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Veterans of Iraq and Afghanistan with post-traumatic stress disorder (PTSD) and other mental health diagnoses were significantly more likely to be prescribed opiates for pain than were other Veterans with pain, according to a study led by Karen Seal, MD, MPH, a physician at SFVAMC.

The Veterans with pain and PTSD who received opiates were significantly more likely to receive higher dose prescriptions, two or more opiate prescriptions and concurrent prescriptions of sedative-hypnotics such as valium. They also were more likely to request early refills.

In addition, all Veterans who were prescribed opiates were also at significantly higher risk of serious adverse clinical outcomes, such as drug and alcohol-related overdoses, suicide and violent injury, with the risk being most pronounced for Veterans with PTSD.

To address the issue, the study authors recommend that the VA implement more broadly its current program of what Dr. Seal called a “multi-faceted, integrated approach” to simultaneously managing pain and PTSD.

Dr. Seal, an associate professor in residence of medicine and psychiatry at UCSF, noted that because of improved body armor and better war zone medical care, more Iraq and Afghanistan Veterans have survived wounds that would have been fatal in earlier conflicts. “Many of these Veterans with severe chronic pain also have PTSD as a result of the same trauma that caused their physical injuries,” she said.

The study of 141,029 Veterans who served in Iraq and Afghanistan from 2005 through 2010 appeared in the March 7 issue of the Journal of the American Medical Association.

The authors found that 77 percent of the opiate prescriptions were prescribed by primary care providers. “This is not surprising,” said Dr. Seal. “Patients in pain are far more likely to present to primary care than to go to mental health clinics for treatment of PTSD, and our ability to treat complex patients with pain and PTSD symptoms in primary care settings is currently somewhat limited.”

When faced with challenging patients who have high levels of distress, she said, “primary care physicians do what they can to relieve pain and suffering. They may have concerns about prescribing opiates, but they want to relieve the pain and continue to maintain contact with their patient.”

Dr. Seal explained that previous studies have shown that patients with PTSD may experience physical pain more intensely because of either lowered pain thresholds or disruption of the production of endorphins – opiates secreted naturally in the brain and body. PTSD, an anxiety disorder, may be a cause, itself, she said. “The more anxious you are, the more likely you are to be attuned to pain symptoms, which in turn, make you more anxious, which makes the pain worse, so it becomes a vicious cycle.”

To break that cycle, Dr. Seal and her co-authors recommend that the VA continue to extend its current stepped approach to treating patients who have both pain and PTSD. “Fortunately,” she said, “the elements of that approach are in place, or can be put in place, throughout the VA health care system.”

Dr. Seal said that those elements include Patient Aligned Care Teams (PACTs), which align primary care physicians with nurse care managers, mental health providers, pharmacists and social workers. “For patients presenting to primary care with pain, PACTs are an important steps in the direction of better care,” she said. “Patients requiring more intensive treatment can ‘step up’ to multi-disciplinary specialty pain management and PTSD services that are available at most VA medical centers. And the VA is also a leader in providing evidence-based combined cognitive behavioral therapy for PTSD and pain.”

Finally, Dr. Seal notes that the VA is “making strides” to implement pain management guidelines developed by the VA and the Department of Defense that discourage the overuse of opiate medications in favor of anti-inflammatory medications, physical therapy, exercise, relaxation techniques and complementary alternative medicine such as acupuncture.

“Even in remote VA clinics and isolated rural areas, many of these resources can be tapped through the use of video teleconferencing with pain experts at the medical centers, as well as online,” said Dr. Seal. She recommended that Veterans visit the VA site MyHealtheVet at

The study was supported by funds from the Department of Veterans Affairs and the National Institutes of Health, some of which were administered by NCIRE – The Veterans Health Research Institute.



Karen Seal, MD, MPH


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January 28, 2019