According to a new government study Morphine and similar powerful painkillers are sometimes prescribed to recent war veterans suffering from post-traumatic stress along with physical pain. The study suggests that these vets are at high risk for drug and alcohol abuse, but they're two times more likely to get prescriptions for addictive painkillers than vets with only physical pain.
This is the first national examination of the problem. Iraq and Afghanistan vets with PTSD who already had substance abuse problems were four times more likely to get these drugs than vets without mental health problems, according to the study. This may be leading to rising number of suicides, other self-inflicted injuries, and drug and alcohol overdoses among vets with PTSD who got these drugs. These consequences were rare but still troubling, the study authors said.
The research involved all veterans of Iraq and Afghanistan wars who were diagnosed with non-cancer physical pain from October 2005 through December 2010 — or 141,029 men and women. Half of them also were diagnosed with post-traumatic stress disorder or other mental health problems.
In the study, 15,676 vets received opiate prescriptions for physical pain. These prescriptions went to almost 18 percent of vets with PTSD and 12 percent of those with other mental health problems, compared with about 7 percent of vets without those problems. Among those with PTSD, subsequent self-inflicted injuries, including suicides, occurred in 3 percent of vets who got the drugs, versus 2 percent who didn't receive those prescriptions. The study doesn't provide a breakdown of suicides vs. nonfatal self-injuries. Findings suggest that physicians treating these veterans should offer less risky treatment, including therapies other than drugs, the study authors and other experts say.
Lead author Dr. Karen Seal, who treats patients at the San Francisco VA Medical Center, said she sometimes prescribes opiates for war vets, but only if other painkillers don't work, and only in collaboration with non-drug treatment from mental health experts, occupational therapists and other specialists. That type of approach is part of a VA pain management policy adopted in 2009, toward the end of the study period.
Opium-based drugs like morphine and hydrocodone can dull excruciating physical pain. Relatively few veterans are prescribed such drugs. But some doctors likely prescribe them for vets who also have mental pain “with the hope that the emotional distress that accompanies chronic pain will also be reduced. Unfortunately, this hope is often not fulfilled, and opioids can sometimes make emotional problems worse,” said Michael Von Korff, a chronic illness researcher with Group Health Research Institute, a Seattle-based health care system. He was not involved in the study.
The results were published Tuesday in the Journal of the American Medical Association. The Department of Veterans Affairs paid for the study, which is based on VA health care data.
Dr. Robert Kerns, the VA's national program director for pain management, said the study “draws attention to growing concerns” about the use of opiate painkillers in veterans. These drugs may have a role in treating chronic pain in vets but only as part of a comprehensive pain management plan, he said. In a written statement about the study, the VA said its pain management approach has been cited as a model of care, but that “we recognize that more work needs to be done.”
“There's really been a culture of, 'Let's get rid of pain,' and I think unfortunately that pendulum may have swung too far,” said Dr. Karen Seal. “Imagine primary care doctors getting about 20 minutes to see a patient expressing high levels of distress,” because of war-related physical and mental trauma, said Seal, the study author. The balance between providing pain relief while being cautious with drugs that can be habit-forming “is always in play,” she said.
The study “brings much needed attention to the complexity of this problem,” said Dr. William Becker, a Yale University instructor and primary care physician who treats substance abuse and has worked with veterans. “Patients are typically younger individuals who are in many cases kind of struggling to find their feet again” after returning home from war, he said. The ideal treatment includes behavioral counseling, therapy for war wounds and management of chronic pain. “The word is spreading and I think this paper is going to send another strong message that this has really got to become the standard of care,” Becker said.
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