Opioid Use Putting 'America's Fighting Force' at Risk

Deborah Brauser

July 09, 2014

The rising prevalence of chronic pain and/or opioid use by combat military personnel in the United States is cause for serious concern, new research suggests.

In a survey of more than 2500 service members administered 3 months after they had returned from Afghanistan or Iraq, 44% reported having chronic pain, and 15% reported recent use of opioid pain relievers. In contrast, the general population has rates of 26% and 4%, respectively.

Of the veterans who had chronic pain, 56% reported daily pain and/or pain of constant frequency, and 48% reported that their pain had been ongoing for at least a year. However, 44% of those who reported using opioids had no pain or only mild pain during the past month.

"These findings suggest a large unmet need for assessment, management, and treatment...in military personnel after combat deployments," write lead author Robin L. Toblin, PhD, MPH, from the Center for Military Psychiatry and Neuroscience at the Walter Reed Army Institute of Research in Silver Spring, Maryland, and colleagues.

"The benefits of opioids for treating pain, particularly in those with combat-related injuries, must be balanced by careful assessment of risks, including the potential for misuse," they add.

The study was published online June 30 as a research letter in JAMA Internal Medicine.

First Study of Its Kind

The investigators note that rates of opioid use and misuse have recently "ballooned," leading to a significant increase in overdose-related hospitalizations and deaths.

However, "the prevalence of chronic pain and opioid use associated with deployment is not well known, despite large numbers of wounded service members," they write.

They add that this is the first study to assess these factors "in a non-treatment-seeking, active duty infantry population following deployment."

The researchers collected confidential surveys in 2011 from 2597 army infantry soldiers between the ages of 18 and 24 years (93.1% men) 3 months after they had returned from Afghanistan or Iraq.

For this study, chronic pain was defined as pain lasting at least 3 months.

Results showed that 45.4% of the survey participants received injuries during combat. In addition, 16.4% reported alcohol misuse, 9.1% had posttraumatic stress disorder (PTSD), and 5.8% had major depressive disorder.

Although 15.1% of the participants reported past-month opioid use, 5.6% of these reported no past-month pain, and 38.5% of the opioid users reported mild pain.

"This is cause for concern because opioids should be prescribed generally for moderate to severe pain and have high abuse and overdose potential," write the investigators.

A total of 37.7% of the opioid users reported moderate pain, and 18.2% reported severe pain.

In addition, 44% of all the service members reported having chronic pain (n = 1131), with 48.3% reporting a duration of 1 year or longer. A total of 31% of the chronic-pain reporters had pain nearly every day, and 24.6% had pain of constant frequency; 51.2% reported moderate to severe pain.

Of those reporting chronic pain, 23.2% used opioids in the past month, but 57.9% of those reported only using the medications for a few or several days.

Still, "prescription practices should be examined to ensure that opioid use is consistent with standards of care and practice guidelines and nonopioid alternatives are considered whenever possible," write the researchers.

America's Fighting Force at Risk

Wayne B. Jonas, MD, LTC (retired), from the Samueli Institute in Alexandria, Virginia, and Eric B. Schoomaker, MD, PhD, LTG (retired), from the Uniformed Services University of the Health Sciences in Bethesda, Maryland, write in an accompanying editorial that the newly released data are important.

"While chronic pain and opioid use have been a long-standing concern of the military leadership, this study is among the first to quantify the impact of recent wars on the prevalence of pain and narcotic use among soldiers."

The editorialists note that the Department of Defense (DoD) developed a Pain Management Campaign in 2010 and that the Institute of Medicine (IOM) released a report in 2011 calling for a comprehensive pain management plan.

"They recommended that the goal should be nothing short of a 'cultural transformation' in how we manage pain, noting that over 100 million people experience chronic pain at an annual cost of over $600 billion," write Dr. Jonas and Dr. Schoomaker.

However, they add that achieving the recommendations from the DoD and the IOM "will require overcoming major obstacles, especially where we are investing our money."

In fact, they note that the National Institutes of Health only spends approximately 1% of its $30 billion budget on researching pain.

In addition, the editorialists write that many service members and veterans with chronic pain have comorbidities, including PTSD or traumatic brain injury.

"Many of them are at risk for a lifetime progression of increasing disability unless the quality, variety, and accessibility of evidence-based 'self-management' skills are improved," they write.

"The nation's defense rests on the comprehensive fitness of its service members ― mind, body, and spirit. Chronic pain and use of opioids carry the risk of functional impairment of America's fighting force."

The study authors and the editorialists have reported no relevant financial relationships.

JAMA Intern Med. Published online June 30, 2014. Abstract, Editorial


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