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Returning combat veterans have high rates of mental and physical disorders, and injury-related pain often prompts prescription of opioid medication. Using records on 291,205 Iraq or Afghanistan veterans receiving Veterans Affairs health care in 2005–2008, researchers examined the association between opioid use and psychiatric diagnoses in the subgroup of 141,029 veterans with noncancer pain (prevalence of diagnoses: post-traumatic stress disorder [PTSD], 32%; other psychiatric diagnoses, 19%).
Of the sample, 11% received opioids. Such prescriptions were given at significantly higher rates to patients with PTSD (and within each demographic subgroup) or with other psychiatric diagnoses than with no psychiatric diagnoses (17.8%, 11.7%, and 6.5%, respectively). The rate was highest when PTSD was comorbid with drug abuse (33.5%). Veterans with PTSD were also more likely than nonpsychiatric veterans to take higher opioid doses, two or more opioids, and concomitant sedative-hypnotic drugs. Although taking opioids significantly increased risk for adverse outcomes in any veteran, those with PTSD had more alcohol-, drug-, and opioid-related accidents and overdoses and more self-inflicted injuries than those without psychiatric diagnoses.
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.
Comment
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.