Kate Johnson

April 19, 2011

April 19, 2011 (Washington, DC) — The strongest predictor of prescription drug misuse in the military is a history of receiving a prescription for pain medication within the past month or past year, according to a secondary analysis of a 2008 Department of Defense (DOD) Health Behavior Survey (Military Medicine. 2010;175:390).

However, the findings, presented here at the American Society of Addiction Medicine 42nd Annual Medical-Scientific Conference, do not address reasons for abuse, said study investigator Diana Jeffery, PhD, DOD, Falls Church, Virginia.

The 2008 DOD survey, which included 28,546 respondents, examined all substance abuse in the military and identified a prescription drug misuse rate of 11% — up from 4% in 2005. "Prescription drug misuse doubled from 2002 to 2005 and almost tripled from 2005 to 2008," the report states.

Misuse or "nonmedical use" was defined as "any use of these drugs without a doctor's prescription, in greater amounts or more often than prescribed, or for reasons such as to get 'high' or for 'thrills' or 'kicks'."

Seventeen percent of responders said they misused pain medications, whereas 6% misused tranquilizers, 2.9% misused sedatives, and 2.3% misused stimulants.

The secondary analysis revealed that among prescription drug misusers, the majority were in the army vs the navy, air force, marines, or combat sectors, reported Dr. Jeffery.

Specifically, army responders accounted for 47% of pain medication abuse, 50% of sedative abuse, 52% of tranquilizer, and 50% of stimulant abuse.

Prescription of pain medications in the past 30 days and in the past year increased the adjusted odds ratio (AOR) of misuse of pain relievers to 2.56 and 2.52, respectively, she said.

In addition, a prescription for pain relievers in the past 30 days, or past year, increased the AOR of tranquilizer misuse by 3.89 and 3.34, respectively. The risk for sedative misuse was also increased by a prescription for pain relief in the past year (AOR, 4.46) or the past 30 days (AOR, 3.55).

Finally, the risks for stimulant misuse were increased if there was no deterrent of random drug testing (AOR, 2.45) or if there had been a prescription for pain relief in the past year (AOR, 2.44) or the past 30 days (AOR, 2.36).

Chronic Pain a Common Concern

When asked by a member of the audience whether the inclusion of prescribing as a variable in the analysis obscured all explanatory variables, such as stress or trauma, Dr. Jeffrey acknowledged this possibility.

She said the reasons for prescription drug misuse are being examined in 2 other ongoing studies, whose results will be combined with these findings to make preliminary recommendations in a year.

In addition to describing prescription drug abuse, the 2008 DOD survey also showed an increase in illicit drug use (from 5% in 2005 to 12% in 2008) and alcohol abuse (from 15% in 1998 to 20% in 2008).

The mental health questions in the survey identified a significant increase in personnel needing further posttraumatic stress disorder evaluations and in personnel who attempted suicide. In addition, chronic pain is a well-documented symptom among both active and veteran personnel.

In a 2009 editorial published in Pain Medicine (Pain Med. 2009;10:1161-1164), Robert Kerns, PhD, from Yale University, New Haven, Connecticut, and Veterans Affairs Connecticut Healthcare System, and Steven K. Dobscha, MD, from the Portland Veterans Affairs Medical Center in Oregon, note that among military personnel receiving primary care in Veterans Health Administration facilities, up to "50% of male veterans and as many as 75% of female veterans report the presence of pain.

"Similarly, high rates of pain are documented among veterans returning from deployment in the recent wars in Iraq and Afghanistan, and painful musculoskeletal conditions are by far the most common diagnosed medical problems among these veterans, far surpassing the prevalence of other medical and mental health disorders," they add.

Tolerance a Driving Force

Commenting on the study for Medscape Medical News, Jeffrey T. Junig, MD, PhD, an addiction treatment psychiatrist in Fond du Lac, Wisconsin, said tolerance is often the driving force behind prescription drug misuse in pain patients.

"The large majority of my patients were started on opioids for chronic, nonmalignant pain. The natural progression of this situation very commonly leads to problems. First, the pain tends to worsen, since the cause is usually wear and tear on the body — causing chronic back pain, knee pain, shoulder pain, headaches, etcetera. Second, tolerance causes the pain medication to become ineffective," said Dr. Junig.

He added that patients enter "a zone of ambiguity — where they have pain that they think needs to be treated...and where the forces of addiction and tolerance push the dependence on pain medications ever higher.

"People treated for chronic pain generally receive other medications to appropriately reduce consequences of chronic pain, such as insomnia or depression, and other medications work in concert with opioids for some conditions," he said.

For example, a combination of muscle relaxants along with opioids for back injury may explain the link between pain relief prescriptions and misuse of other prescription drugs, he noted.

Dr. Lawrence Brown, who was on the program committee for the meeting and is executive vice president of the Addiction Research and Treatment Corporation in Brooklyn, New York, said "You'd expect people who have abused to have some history of legitimate use — so that to me was not such a big finding, it's not earth-shattering. It would seem to me that they should tailor future surveys to be able to get to more difficult questions."

However, he added that it's very difficult for a military study to answer some of these questions. "There may be some perceptions of the respondents about how their response might impact their future in the military."

Dr. Jeffery has disclosed no relevant financial relationships. Dr. Junig reports receiving speaker's fees from GlaxoSmithKline and Shire pharmaceuticals Dr. Brown reports he receives a salary from Amgen.

American Society of Addiction Medicine (ASAM) 42nd Annual Medical-Scientific Conference: Abstract P1. Presented April 15, 2011.

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