Study Finds Increased Prescribing Rates for Concurrent Sedative Medications among Veterans with PTSD
Chronic pain is a common complaint among Veterans returning from Iraq and Afghanistan with PTSD; in addition, a majority experience sleep dysfunction as well as psychiatric comorbidities, particularly depression and substance use disorders. Management of these conditions can lead to an accumulation of multiple sedative medications (polysedatives), which poses an important patient safety concern. To help address this issue, the 2010 revised VA/DoD Clinical Practice Guideline for the management of PTSD cautions providers against the use of benzodiazepines to manage the core symptoms of PTSD and recommends non-pharmacological options for the treatment of pain and insomnia. This is the first national study that sought to characterize polysedative prescribing in Veterans with PTSD. Using VA data, investigators identified Veterans with PTSD who used VA healthcare from FY03 (n=165,391) through FY11 (n=358,992). VA outpatient pharmacy data were then used to determine medication use – including concurrent use – for five classes of sedatives: benzodiazepines, hypnotics, atypical antipsychotics, opioid analgesics, and skeletal muscle relaxants. Investigators also examined patient demographics and rural versus urban residence.
- Over time, there was an increase in the use of polysedatives among Veterans with PTSD: from 34% to 37% for two or more sedative classes, and from 10% to 12% for three or more classes. This represents a concerning clinical trend and a relative increase of nearly 25%.
- The most common combination of sedatives was an opioid plus a benzodiazapine, which were taken concurrently by 16% of Veterans with PTSD. Two other combinations that were used more frequently than expected were opioids plus skeletal muscle relaxants – and benzodiazepines plus atypical antipsychotics.
- Polysedative use varied across demographic subgroups, with higher rates among women, Veterans residing in rural settings, younger adults, Native Americans, and Whites. Also, benzodiazepine prescribing was markedly elevated among women (44%) compared to men (34%), and was somewhat lower among older adults (31%) compared to younger adults (36%).
- This study did not seek to judge the clinical appropriateness of individual prescribing decisions; thus, some concurrent sedative use may be justified.
- The receipt of multiple medications from a single class (e.g., two benzodiazepines) was not counted as polysedative use in this analysis.
- Medications dispensed from non-VA pharmacies and drugs obtained illicitly were not considered.
This study was funded by VA/HSR&D's Mental Health Quality Enhancement Research Initiative (QUERI: RRP 11-001). Dr. Lund was supported by an HSR&D Career Development Award and is part of HSR&D's Center for Comprehensive Access & Delivery Research and Evaluation, Iowa City, IA. Drs. Bernardy and Friedman are part of VA's National Center for PTSD at the VAMC in White River Junction, VT.
Bernardy N, Lund B, Alexander B, and Friedman M. Increased Polysedative Use in Veterans with Post-traumatic Stress Disorder. Pain Medicine December 16, 2013;e-pub ahead of print.