Chronic pain is ubiquitous among Veterans. Over 55 % of Veterans of Afghanistan and Iraq experience chronic myalgia, thought to be due to the heavy load from body armor worn in extreme conditions.1 Mosher and colleagues report that there has been an increase in the receipt of opiates since 2004 among Veterans, from 19 % in 2004 to 33 % in 2012.2 They define receipt of opiates as “receipt of at least one opioid prescription during that year.” This would include Veterans who had surgery and other procedures that require a short course of opiates during the outpatient post-procedure period, as well as Veterans who received opiates for acute injuries.

In the last couple of years, the VA has focused on chronic opiate use with a national Opiate Safety Initiative. Chronic opiate use is being monitored at national, regional and local levels. For example, in 2014, 15.5 % of Veterans received chronic opiates; at my facility, it’s 11.8 %. Opiate policy has been updated nationally,3 and each VA center is required to have an Opiate Safety person to oversee local implementation of national policy. All Veterans receiving chronic opiates are required to sign an opiate consent that details risks and patient responsibilities. Veterans on chronic opiates are required to have at least an annual urine drug screen. Providers must check state databases at least annually to make sure the Veteran is not getting opiates from other sources. The combination of benzodiazepines and opiates are discouraged, as are doses exceeding 100 mg of morphine equivalent daily. Dashboards have been created that allow providers to check what percentage of their patients are on chronic opiates, as well as what percentage of patients have had a urine drug screen, have signed an opiate consent and are on combinations of opiates and benzodiazepines. The VA electronic health record now includes clinical reminders for patients on chronic opiates to alert providers that the Veteran needs to sign an opiate agreement or is due for a urine drug screen. While the VA is no paragon of virtue, it is devoting considerable effort to increase the safety of chronic opiate use among Veterans.