title: Association of mental health disorders with prescription opioids and high-risk opioid use in US veterans of Iraq and Afghanistan.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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.
  
  
  METHODS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: San Francisco VA Medical Center, University of California, San Francisco, Department of Medicine, 4150 Clement St, PO Box 111A-1, San Francisco, CA 94121, USA. karen.seal@ucsf.edu
authors.forename: Karen H
authors.initials: KH
authors.lastname: Seal
authors.forename: Ying
authors.initials: Y
authors.lastname: Shi
authors.forename: Gregory
authors.initials: G
authors.lastname: Cohen
authors.forename: Beth E
authors.initials: BE
authors.lastname: Cohen
authors.forename: Shira
authors.initials: S
authors.lastname: Maguen
authors.forename: Erin E
authors.initials: EE
authors.lastname: Krebs
authors.forename: Thomas C
authors.initials: TC
authors.lastname: Neylan
mesh_terms: D000328:Adult; D055826:Afghan Campaign 2001-; D000701:Analgesics, Opioid / Q000506:poisoning* / Q000627:therapeutic use; D015331:Cohort Studies; D062787:Drug Overdose / Q000453:epidemiology; D005260:Female; D006801:Humans; D054542:Iraq War, 2003-2011; D008297:Male; D001523:Mental Disorders / Q000453:epidemiology*; D009293:Opioid-Related Disorders / Q000453:epidemiology*; D010146:Pain / Q000175:diagnosis / Q000188:drug therapy / Q000453:epidemiology; D055553:Prescription Drugs / Q000506:poisoning / Q000627:therapeutic use; D012189:Retrospective Studies; D012306:Risk; D013313:Stress Disorders, Post-Traumatic / Q000453:epidemiology* / Q000523:psychology*; D014481:United States / Q000453:epidemiology; D014728:Veterans / Q000523:psychology*
chemical_list: D000701:Analgesics, Opioid; D055553:Prescription Drugs