3021 — Prevalence and Trends of Concurrent Opioid Analgesic and Benzodiazepine Use Among Veterans Affairs Patients with PTSD, 2003 - 2011

Hawkins EJ, Center of Excellence in Substance Abuse Treatment and Education; Malte CA, Center of Excellence in Substance Abuse Treatment and Education; Grossbard JR, Center of Excellence in Substance Abuse Treatment and Education; Saxon AJ, Center of Excellence in Substance Abuse Treatment and Education;

Objectives:
Patients with posttraumatic stress disorder (PTSD) have numerous complex symptoms, including anxiety, insomnia and co-occurring pain. Opioid analgesics and benzodiazepines are commonly prescribed to treat these symptoms, but there are growing concerns that long-term use of these medications may pose serious risks with limited therapeutic benefit. Little is known about the trends of long-term concurrent use or the prevalence of high-risk conditions such as substance use disorders, suicide risk, breathing-related disorders, and age > 65 or practices such as prescribing opioid doses exceeding 100mg/day morphine equivalents in this population. Study objectives were to examine trends in annual prevalence of long-term concurrent opioid and benzodiazepine use among patients with PTSD and estimate the prevalence of high-risk conditions and prescribing practices among concurrent users of these medications.

Methods:
This retrospective review of pharmacy records included 66,210 patients with PTSD diagnoses from outpatient visits or inpatient admissions at facilities in the VA Integrated Service Network (VISN 20) from 2003-2011. Long-term concurrent use was defined as overlapping opioid and benzodiazepine prescriptions for > 90 consecutive days. Socio-demographic and clinical covariates were obtained from VA administrative data. Gender-specific logistic regressions estimated long-term concurrent use of these medications and tested for linear trends over 9-years.

Results:
The trend in age-adjusted long-term concurrent opioid and benzodiazepine use over 9-years increased from 3.6% (95% confidence interval, 3.3-3.9) to 5.5%(5.3-5.8), [adjusted odds ratio (AOR) = 1.05 (1.04-1.06)], in men and from 3.9%(3.0-5.0) to 7.0%(6.2-7.9), [AOR = 1.07 (1.05-1.10)], in women. In 2011, 17.1% of long-term concurrent users were prescribed morphine-equivalent daily doses of opioids > 100mg and 49.4% had a documented high-risk condition, with COPD (21.3%) the most common, followed by substance use disorders (18.0%), age > 65 (11.3%), sleep apnea (10.9%) and suicide risk (8.4%).

Implications:
Despite known risks associated with prescribing opioids and benzodiazepines concurrently, the adjusted prevalence of long-term concurrent use rose significantly among men and women with PTSD in VISN 20 over a nine-year period, with one-half of concurrent users having a high-risk condition in FY11.

Impacts:
Common use of these medications among patients with high-risk conditions suggests comprehensive strategies are needed to identify and monitor patients at increased risk for adverse outcomes.