War Veterans, PTSD, Pain Pills, and Addiction

In the March 7, 2012, issue of the Journal of the American Medical Association, there was an interesting article further illustrating the complications that mental health disorders can bring to the treatment of other health disorders (http://bit.ly/KyzEtz).

In their introduction, the authors explain that veterans of the Iraq and Afghanistan wars are surviving injuries that would have been fatal in the past, and due to this better survival, many vets are returning home with severe physical problems. These injuries are, of course, associated with emotional problems. In prior studies, pain has been strongly associated with post-traumatic stress disorder (PTSD).

The authors performed this study to learn more about the risk for opioid misuse and addiction for soldiers who are returning home to the US, where pain pills are now more frequently prescribed than in the past. Since the Gulf War, the number of opioid prescriptions has doubled in the US, and the rates of opioid overdose death and prescription opioid misuse have also risen sharply.

Specifically, the study looked at the effect of PTSD on patterns of opioid prescribing, and the risks for adverse outcomes from this medication. The authors undertook a retrospective study of almost 300,000 Iraq and Afghanistan war veterans leaving military service, who are enrolled in the VA healthcare system. The data was collected from 2005 through 2008. Specifically, the study looked at war veterans diagnosed with new, non-cancer pain. The veteran was included in the study if he/she received an opioid prescription for more than 20 days. To compare different opioids, the dose was translated into morphine-dose equivalents.

Patients who received opioid pain prescriptions were divided into three groups: one group had no mental health diagnoses; the second group had one or more mental health diagnoses, but not PTSD; the third group had a diagnosis of PTSD.

The study looked at the median duration of the opioid prescriptions for all three groups, the morphine-dose equivalent, whether the veteran received more than two opioids, and if he/she received a sedative-hypnotic prescription within 30 days of an opioid prescription. The study looked for the number of adverse events (accidents, overdose from opioids, overdose from non-opioids, self-inflicted injuries, and violence) for each of the three groups.

The study found that among veterans with a new pain diagnosis, veterans with PTSD and other mental health diagnoses were significantly more likely to receive opioid prescriptions than veterans with no mental health disorders. Veterans with PTSD were more likely to be prescribed opioids than veterans with mental health diagnoses other than PTSD. The soldiers’ military rank, sex, or ethnic group did not affect the likelihood of being prescribed an opioid. Veterans with a diagnosis of substance use disorder and PTSD were the most likely to be prescribed an opioid for pain.

Veterans with PTSD and other mental health disorders were significantly more likely to get higher doses of opioids, and have a longer treatment course of opioids. Veterans with PTSD received the highest doses of opioids, and were more likely to receive more than one opioid. Vets with PTSD were also more likely to be prescribed a sedative-hypnotic, more likely to have a substance use disorder, and more likely to obtain early refills on their opioid prescriptions.

The assessment for adverse outcomes for all three groups of war veterans showed that being prescribed one or more opioids for pain was associated with increased likelihood of accidents resulting in wounds or injuries. The risk was greatest among vets with PTSD. This group also had more opioid and non-opioid overdoses, more selfinflicted injuries, and incidents of violence.

The authors concluded that combat veterans returning to primary care appear to have complex and poorly differentiated physical and psychological pain. They also recommend that extra care should be taken when prescribing opioids to these patients with co-existing mental health disorders, and PTSD in particular. The authors encourage the use of non-opioid pain medications, and urge consideration of nonpharmacological treatments for pain. They also emphasize the importance of treating mental health disorders at the same time as the pain problem.

So what’s the bottom line? To me, this study shows how difficult it is to separate physical health disorders from mental health disorders. We are complex beings; our physical state influences our mental state, and vice versa. As science advances we may get more information about why this is true.

Our war veterans are a particularly at-risk group, possibly from the extremes of physical and mental suffering that many vets have faced. The VA system should take this study to heart, as should any doctor treating war veterans. We need to spend more time on these patients and use an excess of caution with careful follow-up. We need to treat physical and mental suffering at the same time, not ignoring one over the other. I believe we owe our vets that much, and more.

Jana Burson, MD, is medical director of the Stepping Stone Wellness Center in Boone, NC. This article originally appeared on Dr. Burson’s blog (http://bit.ly/MWWoZA).