Mental health diagnoses in veterans associated with increased risk of opioid use

Military veterans who have received a mental health diagnosis, in particular post-traumatic stress disorder (PTSD), are more likely to be prescribed opioids, have high-risk opioid use, and experience adverse outcomes, according to a new study.

Researchers performed a retrospective cohort study of veterans of Iraq and Afghanistan who had received one or more diagnoses of non-cancer-related pain within a year of entering the VA health system. The study's main outcome measures were the independent association between mental health disorders and receipt of an opioid prescription, high-risk opioid use, and such adverse outcomes as accidents, overdoses and self-inflicted injuries within a year of a pain-related diagnosis. The study results appeared in the March 7 Journal of the American Medical Association.

Overall, in a cohort of 141,029 veterans who entered the VA health system between Oct. 1, 2005 and Dec. 31, 2010, 15,676 received an opioid prescription within a year of a first pain diagnosis. Such prescriptions were significantly more likely among patients with PTSD (17.8%; adjusted relative risk [RR], 2.58; 95% CI, 2.49 to 2.67) or other mental health diagnoses (11.7%; adjusted RR, 1.74; 95% CI, 1.67 to 1.82) than among patients without mental health disorders (6.5%). Among patients prescribed pain medication, those with PTSD were more likely than those without mental health disorders to receive higher doses of opioids (22.7% vs. 15.9%; adjusted RR, 1.42; 95% CI, 1.31 to 1.54), to receive two or more opioids together (40.7% vs. 7.6%; adjusted RR, 5.46; 95% CI, 4.91 to 6.07), or to refill their opioid prescriptions early (33.8% vs. 20.4%; adjusted RR, 1.64; 95% CI, 1.53 to 1.75). In all veterans, an association was seen between receiving prescription opioids and experiencing adverse clinical outcomes (RR, 2.33; 95% CI, 2.20 to 2.46), but especially among those with PTSD.

The authors acknowledged that their data did not include socioeconomic status and that their results may not be generalizable to all veterans, among other limitations. However, they concluded that mental health diagnoses, particularly a diagnosis of PTSD, were associated with higher risk of receiving opioids, high-risk opioid use, and adverse outcomes in this population of Iraq and Afghanistan veterans. The authors pointed out that many primary care practices may be seeing increasing numbers of returned combat veterans and that physicians should take extra care when prescribing opioids to this population. “These patients may benefit from biopsychosocial models of pain care including evidence-based nonpharmacologic therapies and nonopioid analgesics,” the authors wrote. “Integrated treatments that target both mental health disorders and pain simultaneously are effective for both problems and may decrease harms resulting from opioid therapy.”

In a separate article published online March 7 by Injury Prevention, researchers examined army personnel data and found that 255 active-duty U.S. soldiers committed suicide in 2007-2008. Male gender, lower enlisted rank, and outpatient treatment for mental health disorders were associated with higher suicide risk, as were mood disorders, anxiety disorders, PTSD, personality or psychotic disorders, substance disorders and adjustment disorder. The authors noted that their findings should be confirmed in studies conducted over a longer time period and with a larger sample, but suggested that suicide prevention efforts should focus on soldiers who are treated for mental disorders or substance abuse.