Published March 07, 2012
Morphine and similar powerful painkillers are sometimes prescribed to recent war veterans suffering from post-traumatic stress along with physical pain, and the consequences can be tragic, a government study suggests.
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, according to the study, billed as 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.
Subsequent suicides, other self-inflicted injuries, and drug and alcohol overdoses were all more common in vets with PTSD who got these drugs. These consequences were rare but still troubling, the study authors said.
The results underscore the challenge of treating veterans with devastating physical injuries and haunting memories of the horrors of war. But the findings also suggest that physicians treating these veterans should offer less risky treatment, including therapies other than drugs, the study authors and other experts say.
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 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.
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.
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.
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."
Retired Lt. Col. Steve Countouriotis, a 30-year Army veteran who served in Iraq and Afghanistan, says that after returning home a few years ago, he received a morphine prescription for war-related back and shoulder pain. He refused to take it and used aspirin instead.
"I don't feel comfortable taking those kinds of medicines," said Countouriotis, 60, of Petaluma, Calif. "I don't like mood-altering drugs." He said he doesn't have PTSD, but that some colleagues who do have also been given the drugs.
Doctors are too quick to prescribe them, Countouriotis said, adding, "It's too many, too soon."
Army data provided to The Associated Press last year showed that referrals for opiate abuse among soldiers rose during the decade that ended in 2009, and totaled more than 670 between October 2009 and June 2010.
Some vets in the new study got the drugs from overburdened primary care physicians outside the VA health system.
"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.
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.
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.