Introduction
The problem of the opioid epidemic in the USA has been at the center of an ongoing discussion for several years. Despite its growing relevance to multiple population groups across the nation, evidence shows that veteran populations are twice as likely to die of opioid overdose as average citizens, whose overdose-related deaths are estimated 130 a day (Wilkie, 2018). Indeed, military veterans are disproportionately exposed to the addictive impact of opiate prescription medications due to the particularities of their occupation. On a country level, the number of cases of opioid misuse and overdose among military veterans is estimated of 562,000 US veterans (Substance Abuse and Mental Health Services Administration [SAMHSA], 2018). Statistical data indicate that veterans are more exposed to mental disorders, physical health impairments, and mortality; also, this population is prevalently prescribed opioids to relieve pain, since chronic pain is omnipresent in this group (Hudson et al., 2017). Besides, veterans frequently use opioid-based medications to manage post-traumatic stress disorder (PTSD) as one of the most recurrent issues impacting the military.
Despite broad research and numerous interventions aimed at minimizing the harmful effects of the opioid crisis on veterans, they remain a highly vulnerably population that is 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 level of currently paid attention of authorities to the problem of opioid overdose death across the USA mostly addresses the common issues of the general population leading the particular needs of veterans aside.
Policy Description
The main nationally applied policy that addresses the opioid epidemic is the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act. 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). The policy includes measures for minimizing overprescribing of opioids, the government’s support of research in the sphere of the opioid crisis, additional payment for specialists working with substance abuse disorders, and the integration of a technology-driven monitoring system. Some of the provisions focus on facilitating the performance of the Department of Veteran Affairs (VA) to track the prescriptions and identify the risk factors to enable further prevention of the crisis (“SUPPORT for Patients and Communities Act,” 2018). Despite thorough addressing of 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.
Policy Analysis Using Bardach’s Eight Step Framework
Problem Definition
The level of mortality caused by the opioid crisis among veterans is strikingly high, and the federal-scale efforts for its minimization are insufficient due to the under-addressed social work needs of this vulnerable population and bureaucratic obstacles. Therefore, it is vitally important to analyze the applied policies to verify their effectiveness in solving the identified problem.
Collected Evidence
A variety of evidential data supports the increased mortality rate among the veteran population that is caused by overprescribing and misuse of opiate medications. The national survey conducted among veterans to estimate their drug use shows that the yearly indicators have not significantly changed and the rate of illicit drugs among veterans remains stably high; namely 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). According to Wilkie (2018), “severe pain is 40 percent more common in veterans compared to non-veterans;” also, “more than 50 percent of older veterans live with some form of chronic pain,” which exposes them to seek help in medications (para. 2). Indeed, pain reliever misuse is the most frequent condition estimated by approximately 505,000 veterans out of the total population of 562,000 veterans with opioid misuse (SAMHSA, 2018, p. 13). Importantly, the number of veterans seeking help from specialists has increased in recent years, which indicates the readiness of this population to receive treatment.
Constructing the Alternatives
For the problem of the increased opioid overdose mortality in veterans to be resolved, multifaceted, interdisciplinary, and correlated work needs to be done. Since the problem is rooted in a variety of causal factors, including the social and psychological issues of military service and retirement, the political environment around healthcare, funding, and organizational issues, efficient policies need to address the array of the problem’s reasons and manifestations. The alternative policies that might be included in the analysis are those reflecting the efforts and actions planned to be applied on the level of the country, in the state, and on the level of VA.
In order to solve the problem, the factors relevant to specific locations need to be addressed through an array of efforts. They should include the facilitated process of accessing trauma-informed treatment and therapy for veterans with SUDs, with the help of monitoring opioid prescriptions, and educating both the target population and the specialists working with them about the opioid crisis management (Bennett, Elliott, & Golub, 2015; Bowen & Murshid, 2016). Plans of actions aimed at the implementation of such solutions are outlined in such alternative policies as the SUPPORT for Patients and Communities Act, the VA’s Opioid Safety Initiative and The Hawaii Opioid Initiative (“The Hawaii opioid initiative: A statewide response,” 2017; “Opioid Safety Initiative,” 2019). These initiatives provide a theoretical basis for the budgeting, planning, organizing, and practically applying the social work and healthcare system toward the goals of minimizing the mortality rates caused by the opioid crisis among veterans.
Selecting the Criteria
The criteria for policy outcome measurement should include political acceptability, policy sustainability, and effectiveness (in terms of reducing the number of deaths). The rationale is validated by the dependence of the overall implementation of the policies on their sustainability and acceptability potential. Indeed, political acceptability is of significant importance to policy implementation since it defines whether the initiative is favorably perceived by decision-makers in a given political climate. For example, the Trump administration has constructed a solid system of anti-opioid actions; however, the overall practical implementation of them depends on the reaction of other political forces (Vazquez, 2020). Similarly, policy sustainability accounts for the ability of the proposed alternative to utilize resources effectively and maintain effective results. Finally, effectiveness is the criterion that illustrates the achievement of the policies’ goals, which, in the case of the opioid crisis in veterans, deals with the reduction of opioid overdose deaths.
Projecting the Outcomes
The performance of each policy, according to the criteria of effectiveness, political acceptability, and policy sustainability, has to be analyzed on the basis of realistically anticipated outcomes. According to Bardach and Patashnik (2019), this step is the core of policy analysis since it allows for predicting the outcomes each alternative might provide within the realm of each measurement criterion.
Therefore, the first alternative, which is the SUPPORT for Patients and Communities Act, is likely to lead to improved care for female veterans and minimize opioid prescriptions, as well as will increase the scope of research necessary for preventing opioid misuse among veterans (“SUPPORT for Patients and Communities Act,” 2018). Past trends allow for predicting the outcomes of the policies in the future. Therefore, the second policy, VA Opioid Safety Initiative, is likely to lead to a significant reduction in the number of veterans receiving opioid medications, which is the most favorable outcome. Finally, the Hawaii Opioid Initiative is likely to lead to an increase in the number of veterans with SUDs seeking professional help (Galanis, n. d.). The specific projected outcomes within each criterion are addressed in the next step.
Confronting the Trade-Offs
Each alternative has entered the political agenda due to the alarming increase of fatalities among veterans misusing opioid medications; thus, the reduction of mortality rates is a priority. Since the core of the analysis is the effectiveness of the alternative policies to reduce the number of opioid-related deaths among veterans, this criterion is in focus for confronting the trade-offs. The projected outcomes identified earlier allow for presenting the comparison of trade-offs against each criterion (See Table 1). The issue of policy effectiveness is projected on the basis of past or current results. According to Sharpless (2019), “total drug overdose deaths in the United States dropped 5.1% from 2017 to 2018 – the first decrease in more than two decades” (para. 1). Although the rates illustrate the general public impact, the veteran population is predominant within the scope of opioid-dependent patients.
Since the work is done to facilitate the implementation of effective measures by means of the SUPPORT provisions, it is anticipated that the trend will be maintained on the federal scale. The rate of opioid overdose in veterans (as reflecting the majority of the US population impacted by the opioid crisis) has reduced by approximately 4% (CDC, 2020). Due to the intensified measures for opioid prescription reduction, it is anticipated that the number of deaths will reduce by more than 4%. Since the rate of opioid poisoning in Hawaii has reduced by approximately 1% within the last two years, the reduction of mortality rate under the influence of the Hawaii Opioid Initiative is projected to maintain the same direction.
As for political acceptability and policy sustainability, they are expected to be high for the second and third policies due to the favorable climate of organization-level and state-level initiatives. However, the political acceptability of the first policy might be diminished by the overall partisanship associated with the federal implementation of the administration’s initiatives (Grogan, 2020). Also, policy sustainability might be low due to the upcoming presidential elections that might change the political environment and obstruct the currently implemented initiatives.
Figure 1.
Decision-Making
Considering the alternatives’ projected outcomes and the predicted performance against the chosen criteria, VA’s Opioid Safety Initiative is the most effective. To validate this decision, one should emphasize that the criterion of effectiveness in terms of mortality reduction is thought to be key. However, political acceptability and policy sustainability also play a significant role since they determine whether the policy will be maintained and reach the planned effectiveness rate. Bureaucratic resistance to the implementation of the SUPPORT Act might be a significant obstacle to policy acceptability and sustainability. Also, the relative ineffectiveness of the Hawaii Opioid Initiative does not allow for choosing it as the best option. Therefore, the VA Opioid Safety Initiative is identified as the alternative that is the most likely to lead to the most favorable outcomes.
Telling a Story
The audience, at whom this policy analysis is aimed, includes key policy-makers, who are responsible for the outcomes of policies they choose. The analysis shows that the SUPPORT for Patients and Communities Act is weaker in political acceptability and policy sustainability in comparison to the VA Opioid Safety Initiative. Also, it insufficiently addresses the needs of the veteran population, applying only general approaches to resolving complex issues of SUDs in this, particularly vulnerable population. Therefore, concerning the needs of veterans, who are an underrepresented and underserved population, it is vital to adjust the SUPPORT provisions to those implemented by the VA, since they demonstrated the best-projected outcomes.
Conclusions and Implications
The problem of the opioid crisis takes the lives of thousands of Americans yearly, while military veterans with pain management issues are two times more likely to die of opioid misuse than the general population. Despite a broad scope of planned efforts under the provisions of the SUPPORT Act, veteran mortality statistics remain alarming. It is vital to ensure that the policy relevantly addresses the particularities of veterans and to facilitate the scope of actions aimed at the improvement of policy sustainability and acceptability.
References
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