War veterans with mental health diagnoses more likely to receive prescription opioids for pain

Iraq and Afghanistan war veterans with mental health diagnoses, particularly posttraumatic stress disorder, are more likely to receive prescription opioid medications for pain-related conditions, have higher-risk opioid use patterns and increased adverse clinical outcomes associated with opioid use than veterans with no mental health diagnoses, according to a study in the March 7 issue of JAMA.

Greater exposure to combat coupled with improvements in battlefield medicine and protective gear have resulted in large numbers of veterans of Iraq and Afghanistan surviving injuries that would have been fatal in prior wars. Veterans are returning home with co-existing mental and physical health problems, and posttraumatic stress disorder (PTSD) is the most prevalent mental health disorder. "Nationwide, the prescription of opioid analgesics has nearly doubled since 1994 because of a greater recognition of the importance of treating pain. At the same time, rates of prescription opioid misuse and overdose have increased sharply, and prescription opioids are now a leading cause of death in the United States. Iraq and Afghanistan veterans with pain- and PTSD-prescribed opioids may be at particularly high risk of prescription opioid misuse given the high co-occurrence of substance use disorders among veterans with PTSD," according to background information in the article.

Karen H. Seal, M.D., M.P.H., of the San Francisco Veterans Affairs Medical Center, and colleagues examined the association between mental health disorders and patterns of opioid prescription use, related risks, and adverse clinical outcomes, such as accidents and overdose, among a national sample of 141,029 Iraq and Afghanistan veterans. The study included veterans who received at least 1 non-cancer-related pain diagnosis within 1 year of entering the Department of Veterans Affairs (VA) health care system from October 2005 through December 2010.

Of the veterans in the study (141,029) with pain diagnoses, 15,676 (11.1 percent) were prescribed opioids for 20 or more consecutive days. Compared with 6.5 percent of veterans without a mental health diagnosis, 17.8 percent with PTSD and 11.7 percent with mental health diagnoses but not PTSD were significantly more likely to receive opioids for pain. "Similarly, in the whole population of 291,205 veterans with and without pain diagnoses, 12.3 percent with PTSD and 7.3 percent with mental health diagnoses excluding PTSD were independently more likely to receive opioids than the 2.7 percent of veterans without mental health diagnoses who received opioids for pain," the authors write. Further analyses confirmed that all subgroups of veterans with PTSD were significantly more likely to receive prescription opioids than those with no mental health diagnoses.

The researchers also found that veterans with other specific mental health disorder diagnoses—depression, anxiety, alcohol use disorders, drug use disorders, and traumatic brain injury— were significantly more likely to receive opioids than veterans with no mental health diagnoses. "Of note, veterans with a drug use disorder and comorbid PTSD were most likely to be prescribed opioids than veterans with no mental health disorders (33.5 percent vs. 6.5 percent)."

Compared to veterans without mental health diagnoses, those with PTSD who were prescribed opioids were significantly more likely to be in the highest quintile (one of five groups) for dose (22.7 percent vs. 15.9 percent), receive more than 1 type of opioid concurrently (19.8 percent vs. 10.7 percent), and obtain early opioid refills (33.8 percent vs. 20.4 percent).

Regarding the risk of adverse clinical outcomes, receiving prescription opioids (vs. not) was associated with an increased risk for all veterans (9.5 percent vs. 4.1 percent), which was most pronounced in veterans with PTSD.

"These findings support further efforts to improve care of patients with comorbid pain and PTSD because of the heightened risk of self-medication with opioids and substance abuse in veterans with PTSD, which may result in further declines in interpersonal and occupational functioning," the authors write.

"Returning combat veterans are presenting to primary care in large numbers and are seeking relief from physical and psychological pain. Extra care should be taken when prescribing opioids to relieve their distress. These patients may benefit from biopsychosocial models of pain care including evidence-based nonpharmacologic therapies and nonopioid analgesics. Integrated treatments that target both mental health disorders and pain simultaneously are effective for both problems and may decrease harms resulting from opioid therapy."