Veterans Health Watch Show #157

Welcome back to Veterans Health Watch. This episode is dedicated to harm reduction and ways that veterans could drastically reduce their risk of harming themselves as well as other people in their lives. First, I want to talk about something we know as Prep and how we do can greatly reduce the spread of HIV even 30 years later. More than 30 years later, we're still talking about HIV, but thankfully we've made such strides in reducing the spread of HIV, reducing the infection rates. Now we're her

e to talk about Prep. So, Jennifer, tell us, what is Prep? It's a pill that veterans take one pill a day and it reduces the risk of them getting HIV through either sex or through drug use, typically IV drug use or sharing drug equipment. It can reduce the it can reduce the rates of HIV through sex up to 99% if the medication is taken correctly and up to 74% through drug use. Again, if it's taken as prescribed. So it's a wonderful medication that we have here is an option for reducing harm, reduc

ing I.V. or HIV infections in our veteran population. That is an amazingly high rate for reducing the spread of infection. So is this drug for people who are not infected with HIV or in they maybe participate in certain risk risky behaviors or risk factors, or is it for treatment? Is it. Can you explain the difference? Yep. So it is for HIV negative patients. So that's one of the indications. They cannot have HIV infection. And we do test as close to starting them on the medication as possible t

o make sure that they do not have HIV infection before starting this medication. So it is for the higher risk patients for getting HIV infection. So a lot of the patients that we see are at very high risk of HIV. So we see a lot of the gay and bisexual men, population men having sex with men. We also see a good number of HIV discordant couples. So it we'll see a patient that that is HIV negative and has partner or partners that are HIV positive. And it gives them the sort of ability to have sex

with those partners and not have to worry about the risk of HIV as much. We still do highly recommend the use of barrier protection, such as condoms, but it can really significantly decrease the the worry that that our veterans have when having sex with their partners, other people that are high risk. And we see in our clinics are people that are sex workers, people that have either no or inconsistent condom use, patients that have multiple history of sexually transmitted infections. Maybe they'

ve had a recent sex a sexually transmitted infection. People that engage in group sex and then also the population of those who use use drugs as well as the. Does prep prevent the spread of other sexually transmitted diseases. So it is just HIV. And that's a really good point because, again, we do a lot of education, a lot of educating our patients regarding still using barrier methods, whether it's condoms, internal and external condoms, dental dams and other ways to kind of mitigate the risk o

f getting HIV, but also other STIs. So and a lot of times veterans don't know that we can actually prescribe some of those things like condoms through the VA. So that is definitely something that I advocate for and let our veterans know that, you know, it's something that they can pick up right at the pharmacy or have mailed to them. Yeah, it's good to know that this should be there should be no stigma or shame associated with this is another way of protecting yourself and reducing harm, which w

e've been talking about. And for a veteran who may have listened to that, the list of people who fall into certain risk categories or behaviors that fall into certain risk categories, I should say. Can we talk a little bit more about the medication? How often do they take it? How long should they get your. So it's it's a medication that is so that Disco V and Truvada are both one pill a day. So they would take it 11a day. It's either in the morning or at night or I tell them to take it when they

remember to take it. So if that's in the morning, take it with your other medications in the morning or in the evening. It is actually a two in one medication, which is great. So it reduces the pill burden for for veterans, especially when they're taking so many other pills. So it's two medications within the one pill. They can take it with or without food. And it's very well tolerated, meaning it doesn't typically we don't see a lot of side effects with this medication. And following up to con

tinue testing for HIV, if someone does turn up positive when using this medication, how do you proceed? Does the person continue to take the medication? So the reason why we check patients every three months is because if they were to get HIV, if they were to convert to having HIV, then we would want to get them off prep and we would want to get them on it. Correct. Sort of HIV regimen right away. Patients that take prep that have HIV could become resistant to this medication. And we want to avo

id that from happening. Right. And if a person do that, does a person have to take it for a lifetime? Does that behavior detect or determine when they take it? How does that work? Yeah, that's a good question, too. So they they do not have to take it for a lifetime. I recommend that they take it as long as they're high risk for HIV infection. So it's something that they can sort of start and stop through the COVID pandemic. I will mention that a lot of our veterans, we're not engaging in high ri

sk sex or doing drugs or things like that. And so they did take a break during the COVID pandemic, and they weren't able to come in to get their labs and things like that. So they do take sort of medication vacations, which we do advocate for, but would would want them to stay on the medication if they do remain at that higher risk. Right. And absolutely use secondary precautions if they are taking that risk. Absolutely. And for a veteran who is enrolled in the health care system falls into some

of the risk categories, how do they ask for the medication or is it presented to them? How does that situation work? That's another good question. So we get referrals from all over VA, Maryland, so we'll get referrals from patients, primary cares from the emergency room, Anyone that is again, high risk or anyone that maybe presents to the emergency room with a sexually transmitted infection might get referred. It is definitely a conversation that not only primary care or the emergency room shou

ld be having, but sort of all providers should be asking their veterans and taking a good sexual history. And the other kind of area where we get a lot of referrals is from mental health for especially the veterans that are using using drugs have a substance use disorder. Great. This has been fantastic information and I'm so happy that VA is offering something for our veterans to help prevent the spread of HIV and to help them to know that they have a place to come, to get to get the help that t

hey need. So this is fantastic. And for any of our veterans who heard this information about Prep and would like to know more about how Prep can help you if you are already enrolled in the VA health care system, please follow the information on our screen. If you are enrolled, please contact your VA provider. I was in a lot of pain when my doctor prescribed opioids. I didn't question it and at first it seemed to be helping. I was following my prescription. The pain was never far behind. That's b

ecause opioids mask pain. They don't actually heal it. I was in a tough place. Addiction, overdose. I didn't want that for myself. So I talked to my doctor. It turns out there are other options exercise, acupuncture, massage, non-addictive medications like a cinnamon often, or ibuprofen. It takes persistence. But I found an alternative that really works for me. If I hadn't talked to my doctor, opioids would have taken over my life. Now I feel stronger and better than ever. And my pain? Well, of

days. It's not there at all. I found the pain management option that was right for me. Head to the website to learn about more ways that could work for you. I take images from the inside out and I will be continuing today's show with more ways to promote harm reduction. I'd like to talk about a very important syringe services program within the VA. This is a newer program to promote life saving access to syringes and other therapies for veterans who struggle with substance use problems. Here to

talk about it is me new again, Lee Minu. I want to get right into it. What is a harm reduction program? So harm reduction is it's really a stance towards helping people where instead of, you know, as providers, we tell people what they should be doing. It's really more talking to the person in this case the veteran, and asking them what ways we can be helpful. A lot of traditional health care tends to be pretty bossy and tell people, you know, this is bad, this is unhealthy. With harm reduction,

we're really rather than telling people to stop doing things or to do certain other things, we're really just trying to minimize the harm. So, for example, with substance use disorders, you know, I think most of us would agree that it's not helpful to be using substances. However, harm reduction really focuses on helping people minimize any additional harms. So, you know, we don't want people to overdose. We don't want people to contract disease from sharing needles, even if they may not be rea

dy to stop using drugs. And so the VA has the syringe services program. Tell us about that program and how does it work? So this is a brand new program to us and then also nationally within VA. You know, these programs are being rolled out. So, you know, syringe services program. I don't want people to just think it's just syringes. We also will be talking about things like naloxone, which is that lifesaving medicine that will reverse an overdose. We can obviously give out clean needles. We can

give people fentanyl test strips, which are a way for people who are still using drugs to test their drugs and see whether they have fentanyl in them, and that that will help them make decisions about what to do next. We can give people things like condoms. We can give them some wound care supplies, because often people who are injecting, you know, end up with wounds. We can also refer people to treatment if that's what they want, although it's not a requirement. Let's address the elephant in th

e room. And we're talking about people with with substance use addictions. And and I know I know the VA does offer treatment. What we're you're we mentioned harm reduction. So evidently we're talking about people who are still participating in certain behaviors, who are still using these substances or misusing the substances. How does this work? How, why, why are we considering these alternatives when these people have a problem? So you're absolutely right. The VA has excellent substance use tre

atment. And what we know is that the majority of people who are struggling with substance use don't get treatment. And it's not necessarily because it's not there, it's because often people feel like it's, you know, not what they want. Maybe they're not ready, maybe it's not the thing that they feel is important to them. So there's often a mismatch between what we as providers are offering and what, you know, veterans or whoever else is looking for. So with harm reduction, what we're really tryi

ng to understand is how can we help you right now in your life? Right? Just because someone might want to be using drugs but doesn't mean they want to die or they want to get horrible wounds or they want to contract HIV. How do they find out about the program? So various ways, you know, if they're hopefully they're involved in something like primary care there, any provider can put in a consult. They can also just call on Wednesday mornings from 8 to 11. We're actually down in person in the ER i

n Baltimore and we're really flexible. So we really want to make this easy for people. You know, we can see people over video. We're happy to talk on the phone, even if you're really not sure, you know, if this is for you or you just want some more information, totally fine. If you have like a buddy or you're listening to this and you think like it's really sounds like maybe, you know, my loved one could use this, please send them our way and feel free to reach out to them. We're happy to connec

t you. So what are the studies saying about the syringe service and how this works? Yeah, what's interesting is a big concern. Often when people hear about this is they think like, well, you know, you're just going to give out these supplies and not require people to do anything. And what we've actually found is people who participate in these kinds of programs in the long run tend to engage in treatment at much higher rates and eventually often stop using substances at much higher rates. So I t

hink that's probably because often, you know, historically, people who are living with substance use problems have, you know, potentially really stigmatizing interactions with people. They may not have had great experiences in their health care. And so if they can come in and have nonjudgmental, accepting experiences, sometimes that sets them up to try other health care interactions. And that's kind of what we're here for. We want to be helpful. You know, we want to meet people where they're at.

So this is a very no strings attached sort of service. And that's that's great for our veterans to know and for family members that you're clinicians, you're professionals, you're here to service them and help them and not not to judge them, but to help them to be healthy. So what would you say to a veteran who's maybe on the fence and not sure? Maybe they are hiding their behaviors, not sure what to do, but they are interested in this program. So I would say, first of all, you know, I worked f

or VA for over 20 years. I love veterans. I care about you guys. I think there's no reason to suffer, you know, harms to yourself that are preventable. And so many of the things that happen when you're using substances, they're preventable. You know, we can stop you from overdosing. We can stop you from contracting illnesses from other people. These are not things you should have to live with. And, you know, life is hard enough. Let us at least prevent some of the things that are preventable. Ri

ght? We've all got enough on our plates. And the other thing with substance use disorders is, you know, if you're worried about people judging you on finding things out, then let's try to get your life under control a little and you mentioned earlier about fentanyl and actually a testament, because we hear so many times that people are when they get their drugs from the street or wherever they get it, they're getting them. People are dying because they don't know what's in their drug. So tell me

tell me more about that and how that works. So so you're absolutely right. Fentanyl, I think people are aware it's an opioid, but it's also involved in about three quarters of the cocaine overdoses right now. About half of methamphetamine. That's not as big of a problem here, but still. So we have these little strips that look like this. They look almost like a you know, like a COVID test or pregnancy test. And you can test anything you're planning to use and you just dip it and then it will gi

ve you a result within a minute or so and it'll say either there is fentanyl in there or there is no fentanyl. And then you can decide whether you want to proceed with using and maybe you want to make sure you have locks on on the hand or you want to make sure you're not using alone, something like that. You might want to use less. You might want to use it in a different way. So it's sort of like nutritional labeling where we put calories on things. We put, you know, the nutritional information

so that people can make decisions. And it's the same here. This is amazing. I again, I keep I keep going back on the eighties and even the nineties and we talk about substance use disorder and just facing the reality of it. Not everyone is ready, but we want to make sure we keep them alive until they are ready. And this is a fantastic program. So when a person gets the syringe or the or the the strip, do they get a package? Do they come back regularly? How does how does it work logistically? So

the national program is rolling out kits and they're like, they come out a little packet and people can come in regularly depending on their needs. So depending on how often they're using, they might come in more or less frequently. And you know, if they need more or less from us, we're also really happy to help people connect with other things. So fantastic menu. Thank you so much. We're going to we're going to continue and we're going to continue our conversation. But if you want to know more

about the therapies available to you or to a veteran in your life, please use the contact information on the screen. And up next, menu, and we're going to talk about how our methadone treatment program can save the lives of veterans living with addiction. It's not that we've got overdoses on prescription opioids like this are happening to over 17,000 Americans every year. But it is preventable if you take action now when you first get a prescription for opioids and never shrug off the warnings,

they are there to protect you from opioid addiction and overdose. These pills are powerful, so never take more than you are prescribed and never drink while on your medication because combining alcohol with opioids can shut down your organs. Wake up. Save your own life by paying attention to the warnings on your prescription. Overdoses are preventable. Learn more at the website. I help veterans take care of their eye, health and vision, and I'm on the team. Substance use disorder is a national h

ealth crisis, and VA is here to help veterans fight for their lives. We offer many therapies, including medication therapy for opioid use disorder, to reduce drug cravings and help veterans to not use straight drugs. Let's talk some more about these programs. Mean you. So I mentioned in the intro that substance use disorder is a national crises. And we hear all the time about the opioid crisis and what is VA doing to help address this crisis for our veterans. So actually, this is an area where V

A has really excelled. Substance use disorder, and particularly opioid use disorder. That's an illness that is chronic and potentially lethal. But it really doesn't need to be. It's something that has actually an excellent range of treatments available. So there are a variety of medications, treatments for opioid use disorder that fall under harm reduction. And. Whereas generally are in the non the world about maybe 13% of people living with an opioid use disorder get these medications. In VA, i

t's probably about 40 something percent, which is really great. And so this is something that veterans really should make use of because what we know about medication treatments for opioid use disorder is that getting on them and staying on them can cut the risk of dying by up to 70% compared with like a brief detox. And when you compare people who take medication versus people who just try to go it alone, you know, they they have half of the mortality. But to help people who are listening to us

, we're saying opioid use disorder. Let's let's make that a little more a little more easy for other people to understand what what falls under opioid use. So it's a little bit of a mouthful. And it's just because we used to say addiction, you know, like heroin addiction. And part of the reason we've gotten away from that is that the language is kind of stigmatizing. That's one reason. The other reason is that there are so many different drugs that fall under the umbrella of opioid use disorder

now. So, you know, some people came to it by prescription opioids, you know, things like oxy. Some people came to it by heroin, some people came to it via some other combination. How does it work? How does methadone or these different treatments work? When you're going on your own one day night, you know, we've heard people say you're just substituting one drug for another, but you want to understand how it actually works to benefit the veteran. So I'm really glad you use that phrase, actually,

because it's I think that's a big stigma that prevents people from from getting into treatment. And so from a hammered action perspective, you know, you are substituting one drug from another, right? The same way as when someone has diabetes and we give them insulin. We are literally substituting one thing for another. Or I bet a lot of people listening right now take medicines for hypertension, all kinds of things. We do it all the time and I think the difference is when it's a substance use pr

oblem, we tend to approach it like someone is a moral failure, you know, like they just didn't try hard enough. And so for anyone listening right now who's struggling with a substance use problem, I want you to really ask yourself, like, is it just you really didn't try? Because I bet that's not the answer. I bet you've tried hard, you know, And so the problem is this is a chronic illness. And just the same way as we would never say to someone with diabetes, just try harder. You know, try again.

The way methadone and buprenorphine work, are they they fit in your brain receptors like an opioid because they are an opioid and they occupy that receptor. So they sit in there like a tap, and so they prevent you from going into withdrawal. Unlike something like heroin, they last a really long time. So you can take a dose and you can have the effects for a whole 24 hours. The other thing is, unlike something like heroin, oxy, they're not giving you this big rush. They're more just sort of keep

ing things level. So when people are on the proper dose, you know, one should notice that they're on anything they shouldn't notice or on anything. People will often just say they just feel normal again. And that's a goal. I think if you were to use something like heroin, it won't work because all of those receptors are blocked by the methadone or the view. You just keep surprised me. I mean, this is great information. All right. This is this is fair. It's odd maybe to say, but we really want to

save lives. We want people to get the help they need. So this is great information. How long can someone stay on methadone or any of these treatments? For as long as they want. So, you know, we've treated people, you know, for 40, 50 years. Sometimes I think a big misnomer of a lot of these treatments is that people will often think of like the one person they know that was taking methadone or buprenorphine and was struggling. But the reality is you are surrounded by people who are taking these

medications successfully. And the reason you don't know about them is they're doing well and you don't know. And that is the whole purpose of the medicine, right? Is like you want someone to return to their lives. And I mean, I don't share what medicines I'm taking with people. It's none of their business. And so if these medicines work, no one should know. I mean, you can tell them if you want, but you should just feel like your normal self. So what about the person who are do you have cases o

f people who maybe go on it for a year or two or short a period of time? How does that work for you, for them as a person? Yeah, it depends on the person. It is generally recommended as a longer term medication just because this is a chronic illness. So it's it's not in general recommended to, you know, just do a brief detox. What people usually find is they relapse. But depending on of needs, you know, people do often get stable, you know, take their time, maybe address some of the issues that

we're getting them to using in the first place. And once things are really stable, then they might slowly taper off. Do you offer other treatment therapies or other treatment options in addition to the medication treatment? Yes. So part of you know, again, it depends on the person, but often part of what's keeping somebody addicted or even might be work that got them into it in the first place is, you know, maybe they have PTSD and maybe they have chronic pain if they're homeless. And, you know,

life is a constant struggle. So hopefully successful treatment will mean that once you're not ill and sick and desperate anymore, you can actually look around your life and see how to fix some of those things. But it's really hard to do anything when you're feeling sick every morning. I mean, it's just not reasonable to expect so easier for people to stop using methadone than it is to stop using straight drugs. Well, so when I said, you know, it's replacing one thing with another, I was probabl

y being silly. But I was partly being serious and that we know exactly what you're getting. Right. Because it's legal, it's regulated. And so the problem with going out on the street is that you have no idea what you're getting. You could be getting anything. It's very hard to taper yourself off when you might be getting a different thing every day. So if you're doing it very gradually under a doctor's care, it's certainly a lot more controlled and you can do it plan fully. Yes, absolutely. And

what about that veteran who is on the fence? They're concerned about seeking treatment and Barish just they don't know where to go. What would you say? What would you offer as a clinician? I would say, you know, they can come in and talk, do an intake if they're not even there yet, if they're really super on the fence, that's a great use of the syringe services program. You know, they can kind of just get some information. I will often say to people like if you've tried the same thing over and o

ver and it hasn't worked over and over, you can always try this. If it's not working for you, you can stop, but it's always worth trying. That's right. It works for a lot of people. All right. Well, thank you so much. We knew you provided fantastic information, not only about the treatment services about but about substance use disorder in general. So I really appreciate your time with us today. Absolutely. I hope this is helpful for people. We'd love to see you, I hope take care of our most fra

il and vulnerable veterans. And I'm on that team. I choose VA for health care because they are sincere and compassionate. VA understands veterans and they provide more services with veterans in mind. I'm a veteran and I choose VA. This wraps up this edition of Veterans Healthwatch. If you are a veteran, apply for VA health care today. You deserve it. Just visit our Web page for more information.