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Mental Health Diagnoses Associated with Opioid Prescription, High-Risk Use, and Adverse Outcomes among OEF/OIF Veterans


BACKGROUND:
Nationwide, the prescription of opioid analgesics has nearly doubled since 1994, owing to greater recognition of the importance of treating pain. At the same time, rates of prescription opioid misuse and overdose have increased sharply, and prescription opioids are now a leading cause of death in the U.S. OEF/OIF Veterans with pain and PTSD who are prescribed opioids may be at particularly high risk for prescription opioid misuse given the high co-occurrence of substance use disorders among Veterans with PTSD. This retrospective cohort study examined the impact of mental health disorders, particularly PTSD, on risks and adverse clinical outcomes associated with prescription opioid use among OEF/OIF Veterans. Using VA data, investigators identified 141,029 OEF/OIF Veterans who received >1 non-cancer pain-related diagnoses within one year of entering VA healthcare — from 10/05 through 12/08, with follow-up through 12/10. [This timeframe was chosen to minimize shifts in opioid prescribing patterns in VA as the joint VA/DoD clinical practice guideline for the management of opioid therapy was released in 2003 and was not updated until May 2010.] The main outcome assessed was the independent association of mental health disorders, particularly PTSD, on patterns of opioid prescription, associated risks, and adverse clinical outcomes (e.g., accidents and overdose) within one year of receiving a pain-related diagnosis.

FINDINGS:

  • Among OEF/OIF Veterans with pain, mental health diagnoses, especially PTSD, were associated with an increased risk of receiving opioids, high-risk opioid use, and adverse clinical outcomes.
  • Compared to those without mental health diagnoses, Veterans with PTSD who were prescribed opioids were more likely to receive higher-dose opioids (16% vs. 23%), receive two or more opioids concurrently (11% vs. 20%), receive sedative hypnotics concurrently (8% vs. 41%), and to obtain early opioid refills (20% vs. 34%).
  • Receiving prescription opioids (vs. not) increased risk for serious adverse clinical outcomes for Veterans (10% vs. 4%) across all mental health categories and was most pronounced in Veterans with PTSD.
  • Of the 141,029 Veterans with pain diagnoses, 15,676 (11%) received prescription opioids for ≥ 20 consecutive days; 77% of which were prescribed by VA primary care providers. Veterans with PTSD and mental health diagnoses excluding PTSD were significantly more likely to receive opioids for pain (18% and 12%) compared to Veterans without mental health diagnoses (7%).

LIMITATIONS:

  • Findings are based on adminstrative data only from VA-enrolled OEF/OIF Veterans with pain.

AUTHOR/FUNDING INFORMATION:
This study was partly funded by HSR&D. Drs. Seal and Maguen are part of HSR&D's Program to Improve Care for Veterans with Complex Comorbid Conditions, San Francisco. Drs. Maguen and Krebs were supported by HSR&D Career Development Awards.


PubMed Logo Seal K, Shi Y, Cohen G, Cohen B, Maguen S, Krebs E, and Neylan T. Association of Mental Health Disorders with Prescription Opioids and High-Risk Opioid Use in Veterans of Iraq and Afghanistan. JAMA 2012 Mar 7;307(9):940-7.

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What are HSR&D Publication Briefs?

HSR&D requires notification by HSR&D-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR&D and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR&D based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR&D published articles. Visit the HSR&D citations database for a complete listing of HSR&D articles and presentations.