More Opioid Prescriptions Adverse Effects for Vets With PTSD

by U.S. Medicine

April 9, 2012

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.”

Association of Mental Health Disorders With Prescription Opioids and High-Risk Opioid Use in US Veterans of Iraq and Afghanistan

Back to April Articles

Comments are closed here.

Related Articles

Political Issues Related to VA’s Limited Approval of Esketamine for Depression

WASHINGTON—A VA panel this summer opted not to add the new depression medication esketamine, Spravato, to the department’s formulary in the usual way. This came despite strong support from President Donald Trump and an effort... View Article

Ensuring Community Providers Meet Veteran Suicide Prevention Standards

WASHINGTON—As leaders from across multiple federal agencies begin work on a roadmap to combat veteran suicide, they are searching for ways to turn existing efforts in towns, cities, counties and neighborhoods across the country into... View Article

U.S. Medicine Recommends

More From department of veterans affairs

Department of Veterans Affairs (VA)

Ensuring Community Providers Meet Veteran Suicide Prevention Standards

WASHINGTON—As leaders from across multiple federal agencies begin work on a roadmap to combat veteran suicide, they are searching for ways to turn existing efforts in towns, cities, counties and neighborhoods across the country into... View Article

Department of Veterans Affairs (VA)

VA Manages Drug Costs Better than Medicare Part D

ST. LOUIS – Medicare Part D could save more than $14 billion annually if it paid the same prices for top medications as the VA, according to a new study. A research letter published earlier... View Article

Department of Veterans Affairs (VA)

House Passes Bill to Create Education/Employment Arm of VA

WASHINGTON,—Legislators have reintroduced plans to create a fourth administration within the Department of Veterans Affairs—one dedicated to overseeing veterans’ education, transition and employment benefits. Currently these operations fall under the Veterans Benefits Administration, with VBA... View Article

Department of Veterans Affairs (VA)

Administrative Confusions Results in Little Oversight of VA’s Police Force

Suicides, Violence at VMACs Put Spotlight on Security WASHINGTON—As the number of suicides and other violent incidents at VA facilities grows, a spotlight is being thrown on VA’s internal police force and its ability to... View Article

Department of Veterans Affairs (VA)

Veterans Using Dual Health Systems Have More Problems With Medications

CHARLESTON, SC—More than half of the patients treated by VA are also Medicare eligible, and that is increasing the risk for a range of prescription medication problems—from chronic disease medication nonadherence to opioid overdoses—among dual... View Article

Subscribe to U.S. Medicine Print Magazine

U.S. Medicine is mailed free each month to physicians, pharmacists, nurse practitioners, physician assistants and administrators working for Veterans Affairs, Department of Defense and U.S. Public Health Service.

Subscribe Now

Receive Our Email Newsletter

Stay informed about federal medical news, clinical updates and reports on government topics for the federal healthcare professional.

Sign Up