VA study: PTSD patients more often prescribed potent opioids


HEIDELBERG, Germany — Veterans of the Iraq and Afghanistan wars with mental health diagnoses, particularly post-traumatic stress disorder, were significantly more likely to receive prescriptions for oxycodone, hydrocodone and other opioids than those with pain but no mental health issues, according to a large Veterans Affairs study released Tuesday.

The veterans with mental health diagnoses who were prescribed the powerful, euphoria-causing and potentially addictive drugs had worse outcomes, with more overdoses, accidents and risky use patterns, the study found.

“Iraq and Afghanistan veterans with pain- and PTSD-prescribed opioids may be at particularly high risk of … misuse given the high co-occurrence of substance use disorders among veterans with PTSD,” according to the study, published in the Journal of the American Medical Association.

“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.”

Dr. Robert Kerns, the national director for pain management at the VA, said in an interview the study was important for bringing attention to a common problem among veterans and the “widely accepted appreciation that chronic pain is very commonly associated with mental health conditions.”

The study was conducted by Dr. Karen H. Seal and colleagues at the San Francisco Veterans Affairs Medical Center. They reviewed a national sample of 141,029 Iraq and Afghanistan veterans who’d been diagnosed with pain (excluding cancer pain) within a year of entering the VA health care system from late 2005 through 2010.

Of those, 15,676 — or 11 percent — were prescribed opioids within the year for at least 20 consecutive days.

Compared with 6.5 percent of veterans not diagnosed with any mental health disorder, 17.8 percent had been diagnosed with PTSD in addition to pain, and 11.7 percent had been diagnosed with a mental health problem that did not include PTSD, such as depression, anxiety or drug and alcohol problems.

Paradoxically, veterans diagnosed with PTSD and a drug-use disorder were “most likely to be prescribed opioids,” representing 33.5 percent.

Those with a PTSD diagnosis were prescribed higher doses, received more than one opioid or other prescription drug, and asked for early refills, the study found, suggesting risky use.

They also “had a higher prevalence of all adverse clinical outcomes occurring in the context of emergency department or inpatient admissions,” such as overdoses, accidental injuries, and intentional injuries to themselves or others, the study found.

It was not clear why veterans with mental health conditions were prescribed opioid painkillers more often than those without, although the authors of the study suggested possible reasons.

“PTSD is strongly associated with pain and other physical symptoms,” and patients with PTSD have been observed to have lower pain thresholds, the study said. Also, those with PTSD are often diagnosed with additional maladies.

Veterans with mental health conditions may be more likely to receive pain diagnoses because they make more clinic visits, the study suggested, or they may appear more distressed about symptoms than veterans without mental health issues.

Primary care physicians might be prescribing the drugs to treat a “poorly differentiated state of mental and physical pain … perhaps because physicians do not know how else to handle these challenging patients,” the study said.

In a statement, the VA said it welcomed the study.

“While this research acknowledges that VA is a leader in providing therapy for PTSD and pain, we recognize that more work remains,” the VA statement said.

The study is the latest alarm on the use of prescribed medications in the military health system and beyond. According to the national Centers for Disease Control and Prevention, opioid abuse is a “growing, deadly epidemic,” resulting from vastly more prescriptions starting in the 1990s when pain relief became an important part of medicine.

The drugs were involved in 14,800 overdose deaths in 2008, according to the CDC, more than cocaine and heroin combined, often in combination with alcohol or other drugs. Misuse of the drugs resulted in more than 475,000 emergency room visits in 2009, a number that nearly doubled in just five years, according to the CDC.

An Army health report released in January discussed similar problems in the active-duty force. “Army 2020: Generating Health and Discipline in the Force Ahead of the Strategic Reset” noted that about 47 percent of soldiers returning from Iraq and Afghanistan report pain-related problems and symptoms, that mental health conditions are prevalent, and that the use of psychotropic drugs, including opioids, has been increasing.

The report referenced a Department of Defense 2012 budget submission estimating that “14 percent of U.S. soldiers had been prescribed an opioid painkiller, with oxycodone accounting for 95 percent of those prescriptions” and that “25 to 35 percent of wounded soldiers are addicted to prescription or illegal drugs while they await medical discharge.”

The Army report pointed out the difficulties of diagnosis and treatment when soldiers had several or “comorbid” physical and mental health issues, some of which share common symptoms. For instance, the symptoms of post-concussive syndrome are all shared by traumatic brain injury, PTSD and chronic pain.

If a soldier reports sleep disturbances, “is it a manifestation of chronic pain, PTSD, TBI, PCS or a combination of all four?” the Army report asked.

Eric Shinseki, secretary of veterans affairs, also voiced concern about opioid use at a medical symposium last June.

“Are we courageous enough to ask whether we overmedicate some who are struggling with physical or psychological pain? “ Shinseki said.

Kerns said the VA was well aware that people with chronic pain needed a multimodal, multi-disciplinary approach to care and that a “single modality such as pain medication is unlikely to be effective.”

“These medications can be beneficial to some people with chronic pain,” he said, and so could some antidepressant and anti-seizure medications, as well as nonsteroidal anti-inflammatory drugs, such as aspirin and ibuprofen. Whatever the pharmacological approach, he said, patients should also be instructed in other strategies to deal with chronic pain, such as acupuncture, meditation and exercise.

The study had some flaws, Kerns said, in that it didn’t measure severity of pain, the duration of the opioid use, or make a convincing case that some of the harm, such as accidental injuries, were actually caused by opioid use.

He said that veterans with chronic pain and mental health diagnoses deserved treatment.

“It’s important to give clinicians credit rather than implicate them in harming these disadvantaged patients,” Kerns said. Still, he said, “We are becoming much more aware of the limited role opioids can play in this context. I think we’ll see a more judicious use.”