Introduction
The problem of the opioid epidemic in the United States has been at the center of an ongoing discussion for several years. As reported by the U.S. Department of Health and Human Services (2021), “an estimated 10.1 million people aged 12 or older misused opioids” in 2019 (para. 7). Specifically, over 96% of these individuals abused prescription pain relievers (U.S. Department of Health and Human Services, 2021, para. 8).
Different social groups seem to be disproportionally affected by this issue. Research shows that veterans are at an increased risk of mortality due to opioid overdose compared to the general population (Midboe et al., 2019). A variety of evidential data supports the claim of increased mortality among retired soldiers. The national survey conducted among veterans to estimate their drug use shows that the yearly indicators have not significantly changed. On the country level, the number of opioid misuse and overdose cases among veterans is estimated to be 562,000 US veterans (Substance Abuse and Mental Health Services Administration [SAMHSA], 2018). As can be seen, the rate of illicit drugs among veterans remains stably high.
In addition, statistical data indicate that retired soldiers are more exposed to mental disorders, physical health impairments, and mortality. According to the SAMHSA (2018), survey findings demonstrate that 3.7 million veterans have a mental health problem, a substance use disorder (SUD), or both (p. 7). Specifically, 1.1 million people (5.3%) suffer from SUDs, and 268,000 veterans (2.2%) have both SUDs and mental illnesses (SAMHSA, 2018, p. 7).
Opioids are prevalently prescribed as a method of chronic pain management for this population, which is found to be a frequent issue among retired soldiers (Hudson et al., 2017). Furthermore, veterans often use opioid-based medications to manage post-traumatic stress disorder (PTSD) as one of the most recurrent issues impacting individuals who have experienced war face to face.
At the same time, veterans are willing to receive treatment, which indicates the importance of implementing an effective policy to resolve the problem. Despite broad research and numerous interventions aimed at minimizing the harmful effects of the opioid crisis among veterans, they remain a highly vulnerable population under-addressed within the context of anti-opioid policy (Kertesz, 2017). The number of deaths caused by opioid overdose remains steady, according to the statistical data provided by the CDC (2020). The current attention from authorities to the problem of opioid overdose death across the United States mainly addresses the general population’s everyday issues, leaving the particular needs of veterans aside. The level of mortality caused by the opioid crisis among this population is strikingly high, and the efforts for its minimization are insufficient. Therefore, it is vital to analyze the applied policies to verify their effectiveness in solving the identified problem.
The existing policies provide a foundation for addressing the opioid mortality problem in veterans. For instance, one of the measures is the implementation of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act (2018). The law is designed to stop the opioid crisis by funding the practices of controlled medication prescription and developing the procedures required to manage the opioid epidemic at all levels (“Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment [SUPPORT] for Patients and Communities Act,” 2018).
Another alternative is the Veterans Affair’s opioid safety initiative, which is expected to reduce the percentage of veterans dependent on opioid medication use by tracking the prescriptions and identifying the risk factors to enable further prevention of the crisis (U.S. Department of Veterans Affairs, 2019). Finally, the Hawaii Opioid Initiative focuses on decreasing the number of retired soldiers with substance use disorders who require professional help (“The Hawaii opioid initiative,” 2017).
Overall, current policies need to be supported by effective alternatives for a comprehensive approach to the problem. Despite thoroughly addressing all stages necessary to approach the problem of the opioid epidemic, the law meets the needs of veterans by means applicable to the general population, omitting the issues specific only to the veteran population. Three policy alternatives were designed to be implemented at the state level to supplement the existing federal initiatives.
Stated Alternatives
Alternative 1: Training for Hawaii Clinicians on Non-Opioid Treatment Methods
The first alternative is to reduce the frequency of opioid prescriptions by providing relevant education and training for Hawaii clinicians to encourage them to utilize alternative treatment methods for veterans in need of pain management. This strategy can help decrease the morbidity rate resulting from opium-based medicine overdose. According to Sandbrink et al. (2020), “opioid prescribing was recognized as an important contributor to the U.S. opioid crisis” (p. 927). At the same time, different pain management options can be used, such as acupuncture, yoga, non-addictive medications, and art or cognitive behavioral therapy (Sandbrink et al., 2020).
Reducing the number of opioid prescriptions would mitigate the leading cause of higher morbidity rates among retired soldiers. Therefore, this initiative should focus on organizing and providing training for clinicians at the state level regarding opioid safety and overdose in veterans and explaining other treatment options available for such populations. For instance, the education plan can include lectures or webinars by experts on this subject, access to evidence-based resources on opioid and non-opioid medications, and regular meetings of clinicians to exchange knowledge and discuss relevant issues.
Alternative 2: Hawaii Program for Opioid Overdose Risk Management
The second policy alternative is to introduce a Hawaii program for identifying and monitoring veterans at an exceptionally high risk of opioid overdose. For instance, a risk assessment tool can be developed to collect and analyze veterans’ data and identify patterns of problematic behavior. Such a measure can include a survey measuring one’s symptoms that might indicate an increased risk of depression, overdose, or suicide.
This initiative would allow for early intervention and effective management of the opioid crisis. Associated risk factors that can increase the probability of overdose in veterans include mental health problems, suicidal thoughts and behavior, severe chronic pain, drug or alcohol issues, and others (Sandbrink et al., 2020). Therefore, individuals that fall under these categories should be monitored closely. Based on the risk assessment findings for specific individuals, measures can be suggested to reduce the probability of overdose and suicide events. Implementing this policy alternative would focus on identifying individuals needing close monitoring and additional support to prevent overdose.
Alternative 3: Self-Care Programs for Veterans at a State Level
The third policy option involves providing veterans with access to self-care programs at a state level that help improve mental health and manage pain through nonpharmacological methods. As noted by Meerwijk et al. (2020), such initiatives can decrease the “risk of long-term adverse outcomes” in veterans with chronic pain (p. 775).
Self-care programs should educate patients on the importance of nutrition, exercise, massage, yoga, and psychotherapy and explain self-care strategies to reduce pain and stress in retired soldiers. This initiative can be implemented in healthcare and rehabilitation facilities to raise patients’ awareness about the importance of nonpharmacological treatment for one’s well-being and pain management. Healthcare personnel should be involved in providing access to relevant resources and additional information for veterans. Overall, this policy alternative can help address the problem of opioid overdose by providing the population with knowledge and methods to improve mental and physical health without using medication.
Projected Outcomes
Criteria
The criteria for measuring policy outcomes include political acceptability, cost, and effectiveness, namely, reduced veteran mortality rates and the number of people taking opioids. In this regard, political acceptability was evaluated based on a favorable perception of the policy among the public in the U.S. political context (Shahab et al., 2019). The cost analysis was performed by projecting and summarizing the cost of all components involved in the initiative that contributes to its financial burden. Finally, the effectiveness criterion was assessed by predicting the approximate reduction of opioid overdose deaths in veterans and the number of people taking opioids. The outcome matrix with the evaluation of each criterion for all policy options is presented in the Appendix.
Alternative 1: Training for Hawaii Clinicians on Non-Opioid Treatment Methods
The first alternative is expected to be favorably precepted by the public in the U.S. political context due to the disturbing upsurge in mortalities among veterans misusing opioid medications. In view of the increasing public concern regarding suicide and overdose rates among retired soldiers, it is anticipated that the political acceptability for the training program would be high. The cost analysis should be conducted with regard to the number of healthcare facilities involved in the initiative. Overall, there are 14 clinics of the U.S. Department of Veterans Affairs in Hawaii (“Locations,” n.d.).
Therefore, the estimated cost of implementing training for each facility is $20,000, which covers training supplies, equipment, educational software, instructor fees, and employee compensations, leading to an approximate total cost of $280,000. Furthermore, the development of a knowledge database with evidence-based resources and educational content for lectures or webinars is expected to cost an additional $20,000, which results in $300,000 as a total cost of the initiative.
Finally, the effectiveness is expected to lead to an approximately 5% reduction in the mortality rate and opioid intake among veterans. This estimation is based on a projected decrease in opioid prescriptions for cases of “mild-to-moderate acute pain” where non-opioid treatment options can be applied (“Non-opioid and non-pharmacologic treatment modalities,” 2019, para. 3). Overall, this initiative is likely to significantly reduce the number of veterans receiving opioid medications, which is the most favorable outcome.
Alternative 2: Hawaii Program for Opioid Overdose Risk Management
The second policy is expected to help identify and address opioid overdose risks in veterans. The political acceptability of this problem might be lower than for the other initiatives since such a program implies increased monitoring and collection of sensitive personal and healthcare data among the affected population. Such changes might not be welcomed by certain individuals due to social stigma revolving around the problems of suicide, pain management, and mental health.
The total cost of this policy initiative involves the development of a risk assessment tool that can be used by healthcare facilities to collect and analyze veterans’ data. The developmental costs are projected to reach $50,000, allowing access to the same database and analysis tools for all clinics included in the initiative. Furthermore, the training cost for medical and administrative personnel is expected to be $20,000 per clinic, with a total of $280,000. The operational cost is $30 per month per healthcare facility, which means providing 14 clinics with access to the tool would cost $5040 per year. Overall, the total cost of the second policy alternative is $335,040. At the same time, the predicted effectiveness of this program is a 3% reduction in mortality rates and the number of people taking opioids among retired soldiers. This estimation is made based on the anticipated number of patients at higher risk that can be identified through the risk management tool.
Alternative 3: Self-Care Programs for Veterans at a State Level
The third initiative will likely raise awareness of mental health problems in veterans and increase the number of retired soldiers with SUDs seeking to participate in self-care programs. This policy alternative is anticipated to be favorably precepted by the U.S. public as it emphasizes the importance of mental health and offers a tool for its improvement. The estimated cost of developing one self-care program is $50,000. The suggested subjects include nutrition, exercise, massage, yoga, psychotherapy, and self-care strategies to reduce pain and stress. Therefore, the creation of six educational programs would cost $300,000.
Additional expenses include implementing the initiatives in 14 healthcare facilities and teaching personnel to raise patients’ awareness about self-care programs and providing access to them, which includes $10,000 per clinic, with a total of $140,000. Overall, the cost of the third policy alternative is projected as $440,000. The effectiveness might be lower since the program relies on the voluntary participation of veterans who are willing to accept help, resulting in a 1% mortality rate and opioid intake reduction among retired soldiers.
Discussion of the Trade-Offs
Each alternative has entered the political agenda due to the alarming increase in fatalities among veterans misusing opioid medications. Political acceptability is expected to be high for Alternatives 1 and 3 due to the favorable climate of organization-level and state-level initiatives. Training for Hawaii clinicians and self-care programs for veterans are expected to be favorably precepted by the public in the U.S. political context, given the alarming increase in mortality rates among veterans misusing opioid medications. Alternative 2 might be perceived as less favorable as a result of stigma in society regarding suicide, pain management, and mental health.
The cost analysis indicates that Alternative 1 is the least cost-intensive, followed by Alternatives 2 and 3. It is worth noting that all proposed policies are expected to fall under the category of medium to high expenses, and the difference between the most and least expensive options is $160,000. Finally, the effectiveness measure, such as decreased veteran mortality rates and the number of people taking opioids, is a priority to address the problem at a state level.
Alternative 1 is likely to significantly reduce the number of veterans receiving opioid medications, which is the most favorable outcome. The training initiative is expected to lead to a 5% mortality rate reduction among veterans. The predicted effectiveness of Alternative 2, the risk-monitoring program, is a 3% reduction in mortality rates among retired soldiers, while Alternative 3, the self-care program, is anticipated to reduce the mortality rate and the number of veterans taking opioids only by 1%.
Overall, Alternative 1 is likely to allow for the greatest reduction in mortality rates and the number of veterans taking opioids at the lowest cost and with the highest political acceptability among the public. Alternative 2 is expected to be less effective regarding opioid overdose and prescription rates at a medium cost and with medium support of the population. Alternative 3 is the most cost-intensive and the least effective with regard to mortality rates and the number of veterans taking opioids, while public support is expected to be high.
Recommendation
Considering the projected outcomes, each alternative has the potential to achieve the predicted performance against the chosen criteria. To narrow the judgment in favor of the best-performing approach derived from the previous steps, one should emphasize that the criterion of effectiveness in terms of the reduction of mortality and number of veterans taking opioids is thought to be critical. However, political acceptability and policy cost also play a significant role since they determine whether the initiative will be maintained and reach the planned effectiveness rate. Public reluctance to participate in the Hawaii Program for Opioid Overdose Risk Management might hinder its political acceptability.
Also, the relative ineffectiveness of the Self-Care Programs for Veterans at a State Level does not allow for choosing it as the best option. Therefore, Training for Hawaii Clinicians on Non-Opioid Treatment Methods is recommended as the alternative that is the least cost-intensive and the most likely to lead to the most favorable outcomes at a state level.
References
CDC. (2020). 2019-2020 drug overdose death rate percent change map. Web.
Hudson, T. J., Painter, J. T., Martin, B. C., Austen, M. A., Williams, J. S., Fortney, J. C., Sullivan, M. D, & Edlund, M. J. (2017). Pharmacoepidemiologic analyses of opioid use among OEF/OIF/OND veterans. Pain, 158(6), 1039-1045.
Kertesz, S. G. (2017). Turning the tide or riptide? The changing opioid epidemic. Substance Abuse, 38(1), 1-6.
Locations. (n.d.). Veteran Affairs. Web.
Non-opioid and non-pharmacologic treatment modalities. (2021). Minnesota. Web.
Opioid Safety Initiative. (2019). Web.
Substance Abuse and Mental Health Services Administration. (2018). 2018 NSDUH annual national report. Web.
Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act. (2018). Web.
The Hawaii opioid initiative: A statewide response. (2017). Web.