Wednesday, May 9, 2012

Research: Opioid Use in Veterans of Iraq and Afghanistan Wars


Some recent articles published in March 2012 highlight some issues common in the last 10 years or so in treatment of returning veterans.  Seems that while opioids are prescribed, often by primary care physicians, with the intent to reduce pain and speed healing recovery, opioids are not the best medicine for non-acute pain or injury or any injury that has any traumatic memory associated with it.

In the Journal Watch Psychiatry, the related March 2012 article is "High-Risk Opioid Use More Likely with PTSD Diagnoses in Veterans".  The subtitle:  "Such prescriptions may be trying to address physical and emotional pain, but may result in adverse outcomes, worsened mental health, and impaired functioning". 

Original Research Article:  Association of Mental Health Disorders with Prescription Opioid and High-Risk Opioid Use in US Veterans of Iraq and Afghanistan
The Journal of the American Medical Association published the original research article, "Association of Mental Health Disorders with Prescription Opioid and High-Risk Opioid Use in US Veterans of Iraq and Afghanistan". 
Authors/Investigators:
Karen H. Seal, MD, MPH; Ying Shi, PhD; Gregory Cohen, MSW; Beth E. Cohen, MD, MAS; Shira Maguen, PhD; Erin E. Krebs, MD, MPH; Thomas C. Neylan, MD.
Author affiliations:  San Francisco Veterans Affairs Medical Center, the University of California at San Francisco, the Roudebush Veterans Affairs Medical Center, and the Indiana University School of Medicine and Regestrief Institute, Inc.

Reasons for study and possible hypotheses:  Many veterans of the recent Iraq and Afghanistan wars since 9/11/2001 have pain and disabilities due to their injuries sustained within the operational theatre.  Some of these include chronic pain, mental health disorders, and prescription opioid use. 
The intent of the authors/investigators was "to investigate the effect of mental health disorders, particularly PTSD, on risks and adverse clinical outcomes associated with prescription opioid use."

Study size:  141,029 veterans.  Each veteran must have received at least 1 chronic pain (non-cancer) diagnosis within 1 year of entering the VA health care system.
15,676 of these veterans were prescribed opioids within one year of their chronic pain diagnosis.

Period of time studied:  Oct. 1st, 2005 - Dec. 31st, 2010.
     Megan's question:  Why was this time period chosen?  The first of these two wars started in 2001.
How they chose their measurements:  They looked at the "independent association of mental health disorders and the prescription of opioids, the higher risk opioid use, and adverse clinical outcomes (eg, accidents and overdose) within 1 year of receiving a pain-related diagnosis."

Conclusions: 
  • 141,029 veteran cases were evaluated, all had a diagnosis of chronic pain (non-cancer)
  • 15,676 veterans were prescribed opioids for their chronic pain
  • 6.5% of the veterans studied had no mental health disorder.
  • 17.8% of the veterans were diagnosed with PTSD
  • 11.7% of the veterans were diagnosed with non-PTSD mental health disorders
    1. These 11.7% were significantly more likely to receive opioids for a pain diagnoses
  • Of the 15, 676 veterans who were diagnosed with chronic pain (this includes those who have chronic pain and PTSD), there are two groups: 
    1. veterans with chronic pain and
    2. veterans with chronic pain and PTSD
      • the veterans with chronic pain + PTSD
        • were more likely than the chronic-pain-only group to be prescribed higher-dose opioids
        • more likely to be prescribed two or more opioids concurrently
        • more likely to receive sedative hypnotics concurrently
        • more likely to obtain early opioid refills

Overall, receiving prescription opioids was associated with an increased risk of adverse clinical outcomes for all veterans.  This risk was even greater in veterans who have a PTSD diagnosis.

Megan's Lingering Questions about these numbers
It seems most of the interesting data is from the 15,676 veterans who were diagnosed with chronic, non-cancer pain and prescribed opioids for their pain.  So, perhaps this study is more about the 15,676, not the 141,029.  I wonder about those (141,029 - 15,676 = 124,353) 124,353 who were diagnosed with chronic pain, but were never prescribed opioids.  Did they leave the VA system?  How are they dealing with their chronic pain?  15,676: 124,353.  That is a nearly 1:8 ratio.  I must be missing some information here.  Only 1 in 8 veterans at the VA are diagnosed with a chronic pain condition and prescribed opioids for their pain?  1 in 8 seems like a much smaller ratio than the conclusions of the article lead me to believe.  I want to know what those 7 of 8 veterans are doing or not doing for their chronic pain.  That is a lot of veterans.
Comment from the Journal Watch Psychiatry
"In previous studies, psychiatric disorders were associated with more prescription opioid use. This study further suggests that a PTSD diagnosis is particularly related to this use, consistent with studies showing that PTSD patients are particularly likely to have pain complaints. Opioid prescribing may be intended to address a poorly differentiated syndrome of physical and emotional pain; however, these findings suggest that it creates more adverse outcomes, worsens mental health and substance abuse, and impairs functioning. Optimal treatment of these patients requires familiarity and expertise with PTSD, substance abuse, and pain, which will create significant challenges for the primary care physicians currently treating most of these patients."
Peter Roy-Byrne, MD
Published in Journal Watch Psychiatry March 6, 2012



Megan's Comments
In my opinion, this research points to the need for more primary care physicians to be aware of the benefit of CAM therapies, particularly in cases of chronic pain or when the primary care physician finds the ailment is not entirely physical.  While you are making that referral to a mental health provider, as per your medical guidelines, consider mentioning CAM therapy to your patient.  Complementary medicine is a complement to conventional care.  It is often mind-body medicine and/or mind-body-spirit medicine.  Also consider asking your patient about his or her support group and spirituality (again mind-body-spirit connection).

As a side note, also consider your patient's quality of sleep.  Poor sleep increases pain and stress.  Poor sleep decreases resilience.  CAM therapies are excellent at encouraging good quality sleep and breaking patterns of poor sleep.

Some Complementary Medicine therapies that are useful in the rehabilitative treatment of veterans from Traumatic Brain Injury (TBI), post combat stress, post traumatic stress, and chronic musculoskeletal pain, you may read more about or find links to in this blog are:
Chaplain counseling
Acupuncture, as part of Traditional Chinese Medicine/East Asian Medicine
Meditation
Meditation/movement (Tai Chi/Qi Gong)
Massage Therapy
Art Therapy
Music Therapy
Traditional Chinese Medicine
Acutonics
Yoga

--Megan Kingsley Gale, EAMP/L.Ac.
Master of Science in Acupuncture and Oriental Medicine
www.destressvets.com

Sources cited:
Original research article:  Seal KH et al. Association of mental health disorders with prescription opioids and high-risk opioid use in US veterans of Iraq and Afghanistan. JAMA 2012 Mar 7; 307:940.
Reprinted in:  High-Risk Opioid Use More Likely with PTSD Diagnoses in Veterans JWatch Psychiatry. 2012;2012(306):1

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