatory Affairs Professionals Society<\/cite>, Raps.org<\/a><\/span> (2017). <\/span><\/sup>\r\n<\/p>\r\n

\r\n<\/a>X. Conclusion\r\n<\/h2>\r\n

\r\nThe opioid crisis that is plaguing the United States today is rooted in the Fifth Vital Sign Movement. The mission was to bring more awareness to pain, but instead it opened the floodgates to long-term opioid therapy. At the same time as the Fifth Vital Sign Movement, the medical community touted the unlikelihood of prescription opioids and the efficacy of opioid therapy. The VHA jumped onboard and told its medical providers to do more to treat pain. The market provided a solution with prescription opioids, like OxyContin, that claimed low chances of addiction that proved to be false. Under the VHA\u2019s support, veterans became addicted to opioids. Once the government realized that opioid abuse and overdose was a problem, they quickly curtailed the production\/prescribing of opioids. The government\u2019s quick reaction left many veterans with no alternatives because either their insurance did not cover it or the VA facilities did not offer it. Yet the VHA\/DoD kept telling medical providers to use alternative therapies that essentially did not exist for both the doctor and patient. When veterans began to seek treatment illegally, they were thrown into jail. Luckily, Veteran Treatment Courts have provided an alternative to give veterans the help they need. \r\n<\/p>\r\n

Footnotes<\/h2>
\u200a1<\/a>\u200a<\/span>Jeremiah Fues<\/a> is an associate at Paul Knopf Bigger<\/a> in the firm\u2019s Tampa office. Mr. Fues pursued his dream of becoming a lawyer so he could advocate and seek justice for the disadvantaged. Mr. Fues graduated from Stetson University with a Bachelor of Arts degree in History and American Studies and his Juris Doctorate degree from Stetson College of Law, where he was part of the Trial team. While at Stetson Law, Mr. Fues studied American consumerism and instances of how Big Pharma fraudulently dispensed products knowing they were likely to cause severe injuries to people. Mr. Fues\u2019s studies, combined with personal experience, made him passionate about seeking justice for people who have been wronged by others, especially businesses. In July of 2018, Jeremiah joined Paul Knopf Bigger, where he focuses on product liability and complex litigation. He enjoys complex problem solving and is committed to fighting injustice and helping people during their times of need.<\/div>
\u200a2<\/a>\u200a<\/span>Centers for Disease Control and Prevention, Opiod Overdose<\/cite>, Prescription Opioid Data<\/span>, CDC.gov<\/a><\/span>.<\/div>
\u200a3<\/a>\u200a<\/span>Chris Christie, et al., The President\u2019s Commission on Combating Drug Addiction and the Opioid Crisis Report and Recommendation<\/cite>, Whitehouse.gov<\/a>.<\/span><\/div>
\u200a4<\/a>\u200a<\/span>Greg Allen, et al., Trump Administration Declares Opioid Crisis A Public Health Emergency<\/cite>, NPR<\/a><\/span>.<\/div>
\u200a5<\/a>\u200a<\/span>John Warner, The Therapeutic Perspective: Medical Practice, Knowledge, and Identity in America 1820\u20131885<\/cite>, Harvard University Press<\/a><\/span> (1986).<\/div>
\u200a6<\/a>\u200a<\/span>Jane Porter, et al., Letter to Editor: Addiction Rare in Patients Treated With Narcotics<\/cite>, 302 New Eng. J. Med. 123<\/a> (1980).<\/span><\/div>
\u200a7<\/a>\u200a<\/span>R.K. Portenoy, et al., Chronic use of opioid analgesics in non-malignant pain: report of 38 cases<\/cite>, 25 Journal of Pain 171\u201386<\/a> (1986).<\/span><\/div>
\u200a8<\/a>\u200a<\/span>Sarah Kliff, The Opioid Crisis Changed How Doctors Think About Pain<\/cite>, Vox.com<\/a> (2017).<\/span><\/div>
\u200a9<\/a>\u200a<\/span>Sarah Kliff, The Opioid Crisis Changed How Doctors Think About Pain<\/cite>, Vox.com<\/a> (2017).<\/span><\/div>
\u200a10<\/a>\u200a<\/span>Janice Lynch Schuster, Veterans Health Administration\u2019s Addition of Pain as a Fifth Vital Sign May Have Far-Reaching Effects<\/cite>, Wash. Post<\/a><\/span> (1999).<\/div>
\u200a11<\/a>\u200a<\/span>Geriatrics and Extended Care Strategic Healthcare Group, et al., Pain as the Fifth Vital Sign Toolkit 7<\/a><\/span> (Dep\u2019t. of Veterans Affairs, 2000).<\/div>
\u200a12<\/a>\u200a<\/span>Art Van Zee, The Promotion and Marketing of OxyContin: Commercial Triumph, Public Health Tragedy<\/cite>, 99 Am. J. Pub. Health 221\u2013227<\/a><\/span> (2009).<\/div>
\u200a13<\/a>\u200a<\/span>Aaron Glantz, Veterans: VA hospital nicknamed Candy Land<\/q> because painkillers given out freely<\/cite>, Chi. Trib.<\/a><\/span> (2015). <\/div>
\u200a14<\/a>\u200a<\/span>Art Levine, How the VA Fueled the National Opioid Crisis and Is Killing Thousands of Veterans<\/cite>, Newsweek<\/a><\/span> (2017).<\/div>
\u200a15<\/a>\u200a<\/span>Aaron Glantz, Congressional hearing reveals 4 more deaths at Tomah, Wisconsin, VA<\/cite>, Reveal<\/a><\/span> (2015).<\/div>
\u200a16<\/a>\u200a<\/span>Karen H. Seal, et. al., Association of Mental Health Disorders With Prescription Opioids and High-Risk Opioid Use in US Veterans of Iraq and Afghanistan<\/cite>, 307 J. Am. Med. Asooc'n 940\u2013947<\/a><\/span> (2012).<\/div>
\u200a17<\/a>\u200a<\/span>Dep\u2019t of Veteran Aff., PTSD and Substance Abuse in Veterans<\/cite>, Ptsd.va.gov<\/a>.<\/span><\/div>
\u200a18<\/a>\u200a<\/span>American-Statesman Investigative Team, Prescription drug abuse, overdoses haunt veterans seeking relief from physical, mental pain<\/cite>, Austin American Statesman (Texas)<\/a><\/span> (2016).<\/div>
\u200a19<\/a>\u200a<\/span>Art Levine, How the VA Fueled the National Opioid Crisis and Is Killing Thousands of Veterans<\/cite>, Newsweek<\/a><\/span> (2017).<\/div>
\u200a20<\/a>\u200a<\/span>The Management of Opioid Therapy for Chronic Pain Working Group, Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain<\/cite>, Dep't of Veteran Aff., 7, 12\u201316, 20<\/a> (2010).<\/div>
\u200a21<\/a>\u200a<\/span>Brenda L. Mooney, New VA Initiative Seeks to Reduce Opioid Use<\/cite>, U.S. Med.<\/a><\/span> (2014).<\/div>
\u200a22<\/a>\u200a<\/span>Deborah Dowell, et al., CDC Guideline for Prescribing Opioids for Chronic Pain \u2014 United States<\/cite>, 65 Centers for Disease Control and Prevention 1\u201349<\/a> (2016).<\/div>
\u200a23<\/a>\u200a<\/span>The Opioid Therapy for Chronic Pain Work Group, VA\/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain<\/cite>, Dep't of Veterans Aff. 7<\/a><\/span> (2017).<\/div>
\u200a24<\/a>\u200a<\/span>Andrew J. Vickers, Acupuncture for Chronic Pain Individual Patient Data Meta-analysis<\/cite>, 172 Arch. Intern. Med. 1444\u20131453<\/a><\/span> (2012). <\/div>
\u200a25<\/a>\u200a<\/span>Tricare Covered Services, Acupuncture<\/cite>, Tricare.mil<\/a>.<\/span><\/div>
\u200a26<\/a>\u200a<\/span>Mitch Mirkin, Complementary and Alternative Medicine: yoga, acupuncture and more<\/cite>, Blogs.va.gov<\/a><\/span> (2014).<\/div>
\u200a27<\/a>\u200a<\/span>H.R. 2838, 115th Cong. (2017)<\/a>.<\/div>
\u200a28<\/a>\u200a<\/span>C. Lee Ventola, Direct-to-Consumer Pharmaceutical Advertising: Therapeutic or Toxic?<\/cite>, 36 Pharmacy and Therapeutics 669\u2013684<\/a><\/span> (2011). <\/div>
\u200a29<\/a>\u200a<\/span>Purdue Pharma OxyContin Commercial<\/cite>, Youtube.com<\/a><\/span>.<\/div>
\u200a30<\/a>\u200a<\/span>Proposed Aggregate Production for Schedule I and II Controlled Substances and Assessment of Annual Needs for the List I Chemicals Ephedrine Pseudoephedrine, and Phenylpropanolamine for 2018<\/cite>, 82 Fed. Reg. 36830\u201336831<\/a><\/span> (2017).<\/div>
\u200a31<\/a>\u200a<\/span>Alicia Ault, DEA Proposes Significant Cuts to Opioid Production in 2018<\/cite>, Medscape.com<\/a><\/span> (2017). <\/div>
\u200a32<\/a>\u200a<\/span>Julianne Himstreet, et al., Transforming the Treatment of Chronic Pain Moving Beyond Opioids, a Clinicians Guide<\/span>, Pbm.Va.gov<\/a><\/span> (2017) (citing Walid F. Gellad, Chester B. Good & David J. Shulkin, Addressing the Opioid Epidemic in the United States: Lessons from the Department of Veteran Affairs<\/cite>, 177 J. Am. Med. Assoc'n 611\u2013612<\/a> (2017)). <\/div>
\u200a33<\/a>\u200a<\/span>Jeffery A. Singer, In the Opioid Crisis, Keep Your Eyes on Heroin and Fentanyl<\/cite>, Nationreview.com<\/a><\/span> (2017). <\/div>
\u200a34<\/a>\u200a<\/span>William N. Evans, et al., How the Reformulation of OxyContin Ignited the Heroin Epidemic<\/cite>, 12 J. Econ. Lit. 1<\/a><\/span> (2017).<\/div>
\u200a35<\/a>\u200a<\/span>Edelman G. Banerjee, et. al., Non-medical use of prescription opioids is associated with heroin initiation among US veterans: a prospective cohort study<\/cite>, 111 Addiction 2021\u20132031<\/a><\/span> (2016).<\/div>
\u200a36<\/a>\u200a<\/span>Mark Brunswick, VA doctors freely handed out pain medications to veterans for years. Then they stopped. The results have sometimes turned tragic<\/cite>, Star Trib.<\/a><\/span> (2015).<\/div>
\u200a37<\/a>\u200a<\/span>Aaron Glantz, Center for Investigative Reporting, VA increases opiate prescriptions for veterans<\/cite>, The Oklahoman<\/a><\/span> (2013).<\/div>
\u200a38<\/a>\u200a<\/span>Dep\u2019t of Justice, Off. Pub. Aff., Department of Justice Awards Nearly $59 Million to Combat Opioid Epidemic, Fund Drug Courts<\/cite>, Dep't. of Justice<\/a><\/span> (2017). <\/div>
\u200a39<\/a>\u200a<\/span>C. Bernie Good, et al., There\u2019s little evidence abuse-deterrent opioids work. Why should we use them?<\/cite>, Statnews.com<\/a><\/span> (2017). <\/div>
\u200a40<\/a>\u200a<\/span>C. Bernie Good, et al., There\u2019s little evidence abuse-deterrent opioids work. Why should we use them?<\/cite>, Statnews.com<\/a><\/span> (2017). <\/div>
\u200a41<\/a>\u200a<\/span>C. Bernie Good, et al., There\u2019s little evidence abuse-Deterrent opioids work. Why should we use them?<\/cite>, Statnews.com<\/a><\/span> (2017). <\/div>
\u200a42<\/a>\u200a<\/span>Michael Mezher, FDA to Take Closer Look at Abuse-Deterrent Opioids, Regulatory Affairs Professionals Society<\/cite>, Raps.org<\/a><\/span> (2017). <\/div>\r\n","protected":false},"excerpt":{"rendered":"

Jeremiah Fues<\/p>\n","protected":false},"meta":{"_citation":"7 Stetson J. Advoc. & L. 124 (2020)","_first_para":124,"footnotes":""},"class_list":["post-1253","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-24"]}