{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,21]],"date-time":"2026-04-21T13:28:11Z","timestamp":1776778091894,"version":"3.51.2"},"reference-count":68,"publisher":"Oxford University Press (OUP)","issue":"5-6","funder":[{"DOI":"10.13039\/100000774","name":"Defense Threat Reduction Agency","doi-asserted-by":"publisher","award":["HDTRA1-09-D-0009"],"award-info":[{"award-number":["HDTRA1-09-D-0009"]}],"id":[{"id":"10.13039\/100000774","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2020,6,8]]},"abstract":"<jats:title>Abstract<\/jats:title>\n               <jats:sec>\n                  <jats:title>Introduction<\/jats:title>\n                  <jats:p>We examine the current status of the military relevance of opioids, their use and misuse in military and veteran populations, the national security consequences of opioid use in our military age population, public health implications, and military, veteran, and government solutions for opioid addiction.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Materials and Methods<\/jats:title>\n                  <jats:p>A literature search of recent published research, federal government, and related open source materials was conducted using PubMed, Google, and Google Scholar, and all materials retrieved were manually identified, screened, and evaluated for inclusion. A modified Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) approach was used for the selection of relevant articles. Heath policy literature and relevant demographic information published within the last 5 years was also included to provide current information and search for solutions to address the escalating national opioid crisis.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Results<\/jats:title>\n                  <jats:p>Synthetic opioids are used for pain and trauma management, not readily substituted, and have exceptionally high addiction potential. Combat wounded veterans have greater potential for opioid misuse than civilian populations. Assessment, management, and treatment of opioid use in this population are essential. Veterans receiving synthetic opioids have been noted to have multiple overdose risk factors. Opioids are readily available nationally as \u201cstreet drugs\u201d and also in the form of fentanyl-contaminated heroin. The opioid crisis affects the military age population and the top states for military enlistments. Younger age males with lower education and income are at significant risk for opioid use disorder. Recently increased drug overdose deaths contribute to an increased U.S. mortality rate with a commensurate decline in life expectancy at birth. Opioid abuse contributes to increased incidence of infectious disease. Behavioral health programs directed at military and veterans to identify risk factors for opioid misuse have been introduced. Prescription drug monitoring initiatives continue for these populations with increased information exchanged between military and civilian healthcare. Lifesaving interventions for opioid addiction include methadone maintenance and fentanyl test strip accessibility. Newly implemented federal funding healthcare initiatives to the states are now directed at opioid use prevention and enhanced surveillance.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Conclusions<\/jats:title>\n                  <jats:p>Given increasing rates of opioid addiction and death, viable solutions are universally needed. Successful intervention measures should be widely shared between military, veteran, and civilian healthcare and public health communities. Increased collaboration between these groups could inculcate successful programs to prevent and decrease opioid use. Results received from recent military and veterans\u2019 programs for prescription and electronic medical record (EMR) monitoring and data sharing may also prove useful for civilian healthcare providers and hospital systems. Future evaluations from ongoing federally funded programs to the states for addiction surveillance and intervention may help create measures to address the proliferation of opioid addiction with increased death rates. Anticipated results from these federal efforts should help inform opioid programs in military and veterans\u2019 health systems.<\/jats:p>\n               <\/jats:sec>","DOI":"10.1093\/milmed\/usz487","type":"journal-article","created":{"date-parts":[[2020,2,20]],"date-time":"2020-02-20T15:40:10Z","timestamp":1582213210000},"page":"e662-e667","source":"Crossref","is-referenced-by-count":25,"title":["The Opioid Epidemic: Challenge to Military Medicine and National Security"],"prefix":"10.1093","volume":"185","author":[{"given":"Zygmunt F","family":"Dembek","sequence":"first","affiliation":[{"name":"Battelle Connecticut Operations, 50 Woodbridge Drive, Suffield, CT 06078-1200"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Tesema","family":"Chekol","sequence":"first","affiliation":[{"name":"Battelle, Defense Threat Reduction Agency, Technical Reachback (J9-ISR), 8725 John J. Kingman Road, Stop 6201, Fort Belvoir, VA 22060-6201"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Aiguo","family":"Wu","sequence":"first","affiliation":[{"name":"Defense Threat Reduction Agency, Technical Reachback (J9-ISR), 8725 John J. Kingman Road, Stop 6201, Fort Belvoir, VA 22060-6201"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"286","published-online":{"date-parts":[[2020,2,20]]},"reference":[{"key":"2020060904542913000_ref1","article-title":"Progress in preventing opioid abuse, more needs to be done","author":"Ferdinando","year":"2018","journal-title":"Military Health System"},{"key":"2020060904542913000_ref2","doi-asserted-by":"crossref","first-page":"168","DOI":"10.1016\/j.addbeh.2018.12.007","article-title":"Opioid and sedative misuse among veterans wounded in combat","volume":"92","author":"Kelley","year":"2019","journal-title":"Addict Behav"},{"key":"2020060904542913000_ref3","article-title":"China is poisoning America with fentanyl","author":"Von Spakovsky","year":"2019","journal-title":"The Heritage Foundation"},{"key":"2020060904542913000_ref4","doi-asserted-by":"publisher","first-page":"183","DOI":"10.1016\/j.drugpo.2019.01.010","article-title":"The triple wave epidemic: supply and demand drivers of the US opioid overdose crisis","volume":"71","author":"Ciccarone","year":"2019","journal-title":"Int J Drug Policy"},{"key":"2020060904542913000_ref5","article-title":"The underestimated cost of the opioid epidemic","author":"The Council of Economic Advisors","year":"2017"},{"key":"2020060904542913000_ref6","article-title":"SAMHSA\/HHS: an update on the opioid crisis","author":"McCance-Katz","year":"2018","journal-title":"SAMHSA"},{"issue":"2S","key":"2020060904542913000_ref7","doi-asserted-by":"crossref","first-page":"S109","DOI":"10.1016\/j.wem.2017.04.001","article-title":"Battlefield analgesia in tactical combat casualty care","volume":"28","author":"Wedmore","year":"2017","journal-title":"Wilderness Environ Med"},{"key":"2020060904542913000_ref8","doi-asserted-by":"crossref","first-page":"S490","DOI":"10.1097\/TA.0b013e3182754674","article-title":"Safety and efficacy of oral transmucosal fentanyl citrate for prehospital pain control on the battlefield","volume":"73","author":"Wedmore","year":"2012","journal-title":"J Trauma Acute Care Surg"},{"key":"2020060904542913000_ref9","volume-title":"AcelRx","author":"Dsuvia","year":"2018"},{"key":"2020060904542913000_ref10","volume-title":"Is there really a need for another opioid? US News and World Report","author":"Scroeder","year":"2018"},{"issue":"4","key":"2020060904542913000_ref11","doi-asserted-by":"publisher","first-page":"315","DOI":"10.1080\/14728222.2019.1586882","article-title":"Current strategies towards safer mu opioid receptor drugs for pain management","volume":"23","author":"Ehrlich","year":"2019","journal-title":"Expert Opin Ther Targets"},{"key":"2020060904542913000_ref12","volume-title":"HDIAC Webinar: Battlefield Pain Management","author":"Geisler","year":"2019"},{"key":"2020060904542913000_ref13","doi-asserted-by":"crossref","first-page":"281","DOI":"10.3390\/md10020281","article-title":"Tetrodotoxin (TTX) as a therapeutic agent for pain","volume":"10","author":"Nieto","year":"2012","journal-title":"Mar Drugs"},{"key":"2020060904542913000_ref14","volume-title":"Fentanyl vs. heroin: the similarities and differences between two powerful opioids. American Addiction Centers","author":"Crane","year":"2019"},{"issue":"1\u20132","key":"2020060904542913000_ref15","doi-asserted-by":"crossref","first-page":"e101","DOI":"10.1093\/milmed\/usy162","article-title":"Predictors of postdeployment prescription opioid receipt and long-term prescription opioid utilization among army active duty soldiers","volume":"184","author":"Adams","year":"2019","journal-title":"Mil Med"},{"issue":"8","key":"2020060904542913000_ref16","doi-asserted-by":"crossref","first-page":"1400","DOI":"10.1001\/jamainternmed.2014.2726","article-title":"Chronic pain and opioid use in US soldiers after combat deployment","volume":"174","author":"Toblin","year":"2014","journal-title":"JAMA Intern Med"},{"issue":"8","key":"2020060904542913000_ref17","doi-asserted-by":"crossref","first-page":"1402","DOI":"10.1001\/jamainternmed.2014.2114","article-title":"Pain and opioids in the military: we must do better","volume":"174","author":"Jonas","year":"2014","journal-title":"JAMA Intern Med"},{"issue":"2","key":"2020060904542913000_ref18","doi-asserted-by":"crossref","first-page":"e150","DOI":"10.1097\/MJT.0000000000000141","article-title":"Misuse of prescribed pain medication in a military population \u2013 a self-reported survey to assess a correlation with age, deployment, combat illnesses, or injury?","volume":"24","author":"Ramirez","year":"2017","journal-title":"Am J Ther"},{"issue":"10","key":"2020060904542913000_ref19","doi-asserted-by":"crossref","first-page":"1281","DOI":"10.7205\/MILMED-D-15-00508","article-title":"A 3-year comparison of overdoses treated in a military emergency department\u2014complications, admission rates, and health care resources consumed","volume":"181","author":"Ganem","year":"2016","journal-title":"Mil Med"},{"issue":"3\u20134","key":"2020060904542913000_ref20","doi-asserted-by":"crossref","first-page":"e157","DOI":"10.1093\/milmed\/usx014","article-title":"Opioid use patterns among active duty service members and civilians: 2006\u20132014","volume":"183","author":"Kazanis","year":"2018","journal-title":"Mil Med"},{"issue":"10","key":"2020060904542913000_ref21","doi-asserted-by":"crossref","first-page":"1141","DOI":"10.7205\/MILMED-D-14-00002","article-title":"Use and abuse of prescribed opioids, central nervous system depressants, and stimulants among U.S. active duty military personnel in FY 2010","volume":"179","author":"Jeffrey","year":"2014","journal-title":"Mil Med"},{"issue":"1","key":"2020060904542913000_ref22","doi-asserted-by":"crossref","first-page":"42","DOI":"10.1080\/10550887.2016.1107264","article-title":"Risk factors for opioid overdose and awareness of overdose risk among veterans prescribed chronic opioids for addiction or pain","volume":"35","author":"Wilder","year":"2016","journal-title":"J Addict Dis"},{"key":"2020060904542913000_ref23","doi-asserted-by":"publisher","first-page":"h2698","DOI":"10.1136\/bmj.h2698","article-title":"Benzodiazepine prescribing patterns and deaths from drug overdose among US veterans receiving opioid analgesics: case-cohort study","volume":"350","author":"Park","year":"2015","journal-title":"BMJ"},{"issue":"11","key":"2020060904542913000_ref24","doi-asserted-by":"crossref","first-page":"2021","DOI":"10.1111\/add.13491","article-title":"Non-medical use of prescription opioids is associated with heroin initiation among U.S. veterans: a prospective cohort study","volume":"111","author":"Bannerjee","year":"2016","journal-title":"Addiction"},{"issue":"9","key":"2020060904542913000_ref25","doi-asserted-by":"crossref","first-page":"2126","DOI":"10.1097\/j.pain.0000000000001606","article-title":"High-dose prescribed opioids are associated with increased risk of heroin use among United States military veterans","volume":"160","author":"Bannerjee","year":"2019","journal-title":"Pain"},{"issue":"1","key":"2020060904542913000_ref26","first-page":"106","article-title":"Changing trends in opioid overdose deaths and prescription opioid receipt among veterans","volume":"57","author":"Lin","year":"2019","journal-title":"AJPM"},{"key":"2020060904542913000_ref27","volume-title":"Carfentanil. Critical Review Report. Agenda Item 4.8. Expert Committee on Drug Dependence. Thirty-Ninth Meeting. Geneva, 6-10 November 2017","author":"World Health Organization"},{"key":"2020060904542913000_ref28","volume-title":"Stopping the poison pills: combatting the trafficking of illegal fentanyl from China. Statement before the United States Senate Caucus on International Narcotic Control, October 2, 2018","author":"Allen"},{"key":"2020060904542913000_ref29"},{"key":"2020060904542913000_ref30","volume-title":"Key Substance Use and Mental Health Indicators in the United States: Results from the 2017 National Survey on Drug Use and Health (HHS Publication No. SMA 18-5068, NSDUH Series H-53)","author":"Substance Abuse and Mental Health Services Administration"},{"key":"2020060904542913000_ref31","doi-asserted-by":"crossref","first-page":"371","DOI":"10.1016\/j.drugalcdep.2018.11.002","article-title":"Evaluating opioid overdose using the National Violent Death Reporting System, 2016","volume":"194","author":"Clinton","year":"2019","journal-title":"Drug Alcohol Depend"},{"key":"2020060904542913000_ref32","volume-title":"Drug overdose deaths in the United States, 1999\u20132017. NCHS Data Brief No. 329","author":"Hedegaard","year":"2018"},{"issue":"10","key":"2020060904542913000_ref33","first-page":"1053","article-title":"The military, industrial and public health features of narcotic addiction","volume":"319","author":"Stokes","year":"1918","journal-title":"JAMA"},{"key":"2020060904542913000_ref34","doi-asserted-by":"crossref","first-page":"95","DOI":"10.1016\/j.ypmed.2019.02.017","article-title":"Trends in the medical supply of fentanyl and fentanyl analogues: United States, 2006 to 2017","volume":"123","author":"Collins","year":"2019","journal-title":"Prev Med"},{"key":"2020060904542913000_ref35","volume-title":"States with the highest rates of military enlistments. Stacker","author":"Lisa","year":"2018"},{"key":"2020060904542913000_ref36","article-title":"The Army is supposed to be growing, but this year, it didn\u2019t at all","author":"Myers","year":"2018","journal-title":"Army Times"},{"issue":"1","key":"2020060904542913000_ref37","first-page":"36","article-title":"Which US states possess the greatest threats to military readiness and public health? Public health policy implications for a cross-sectional investigation of cardiorespiratory fitness, body mass index, and injuries among Army recruits","volume":"25","author":"Bornstein","year":"2019","journal-title":"JPHMP"},{"issue":"10182","key":"2020060904542913000_ref38","doi-asserted-by":"crossref","first-page":"P1760","DOI":"10.1016\/S0140-6736(18)33078-2","article-title":"Management of opioid use disorder in the USA: present status and future directions","volume":"393","author":"Blanco","year":"2019","journal-title":"Lancet"},{"issue":"3","key":"2020060904542913000_ref39","doi-asserted-by":"crossref","first-page":"123","DOI":"10.1053\/j.semperi.2019.01.001","article-title":"The United States opioid epidemic","volume":"43","author":"Lyden","year":"2019","journal-title":"Semin Perinatol"},{"issue":"2","key":"2020060904542913000_ref40","first-page":"37","article-title":"Overdose deaths involving fentanyl and fentanyl analogs\u2014New York City, 2000\u20132017","volume":"69","author":"Colon-Berezin","year":"2019","journal-title":"MMWR"},{"key":"2020060904542913000_ref41"},{"key":"2020060904542913000_ref42","volume-title":"Fentanyl","author":"National Institute on Drug Abuse","year":"2019"},{"key":"2020060904542913000_ref43","first-page":"k5118","article-title":"US life expectancy drops for third year in a row","volume":"363","year":"2018","journal-title":"Br Med J"},{"key":"2020060904542913000_ref44","article-title":"Drug deaths in America are rising faster than ever","author":"Katz","year":"2017","journal-title":"The New York Times"},{"key":"2020060904542913000_ref45","doi-asserted-by":"crossref","first-page":"107","DOI":"10.1016\/j.drugpo.2017.06.010","article-title":"Fentanyl in US heroin supply: a rapidly changing risk environment","volume":"46","author":"Ciccarone","year":"2017","journal-title":"Int J Drug Policy"},{"key":"2020060904542913000_ref46","volume-title":"Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use","author":"National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Health Sciences Policy; Committee on Pain Management and Regulatory Strategies to Address Prescription Opioid Abuse","year":"2017"},{"issue":"3","key":"2020060904542913000_ref47","doi-asserted-by":"crossref","first-page":"1175","DOI":"10.1007\/s13524-017-0565-3","article-title":"The contribution of drug overdose to educational gradients in life expectancy in the United States, 1992\u20132011","volume":"54","author":"Ho","year":"2017","journal-title":"Demography"},{"key":"2020060904542913000_ref48"},{"key":"2020060904542913000_ref49","doi-asserted-by":"crossref","first-page":"511","DOI":"10.1093\/pm\/pnx015","article-title":"Increase in drug overdose deaths involving fentanyl \u2013 Rhode Island, January 2012\u2013March 2014","volume":"19","author":"Mercado","year":"2018","journal-title":"Pain Med"},{"key":"2020060904542913000_ref50","doi-asserted-by":"crossref","first-page":"35","DOI":"10.1016\/j.addbeh.2017.01.014","article-title":"Prevalence and correlates of fentanyl-contaminated heroin exposure among young adults who use prescription opioids non-medically","volume":"68","author":"Macmadu","year":"2017","journal-title":"Addict Behav"},{"issue":"3","key":"2020060904542913000_ref51","doi-asserted-by":"crossref","first-page":"346","DOI":"10.1093\/infdis\/jiz133","article-title":"Opioids and infectious diseases: a converging public health crisis","volume":"220","author":"Schwetz","year":"2019","journal-title":"J Infect Dis"},{"key":"2020060904542913000_ref52","volume-title":"Project ECHO","author":"Opioid and Pain Related ECHOs","year":"2019"},{"issue":"3","key":"2020060904542913000_ref53","doi-asserted-by":"crossref","first-page":"387","DOI":"10.1007\/s11606-018-4710-5","article-title":"Army and navy ECHO pain telementoring improves clinician opioid prescribing for military patients: an observational cohort study","volume":"34","author":"Katzman","year":"2019","journal-title":"J Gen Intern Med"},{"issue":"5","key":"2020060904542913000_ref54","doi-asserted-by":"crossref","first-page":"833","DOI":"10.1097\/j.pain.0000000000000837","article-title":"Impact of the opioid safety initiative on opioid-related prescribing in veterans","volume":"158","author":"Lin","year":"2017","journal-title":"Pain"},{"issue":"1","key":"2020060904542913000_ref55","doi-asserted-by":"crossref","first-page":"34","DOI":"10.1037\/ser0000099","article-title":"Development and applications of the veterans health administration\u2019s stratification tool for opioid risk mitigation (STORM) to improve opioid safety and prevent overdose and suicide","volume":"14","author":"Oliva","year":"2017","journal-title":"Psychol Serv"},{"issue":"8","key":"2020060904542913000_ref56","first-page":"e265","article-title":"Reducing coprescriptions of benzodiazepines and opioids in a veteran population","volume":"24","author":"Shayegani","year":"2018","journal-title":"Am J Manag Care"},{"key":"2020060904542913000_ref57","article-title":"Opioid prescribing limits across the states","author":"Whitmore","year":"2019","journal-title":"Pharm Times"},{"key":"2020060904542913000_ref58","doi-asserted-by":"crossref","first-page":"168","DOI":"10.1016\/j.drugpo.2017.05.057","article-title":"Toxicosurveillance in the US opioid epidemic","volume":"46","author":"Lucyk","year":"2017","journal-title":"Int J Drug Policy"},{"key":"2020060904542913000_ref59","volume-title":"Health.mil","author":"Prescription Drug Monitoring Program"},{"key":"2020060904542913000_ref60","volume-title":"Pentagon launches prescription monitoring program to curb substance abuse. Military.com","author":"Kime","year":"2019"},{"key":"2020060904542913000_ref61","doi-asserted-by":"crossref","first-page":"94","DOI":"10.1016\/j.drugalcdep.2018.07.019","article-title":"Methadone maintenance treatment among patients exposed to illicit fentanyl in Rhode Island: safety, dose, retention, and relapse at 6 months","volume":"192","author":"Stone","year":"2018","journal-title":"Drug Alcohol Depend"},{"issue":"1","key":"2020060904542913000_ref62","doi-asserted-by":"publisher","first-page":"25","DOI":"10.1186\/s13722-018-0127-z","article-title":"Advancing pharmacological treatments for opioid use disorder (ADaPT-OUD): protocol for testing a novel strategy to improve implementation of medication-assisted treatment for veterans with opioid use disorders in low-performing facilities","volume":"13","author":"Hagedorn","year":"2018","journal-title":"Addict Sci Clin Pract"},{"issue":"3","key":"2020060904542913000_ref63","doi-asserted-by":"publisher","first-page":"11","DOI":"10.1186\/s12954-018-0276-0","article-title":"Perspectives on rapid fentanyl test strips as a harm reduction practice among young adults who use drugs: a qualitative study","volume":"16","author":"Goldman","year":"2019","journal-title":"Harm Reduct J"},{"key":"2020060904542913000_ref64","doi-asserted-by":"crossref","first-page":"122","DOI":"10.1016\/j.drugpo.2018.08.007","article-title":"Fentanyl test strips as an opioid overdose prevention strategy: findings from a syringe services program in the southeastern United States","volume":"63","author":"Peiper","year":"2019","journal-title":"Int J Drug Policy"},{"key":"2020060904542913000_ref65","volume-title":"State Information. Centers for Disease Control and Prevention","author":"Opioid Overdose","year":"2017"},{"key":"2020060904542913000_ref66","volume-title":"Funded programs and activities by state or territory (Fiscal Year 2017). Injury Prevention & Control","author":"Centers for Disease Control and Prevention","year":"2018"},{"key":"2020060904542913000_ref67","doi-asserted-by":"crossref","first-page":"231","DOI":"10.1016\/j.jsr.2018.10.011","article-title":"From the CDC: the prevention for states program: preventing opioid overdose through evidence-based intervention and innovation","volume":"68","author":"Robinson","year":"2019","journal-title":"J Saf Res"},{"key":"2020060904542913000_ref68","volume-title":"National Institute on Drug Abuse","author":"Opioid Summaries by State","year":"2019"}],"container-title":["Military Medicine"],"original-title":[],"language":"en","link":[{"URL":"http:\/\/academic.oup.com\/milmed\/article-pdf\/185\/5-6\/e662\/33370244\/usz487.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"http:\/\/academic.oup.com\/milmed\/article-pdf\/185\/5-6\/e662\/33370244\/usz487.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2020,6,9]],"date-time":"2020-06-09T08:54:59Z","timestamp":1591692899000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/milmed\/article\/185\/5-6\/e662\/5741369"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2020,2,20]]},"references-count":68,"journal-issue":{"issue":"5-6","published-online":{"date-parts":[[2020,2,20]]},"published-print":{"date-parts":[[2020,6,8]]}},"URL":"https:\/\/doi.org\/10.1093\/milmed\/usz487","relation":{},"ISSN":["0026-4075","1930-613X"],"issn-type":[{"value":"0026-4075","type":"print"},{"value":"1930-613X","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2020,5]]},"published":{"date-parts":[[2020,2,20]]}}}