Veterans with PTSD at Risk of Prescription Opioid Abuse

Across the country, there's been a greater understanding of treating pain. The prescription of opioid pain relievers--drugs like codeine, vicodin or morphine--has nearly doubled since 1994. But at the same time, prescription opioid abuse, overdose and death has also increased dramatically. The same trends are true for veterans of the Iraq and Afghanistan wars. Today, due to medical advances and improvements in combat protective gear, higher numbers of veterans of these wars are surviving injuries. But once home, they continue to suffer both pain and mental health problems. They are often prescribed opioid pain relievers.

But little has been known about mental health disorders and the prescribing of opioids to veterans. Researchers at the San Francisco Veterans Affairs Medical Center and UCSF set out to address this question and found that veterans with mental health problems were more likely to be prescribed opioid drugs than veterans without mental health issues.

The study, published Tuesday in the Journal of the American Medical Association, reviewed information from more than 140,000 Iraq and Afghanistan war veterans who were diagnosed with pain. Veterans without mental health problems were prescribed opioids much less frequently--about 6.5 percent of them received these prescriptions. That rate went up to 11.7 percent in veterans with a mental health diagnosis. And the rate was highest--17.8 percent--for veterans with Post-Traumatic Stress Disorder (PTSD).

The study also showed that all veterans that were prescribed opioids had a higher risk of misusing their prescription opioid by either over-dosing, having drug-related accidents, hurting oneself, or other things that would cause them to end up in the Emergency Room. That risk was the greatest among those with PTSD.

Lead author Karen Seal is a physician at the San Francisco Veterans Affairs Medical Center and a professor at UCSF. She says the study results are troubling. "The message to me is to keep redoubling our efforts to really have conversations with patients about these risks, and really provide them alternatives to just taking Vicodin or oxycodone or morphine, which has become very, very common in our society."

Seal says there were clear patterns in the data showing that Veterans Affairs (VA) patients with PTSD were more at risk for being on higher doses of opioids, and for longer periods of time. PTSD patients also had a higher risk of being prescribed two or more opioids simultaneously, and were more likely to get early refills on medications. She says getting early refills is a good indication that veterans may be abusing drugs by taking more than prescribed.

Seal says the VA often offers alternatives to opioid pain medication first, such as anti-inflammatory drugs, physical therapy, complementary alternative medicine, and various relaxation techniques. She says in her own practice, she's found that when she approaches her patients about alternatives to opioid prescriptions, many patients say they would rather avoid the opioids and try these alternative therapies first.

"They particularly like going to physical therapy," Seal said. "And actually trying -- usually for the first time -- modalities like acupuncture, chiropractory, relaxation, and even in some case psychotherapy that's really meant to address their pain and PTSD, or other mental health problems, simultaneously."

But Seal cautions that these alternative methods don't always work. Some patients require opioid medication to relieve their pain. "In those cases you would still prescribe [opioids] to relieve pain and suffering, but you would do so in a way that you are assessing for risk, and you are monitoring their use of the medication."

In the study, the authors note that the VA has guidelines that "urge caution in opioid prescribing" in people with substance abuse issues.

The Department of Veterans Affairs issued a written statement in response to the study saying it "agrees with the recommendation that VA continue to build upon its current approach to treating patients who have both pain and PTSD. This includes expanding Patient Aligned Care Teams (PACTs) that align primary care physicians with nurses, mental health providers, pharmacists and social workers. VA is committed to ensuring Veterans receive the quality care and benefits they have earned."