By Stephen Spotswood
WASHINGTON — Veterans with PTSD are more likely than others to be prescribed opioids for post-injury pain, and that can lead to an increase in adverse mental and physical effects, according to a recent VA study.
“Iraq and Afghanistan veterans with mental-health diagnoses, but especially those with PTSD, were far more likely than their counterparts without mental-health diagnoses to receive prescriptions for opiates,” said Karen Seal, MD, one of the authors of the VA study and a physician at the San Francisco VA Medical Center who works with returning veterans. “And, among those, those with mental-health and PTSD diagnoses were far more likely to have higher risk of [adverse events].”
According to VA records, more than 141,000 Iraq and Afghanistan veterans have been diagnosed with noncancer pain. The prevalence of PTSD among that group is 32%, with 19% diagnosed with other psychiatric disorders.
Of that group, 11% have been prescribed opioids. For veterans with PTSD, that percentage grew to 17.8%. For other psychiatric illnesses, it’s 11.7%, with a 6.5% prescription rate for veterans with no psychiatric diagnoses.
The rate was highest (33.5%) when PTSD was comorbid with drug abuse.
Veterans with PTSD also were more likely to take higher opioid doses (22.7% vs. 15.9%), two or more opioids (19.8% vs. 10.7%) and concomitant sedative-hypnotic drugs (40.7% vs. 7.6%). These veterans also are more likely to request early refills, Seal said.
Receiving prescription opioids was associated with adverse clinical outcomes for all veterans, but adverse effects were most pronounced in veterans with PTSD. Those outcomes included general wounds and injuries, accidents and overdoses, violent injuries and suicide attempts.
While previous studies have shown that prescription opioids are more often prescribed for patients with psychiatric disorders, this trend was even more pronounced when the patient was diagnosed with PTSD.
According to the researchers, this might be evidence of clinicians’ attempts to treat a complex condition with emotional, psychiatric and physical facets, but those efforts come at a cost: poor mental health, increased substance abuse and adverse clinical outcomes. What is needed, the study notes, is a better understanding among clinicians of PTSD, pain and substance abuse.
This was the same conclusion reached in a June 2011 IOM report on pain treatment and research in the United States. That report looked at the population in general but also examined pain in the military and veteran setting.
The report found VA sorely lacking in its ability to understand and treat its patients’ pain. The report cited research showing pain-care planning frequently was absent from VA medical records of patients reporting moderate or severe pain and that a diagnosis of substantial pain was infrequently followed by treatment.
The report also indicated that opioid use in VA rose from 3% in 2003 to 4.5% in 2007 but that little improvement in patients’ median pain scores resulted from the use of long-acting opioids.
According to a study that report cited, while 71% of VA clinicians felt confident in their ability to treat chronic pain, 73% said patients with chronic pain were a major source of frustration.
The next step for Seal and her colleagues will be to look at barriers to implementing DoD and VA joint clinical practice guidelines, which include guidelines on the use of opiate-pain medication.
“VA and DoD have developed these guides that include the use of medications that are alternatives to opiates,” Seal said. “What would make it easier for clinicians to follow these guidelines?”
Understanding Chronic Pain
Recently, researchers involved in the IoM report, as well as NIH officials, pointed out during testimony before the Senate Health Committee on pain management in America that the problem of treating chronic pain is not limited to the veteran population.
According to NIH, 161 million adults in America — not including servicemembers, children or people in custodial facilities — suffer from some form of chronic pain, and it remains one of the most difficult conditions to treat. More than $600 billion is spent a year on pain treatment in the U.S., a sum greater than is spent on other cancer, heart disease and diabetes treatment combined.
“Recognizing pain as a disease itself has helped us restructure how we think about pain,” explained Lawrence Tabak, DDS, PhD, principal deputy director at NIH. “Chronic pain is a complex, multifaceted syndrome of its own. Progress will require a better understanding of the biology of pain and removal of barriers to care in society at large.”
This understanding will require considerably more research than is currently in the portfolio, including studies into exactly how mental and physical factors play into chronic pain.
“There is today a significant amount of perception felt by those suffering from chronic pain [and their clinicians] that there is a significant amount of emotional contribution,” said Phillip Pizzo, MD, dean of the Stanford University School of Medicine and chair of the IoM report. “While there’s no doubt that emotions can contribute to physiology, I think that we have much work to do to look at our approach to pain, just as we do other neurological and psychiatric illnesses from a psychological perspective.”
Current treatment is focused on surgery and drugs, he said. However, behavioral therapies, cognitive therapies and rehabilitation of various sorts could work equally as well or better, without the kind of mental-health and substance-abuse side effects seen in opioid treatment for patients with PTSD and pain.
“The scope of the problems in pain management is daunting, and the limitations in the knowledge and education of healthcare professionals are glaring,” Pizzo said. “The medical community must actively engage in the necessary cultural transformation to reduce the pain and suffering of Americans.”
Most people looking at a hospital room will see an environment specifically designed to keep human beings alive through even the most traumatic circumstances.
A facility-specific survey found that 138 of 140 VA facilities reported shortages of medical officers, with psychiatry and primary care positions being the most frequently listed.