By James Dao
Veterans with post-traumatic stress disorder are more likely to be prescribed opioid pain killers than other veterans with pain problems and more likely to use the opioids in risky ways, according to a study published Wednesday by the Department of Veterans Affairs.
The study, published in the Journal of the American Medical Association, also found that veterans returning from Iraq and Afghanistan who were prescribed opioids for pain â€“ and particularly those with post-traumatic stress disorder â€” had a higher prevalence of "adverse clinical outcomes," like overdoses, self-inflicted injuries and injuries caused by accidents or fighting.
The Department of Veterans Affairs and the Department of Defense have for years been trying to reduce the use of opioid pain therapy among active duty troops and veterans amid reports of overmedication, addiction, rampant drug abuse and accidental deaths caused by overdoses or toxic mixing of medications.
But the study raises new concerns that primary care doctors â€” the main prescribers of opioids to veterans â€” are not always following government guidelines intended to restrict opioid pain therapy for veterans with PTSD and other mental health diagnoses.
"There is often a big gulf between policies and practice," said Dr. Karen Seal, the director of an integrated care clinic at the San Francisco Veterans Affairs Medical Center who was the lead investigator on the study. "That is where the work needs to be done, in implementing policies and guidelines that are already there."
Dr. Robert D. Kerns, the national program director for pain management at the Department of Veterans Affairs, said in an interview that the department would draw attention to the new findings to push doctors to consider alternatives to opioid therapy, particularly with PTSD patients.
"This reinforces what's on the books and draws attention to an important challenge," Dr. Kerns said. "And it encourages us to continue to look for other innovations that can build on our existing initiatives."
Dr. Kerns said the veterans affairs medical system, as well as the Pentagon's health system, have been expanding alternative pain treatment programs to reduce the use of opioids, including acupuncture, chiropractic medicine, physical therapy, exercise therapy and relaxation techniques.
The veterans department is also looking to expand the use of psychological therapies already used for PTSD, mainly cognitive behavioral therapy, for treating chronic pain as well, said Dr. Kerns, who is himself leading research into that area.
Understanding the potential links between post-traumatic stress disorder and chronic pain is important because both are common among service members. By some estimates, one in five combat veterans report symptoms of PTSD, which can include nightmares, flashbacks, irritability and sleeplessness.
Chronic pain is also prevalent among troops and veterans, even those who have not experienced major battlefield injuries, like the loss of a limb. Lower back, knee, shoulder and other joint pains are common because of the routine physical stresses of the work, including wearing heavy body armor and packs.
Previous studies have shown that patients with post-traumatic stress disorder use opioid pain killers at higher rates than other patients. Dr. Seal said that one theory for the connection is that patients with anxiety disorders like PTSD may be more sensitive to pain.
"It's a vicious cycle," she said. "When you have an anxiety disorder, when you feel pain, you become anxious about it are more aware of it, and tend to complain about it."
She said most younger veterans tend to receive health care from primary care doctors who are not typically expert in handling post-traumatic stress disorder. But those doctors are trained to treat chronic pain, and many turn to opioids first because they want to relieve their patients' suffering quickly. The result, the study concluded, may be inappropriate prescriptions.
"Patient distress can drive potentially inappropriate opioid therapy, perhaps because physicians do not know how else to handle these challenging patients," the study said.
Dr. Seal said there were also studies suggesting that post-traumatic stress disorder disrupts the body's natural opiate system, which releases endorphins that reduce pain. The result is that people with PTSD may perceive pain at a lower threshold, she said.
The new study is considered particularly significant because of the sheer size of its sample: more than 141,000 veterans of Iraq and Afghanistan who received pain therapy for problems other than cancer from 2005 to 2010. Dr. Seal said the study was spurred in part by an article in The New York Times about troops and veterans who had died apparently from the toxic mixing of prescription medicines.
The researchers, most of them affiliated with the Department of Veterans Affairs, found that patients who had received mental health diagnoses were significantly more likely to receive opioid medication for pain than those without mental health problems. And veterans with post-traumatic stress disorder or a drug use disorder were the most likely to receive the prescriptions.
The researchers also looked at what they considered high-risk use of opioids, including high doses; using multiple types of opioids at one time; getting prescriptions for sedative hypnotics as well as opioids; and refilling opioid prescriptions early. Those actions could be indicators of drug abuse and addiction, as well as potential precursors for overdoses or toxic mixing of medications.
The study found that patients who had received mental health diagnoses showed patterns of higher-risk opioid use, and that the patterns were strongest among PTSD patients.
The researchers also found that veterans with post-traumatic stress disorder were more likely to receive opioid therapy even if they had known substance-use disorders, despite clear warnings that such prescriptions could be dangerous.
Dr. Seal said the researchers also found that more than four in 10 veterans with post-traumatic stress disorder were receiving opiates at the same time as benzodiazepines â€“ a family of medications, including Xanax, that is prescribed for anxiety disorders like PTSD. Dr. Seal said the finding was "unsettling" because the mixing of opioids, benzodiazepines and alcohol could lead to respiratory depression and death.
But Dr. Seal, who treats many veterans with chronic pain problems in her clinic, said she was finding that more of her patients were willing to try alternative pain therapies.
"They know people who have had problems," she said. "They don't want to get hooked on narcotics. So there is great openness to treating pain with therapies other than opiates."
James Dao is an editor of At War.