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Association of Mental Health Disorders With Prescription Opioids and High-Risk Opioid Use in US Veterans of Iraq and Afghanistan
Abstract
CONTEXT: Record numbers of Iraq and Afghanistan veterans survive their war injuries and yet continue to experience pain and mental health problems, particularly posttraumatic stress disorder (PTSD). Little is known about the association of mental health disorders and prescription opioid use. OBJECTIVE: To investigate the effect of mental health disorders, particularly PTSD, on risks and adverse clinical outcomes associated with prescription opioid use. DESIGN: Retrospective cohort study involving 141,029 Iraq and Afghanistan veterans who received at least 1 non-cancer-related pain diagnosis within 1 year of entering the Department of Veterans Affairs (VA) health care system from October 1, 2005, through December 31, 2010. MAIN OUTCOME MEASURES: Independent association of mental health disorders and the prescription of opioids, higher risk opioid use, and adverse clinical outcomes (eg, accidents and overdose) within 1 year of receiving a pain-related diagnosis. RESULTS: A total of 15,676 veterans were prescribed opioids within 1 year of their initial pain diagnosis. Compared with 6.5% of veterans without mental health disorders, 17.8% (adjusted relative risk [RR], 2.58; 95% CI, 2.49-2.67) of veterans with PTSD and 11.7% (adjusted RR, 1.74; 95% CI, 1.67-1.82) with other mental health diagnoses but without PTSD were significantly more likely to receive opioids for pain diagnoses. Of those who were prescribed pain medication, veterans with PTSD were more likely than those without mental health disorders to receive higher-dose opioids (22.7% vs 15.9%, adjusted RR, 1.42; 95% CI, 1.31-1.54), receive 2 or more opioids concurrently (19.8% vs 10.7%, adjusted RR, 1.87; 95% CI, 1.70-2.06), receive sedative hypnotics concurrently (40.7% vs 7.6%, adjusted RR, 5.46; 95% CI, 4.91-6.07), or obtain early opioid refills (33.8% vs 20.4%; adjusted RR, 1.64; 95% CI, 1.53-1.75). Receiving prescription opioids (vs not) was associated with an increased risk of adverse clinical outcomes for all veterans (9.5% vs 4.1%; RR, 2.33; 95% CI, 2.20-2.46), which was most pronounced in veterans with PTSD. CONCLUSION: Among US veterans of Iraq and Afghanistan, mental health diagnoses, especially PTSD, were associated with an increased risk of receiving opioids for pain, high-risk opioid use, and adverse clinical outcomes.
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“Over reliance on the use of prescription opioids as a frontline treatment for chronic pain contributed to a national epidemic including increased rates of opioid addiction, accidental overdose, and even mortality [16–20].”
From Benchmark findings from a veteran electronic patient-reported outcomes evaluation from a chronic pain management telehealth program (2024) · cites this paper as [19]
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Metadata
- Authors
- Seal, K. H., Shi, Y., Cohen, G., Cohen, B. E., Maguen, S., Krebs, E. E., & Neylan, T. C.
- Affiliations
- San Francisco VA Medical Center (US)
- University of California, San Francisco (US)
- Indiana University (US)
- Corresponding author
- Seal, Karen H.
- ORCID
- Venue
- JAMA
- Publisher
- American Medical Association (AMA)
- Published
- 2012-03-07
- Volume
- 307
- Issue
- 9
- Pages
- 940-7
- ISSN
- 0002-9955 (ISSN-L)
- 0098-7484
- OpenAlex
- W1972850166
- Cited by
- 515
- References
- 49
- Citations by year
- 2026: 7 · 2025: 17 · 2024: 19 · 2023: 33 · 2022: 31 · 2021: 36 · 2020: 42 · 2019: 52 · 2018: 59 · 2017: 47 · 2016: 44 · 2015: 37 · 2014: 34 · 2013: 38 · 2012: 16
- FWCI
- 38.64
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- JAMA (publishedVersion)
- PubMed (publishedVersion)
- Funders
- National Heart, Lung, and Blood Institute (K23HL094765)
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Opioid Use Disorder Treatment
- Health Sciences › Medicine › Anesthesiology and Pain Medicine › Pain Management and Opioid Use
- Health Sciences › Medicine › Epidemiology › Substance Abuse Treatment and Outcomes
- Keywords
- opioid use, post-traumatic stress disorder, mental illness, Iraq and Afghanistan veterans, opioid overdose, opioid refills, sedative-hypnotic drugs, adverse clinical outcomes, veterans' health care, pain management, opioid prescribing practices, opioid-related deaths, opioid-related hospitalizations, opioid-related emergency department visits
- MeSH terms
- Adult, Analgesics, Opioid, Mental Disorders, Female, Humans, Male, Opioid-Related Disorders, Pain, Retrospective Studies, Risk, Stress Disorders, Post-Traumatic, United States, Veterans, Cohort Studies, Iraq War, 2003-2011, Prescription Drugs, Afghan Campaign 2001-, Drug Overdose
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