Veterans With Mental Illness More Likely to Receive Opioids

Fran Lowry

March 07, 2012

March 7, 2012 — Veterans of Iraq and Afghanistan with mental health diagnoses, particularly post-traumatic stress disorder (PTSD), are more likely to be prescribed opioid drugs for pain than are their counterparts without mental health diagnoses, new research shows.

They are also more likely to have patterns of opioid use that put them at high risk for adverse clinical outcomes, lead author Karen H. Seal, MD, MPH, told Medscape Medical News.

Dr. Karen Seal

Exploring other options to treat pain, such as the use of higher-dose anti-inflammatory drugs, physical therapy, and complementary or alternative medicine such as acupuncture and chiropractic, is something that should be tried in this population, said Dr. Seal.

A primary care clinician in the San Francisco Veterans Affairs Medical Center, Dr. Seal sees young Iraq and Afghanistan vets for the first time as they come back from war. Many return with a complex set of problems, including acute and chronic pain, bundled with mental health problems.

"Because of improved body armor and better war zone medical care, more Iraq and Afghanistan veterans are surviving wounds that would have been fatal in earlier wars, and many of them have PTSD as a result," Dr. Seal noted.

Not all of these veterans request opioids to ease their pain, but many do. "I have been very concerned about the risks associated with providing them with opiate pain meds," she added.

The study is published in the March 7 issue of JAMA.

Higher Doses

To explore this issue, the investigators used an extensive database from the US Department of Veteran Affairs (VA) to study 141,029 veterans who served in Iraq and Afghanistan from 2005 through 2010, who received a pain diagnosis on their first visit to the VA, and who were subsequently prescribed an opioid.

They then looked to see whether there was a mental health diagnosis in addition to the pain diagnosis, and if there was, whether that diagnosis increased the likelihood that the patients would be prescribed an opioid medication.

The study showed that 15,676 veterans were prescribed opioids within 1 year of their initial pain diagnosis.

Veterans diagnosed with PTSD were 2.5 times more likely to be prescribed an opioid drug for their pain compared with veterans with no mental health disorders.

Of the veterans without mental health disorders, 6.5% were prescribed opioids compared with 17.8% of veterans with PTSD (adjusted relative risk [RR], 2.58; 95% confidence interval [CI], 2.49 - 2.67). Among veterans with another mental health diagnosis, 11.7% were prescribed an opioid for their pain.

Veterans with PTSD were also more likely to get higher doses of opioids than were those with no mental health disorders (22.7% vs 15.9%; adjusted RR, 1.42; 95% CI, 1.31 - 1.54), get 2 or more opioids at the same time (19.8% vs 10.7%; adjusted RR, 1.87; 95% CI, 1.70 - 2.06), and get sedative hypnotic medications at the same time (40.7% vs 7.6%; adjusted RR, 5.46; 95% CI, 4.91 - 6.07).

Early Refills

Those with PTSD were also more likely to ask for an early refill of their medication, suggesting they were using the opiate a little faster than was prescribed, compared with veterans with no mental health problems (33.8% vs 20.4%; adjusted RR, 1.64; 95% CI, 1.53 - 1.75).

All veterans, whether they had mental illness or not, had an increased risk for adverse clinical outcomes, such as accidents, alcoholism, violent injuries, suicides, and overdose, if they received opioids (9.5% vs 4.1%; RR; 2.33; 95% CI, 2.20 - 2.46),

"We need to better evaluate and assess patients who complain of pain," Dr. Seal said. "It's important for physicians and patients to take the time and have an up-front conversation about the risks of starting an opiate pain medication such as Vicodin [hydrocodone and acetaminophen] and Percocet [oxycodone and acetaminophen], given the patient's history."

There may be other options, she added.

"Higher-dose anti-inflammatory drugs, going to physical therapy, using complementary alternative medicine such as acupuncture and chiropractic, exercise, relaxation therapies, and psychotherapies that address pain and PTSD or other mental health disorders — there are a host of other options that can be tried," Dr. Seal said.

Alternative Therapies

Retired US Army Colonel Elspeth Cameron Ritchie, MD, MPH, chief clinical officer of the District of Columbia Department of Mental Health, in Washington, DC, endorsed this suggestion.

Dr. Elspeth Ritchie

"Other means to manage pain in this population should and in fact are already being explored," Dr. Ritchie told Medscape Medical News.

"In the last few years, the Army has been exploring a number of different alternative forms of pain control, including acupuncture, yoga, and the use of therapy dogs, which is an area that I am particularly interested in," she said.

Regarding the latter, there is anecdotal evidence that therapy dogs are particularly effective in helping people with pain and PTSD, Dr. Ritchie said.

"They find their pain and PTSD symptoms less if they have a service dog. Also, acupuncture is obviously helpful for pain, but there's more and more evidence that it's helpful for PTSD as well.

"One of the challenges is that there are not enough people who are able to do acupuncture in the military system to provide that kind of pain control where it's needed, but evidence is increasing that these alternative measures are helpful," she said.

Dr. Ritchie added that acupuncture has been "widely accepted" by soldiers and armed services members. "A colleague of mine took needles with him to Afghanistan and was very successful in treating pain, and often people would come in with the combination of pain and PTSD, and they found that the use of acupuncture helped with both sets of symptoms."

Dr. Seal and Dr. Ritchie have disclosed no relevant financial relationships.

JAMA. 2012;307:940-947. Abstract

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