Ryan Miller describes the year after his leg amputation as the best year of his life. He worked out. He traveled. He tanned. He was done with opioids.
After an explosively formed projectile destroyed his leg and damaged his stomach in Iraq, Miller had been caught in a vicious cycle of surgery and prescribed painkillers. The wounded Army infantry captain would have a surgery every few months, broken up by unsuccessful physical therapy.
"It wasn't just a pain, physical thing," Miller said. Physical dependence on opioids, coupled with pain from the injury, crushed Miller's spirit. "It just sucks. You feel like a prisoner."
The opioid crisis, which killed more than 42,000 Americans in 2016, continues to devastate the country. Doctors prescribe opioids for chronic pain, an ailment that is especially prevalent among military veterans. Of all the veterans returning from the Middle East, about 60 percent experience chronic pain.
A 2011 Veterans Affairs study found that veterans were twice as likely to die from an opioid overdose compared to the rest of the population. A 2014 study examined 2,500 soldiers after a deployment and found that 15 percent regularly used opioids. Many veterans also take benzodiazepines (antianxiety medication) for post-traumatic stress disorder. Benzodiazepines and opioids are both sedatives, and the combination is especially deadly.
The devastating toll opioids have taken on veterans has the VA scrambling to find alternative solutions. The VA enacted the Opioid Safety Initiative in 2013 and cut the number of veterans on opioids by almost a third. Although the initiative was enacted with good intentions, studies show the safest way to wean patients off opioids is in conjunction with alternative treatments. "This my-way-or-the-highway stuff is what really causes a lot of harm, and that's one of the things that I think we're running into a lot," said Michael Krawitz, an Air Force veteran and the executive director of Veterans for Medical Cannabis Access.
VA clinics have implemented practices like yoga, meditation and acupuncture as alternatives to opioids. But activists like Nick Etten, a former Navy SEAL and the founder and director of the Veterans Cannabis Project, believe medical marijuana can help. "We see cannabis not as a gateway drug," Etten said. "We see it as an exit path off opiates."
Etten argues that chronic pain is the signature war wound of the past 16 years. "Veterans and a lot of patients across the country are finding, especially as it relates to chronic pain, that CBD-based products are working very effectively."
"They're obviously much safer and less addictive than anything in the realm of opiates," Etten said.
A 2014 JAMA study found significant decreases in opioid overdose deaths where states had legalized medical marijuana. On average, these states had a near-25 percent lower mortality rate from opioids than states without such laws, and this correlation strengthened the longer medical marijuana was legal. Despite the potential for medical cannabis to curb the opioid epidemic, Attorney General Jeff Sessions repealed a memo from the Obama era in January that allowed state's with legal marijuana to operate without federal interference.
The VA's opioid crisis echoes the nationwide pattern of suspect partnerships between painkiller companies and medical professionals. Purdue Pharma, the maker of OxyContin, donated $200,000 to the VA pain management team in 2001, and concerns about opioid addiction were labeled as "barriers" to appropriate care in 2003 by the VA. These 2003 guidelines called opioids "the most effective option" for many patients, and they "only rarely cause addiction."
The American Pain Foundation, an organization that received most of its funding from pharmaceutical companies and has fought tighter opioid regulation, furthered the VA's dangerous practices. The foundation created the Freedom from Pain campaign in 2006 and wrote the "chronic pain" chapter in The American Veterans and Service Members Survival Guide in 2007. The Senate Finance Committee began investigating the American Pain Foundation in 2012, and the foundation shut down days later.
Air Force veteran and medical marijuana advocate Krawitz experienced a non-combat motorcycle accident in Guam. His stomach was so damaged, he couldn't tolerate opioids well for the chronic pain from the accident. Medical cannabis is crucial for his pain relief, and he finds the gateway drug argument indefensible.
"Based on their line of thinking, if you parked your car illegally, it's going to cause you to rob banks, because most people who rob banks park their cars illegally," Krawitz said.
Prescription painkillers, however, have been linked to heroin use. For every five new heroin users, four started with prescription pills.
A comprehensive program is required
Miller considers himself fortunate because he had access to important resources that got him off opioids. Before his amputation, doctors at Fort Sam Houston in San Antonio gave him a state-of-the-art orthotic brace. His doctors insisted he try the orthotic before resorting to surgery. He scoffed at the idea and just wanted to get rid of his leg once and for all, but it ended up being a turning point in his recovery.
Although he eventually needed the amputation, Miller credits his time with the orthotic for getting him off opioids. He could finally be active again. He had a support group recovering with him. He had doctors weaning him off prescription painkillers. "You need a comprehensive program," Miller said. "You need to give them every tool available." Nerve damage was still causing functionality issues, so despite being pain-free, off opioids and in good shape, the leg had to go.
Miller describes himself as a stubborn jock in high school who yelled at other players on the football team for smoking marijuana, and he laughs when he remembers endorsing alcohol. After avoiding marijuana most of his life, Miller got a medical card in California, at least initially, for the novelty of it. This was after his amputation and military service. Much to his surprise, he actually enjoyed how marijuana made him relax. He no longer feels the need for alcohol in social situations. The Staten Island native now lives in Oakland and has seen the power of medical marijuana for veterans firsthand.
Miller is working on two businesses tied to the marijuana boom. He firmly believes hemp and marijuana farming will help veteran employment. But it's the healing powers of marijuana that Miller feels is invaluable to veterans. He has become involved in an organization called Operation EVAC (founded by another Ryan Miller, who is a former Marine). The organization hosts meetings at various marijuana dispensaries, where veterans talk for an hour, then use medical marijuana and do guided meditation. EVAC meets in dispensaries in the Bay Area and Sacramento.
Many veterans come to EVAC after hitting rock bottom. Miller recalls meeting a veteran who had been on the streets before finding Operation EVAC. Miller doesn't know what started this specific veteran down a destructive path, but he knows many recovering addicts in EVAC who started on prescription painkillers. The veteran started each day by purchasing a bag of heroin and injecting the drugs. He was equally at peace with the two possible outcomes: getting high or death. The shame made him feel afraid to reach out to other veterans. When he finally reached out to EVAC, the group put him in rehab that very night.
EVAC's focus on discussion therapy and inclusion has kept the veteran off heroin, and he is now planning on reuniting with his daughter. Miller asked the former heroin addict what was appealing about EVAC after years of failed rehabilitation. The veteran told Miller he felt he wouldn't be judged at EVAC.
"Even now, thinking about that, hearing him say that in my head, I'm kind of choking up a little bit," Miller said. He thinks more groups like Operation EVAC would get veterans off narcotics and help curb the veteran suicide rate, which has been shown to worsen with opioid use. In fact, when he was first considering getting a medical card, many veterans told Miller they were suicidal before using cannabis. Miller uses marijuana before workouts because he feels less tired during and less sore after; he can only imagine how much this would have helped him when he was recovering from his leg injury.
The VA is stuck in a difficult position
Twenty-nine states and the District of Columbia have legalized medical marijuana, but the VA remains stuck in a difficult position because it is a federal entity and must abide by federal law, which still labels marijuana as a Schedule I drug (no medical use and high potential for abuse). For years the VA simply looked the other way; veterans using marijuana (even if done legally) didn't disclose this use, because they feared losing benefits. They could lose access to other medications if the VA thought they had a substance problem.
But new VA guidelines that came out in December are as close to endorsing medical marijuana as they can get without actually endorsing it.
The guidelines state that providers "are prohibited from completing forms or registering veterans for participation in a state-approved marijuana program." But they are supposed to "discuss with the veteran marijuana use, due to its clinical relevance to patient care, and discuss marijuana use with any veterans requesting information about marijuana."
The VA is required to document any disclosed marijuana use, but doing so won't force veterans to lose their benefits.
VA Secretary David Shulkin has admitted medical marijuana might help veterans, but he won't allow VA doctors to officially recommend marijuana until the federal law changes. And the stance from Attorney General Jeff Sessions — that regardless of state legalization efforts, the federal government should prosecute — could mean trouble for veterans using medical cannabis, memo be damned.
"We certainly hope that they don't take action in that way," Etten said. "We, as veterans, with already limited and imperfect access at the state level, will have even less access."
The "limited and imperfect access" Etten is referring to lies in mixed messaging. Although the new guidelines allow veterans to disclose marijuana use to their VA provider, the VA still labels cannabis use as a substance-use disorder. Etten knows of cases where veterans have been taken off their other medications after testing positive for marijuana during a urinalysis. The VA is simultaneously condemning marijuana and telling veterans to be open about their marijuana use with VA providers, and many veterans simply avoid cannabis altogether because of the confusion.
Almost half of veterans rely on the VA for health care. These veterans must rely on outside sources to get a medical marijuana recommendation, which isn't a very strenuous process. But veterans advocates argue that the longer the VA keeps a hands-off approach, the more veterans will suffer. Etten says many veterans are afraid to get medical cards, because they think being on some kind of government list will come back to haunt them, and Attorney General Sessions' statements intensify this fear.
The Veterans Cannabis Project wants clear guidelines protecting veterans who legally use cannabis. The group wants cannabis removed from the Schedule I list, and it wants more research on cannabis' medical potential.
Advocacy groups believe the VA has good intentions with the new guidelines. "I don't look at it as kicking the can down the road," Etten said. "Cannabis has become so politicized, it's difficult for the VA to do what it wants to do."
Despite the VA's checkered past regarding prescription drugs, the agency has taken responsible steps in recent years. The VA's Opioid Safety Initiative flagged providers with dangerous prescribing habits and started a prescription drug monitoring program to catch patients with multiple prescriptions.
"We all know [legal cannabis] is going to happen; it's just when. If this happens in a year, there will be people that will probably be alive in a couple years as opposed to dead."-Ryan Miller, Army infantry captain, wounded in Iraq
At the local level, Krawitz believes VA doctors are less likely to line up in support of the new VA policy that encourages discussion of medical marijuana. "Often, the [VA] doctors and the local staff perceive it very, very differently through a very different lens," he said. He argues that local VA doctors still associate social stigmas with cannabis.
The VA declined to comment or provide any of its medical professionals to answer questions.
The fight for medical and recreational marijuana has long stood counter to traditional conservative values. But as more veterans advocate for medical cannabis, the dynamic is shifting. Krawitz believes his dad, a "real conservative World War II vet," would support medical marijuana. As the opioid crisis worsens for veterans, coupled with a veteran suicide rate that is much higher than that of the general population, traditional politics are fading.
Miller says state Rep. Eric Nelson of Pennsylvania, an "old-school conservative" who has the 10 Commandments on his wall, is now eager to bring in medical marijuana throughout his state. The business of it appeals to his libertarian side, but it's the potential to curb the opioid crisis that really changed the Republican's mind. The American Legion, the nation's largest wartime veterans service organization, has voted twice in favor of medical marijuana access for veterans.
Dr. Edward Bilsky, the provost and chief academic officer at Pacific Northwest University of Health Sciences, spent years educating medical professionals about opioids. With a background as an opioid pharmacologist neuroscientist, Bilsky has spent his career studying opioid receptors in the brain. He doesn't know if medical marijuana can treat chronic pain or curb opioid use, but he says the topic is in dire need of more research.
"This is the million-dollar question," Bilsky said. "There is, in the scientific literature, very few well-controlled and well-powered studies that have addressed this."
Through his advocacy work, he has met patients with chronic pain who use cannabis, and they report helpful effects such as better sleep and numbing the pain. There is not enough evidence, however, to call it a true analgesic. "We're just thinking that marijuana is all bad, but we need to do the studies. Until we have those studies in hand, we can't conclude strongly one way or the other," Bilsky said.
He understands cannabis has detrimental side effects on developing brains, such as short-term memory loss and learning impairment. But until there is more research on its medical potential, physicians won't know if it has positive uses for specific medical conditions.
For advocates, every day that goes by without further research and federal immunity for veteran cannabis use hurts.
Despite Sessions' threats, states are continuing to support legal cannabis, and there has been bipartisan disapproval of Sessions' stance. The day when veterans don't have to worry about having a medical card or talking to their provider about marijuana might soon be over.
"We all know it's going to happen; it's just when," Miller said. "If this happens in a year, there will be people that will probably be alive in a couple years as opposed to dead."
— By Rick Morgan, special to CNBC.com