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5 Articles in this Series
Introduction
Interdisciplinary Pain Rehabilitation Program
Neuropathic Pain Following Weight-Loss Surgery
Opioid Tapering: When, Where, How
Profile of Pain in the Military
Psychosocial Elements of Opioid Cessation

Profile of Pain in the Military

As a result of the injuries sustained during the recent Iraq and Afghanistan conflicts, pain is now the leading cause of short- and long-term disability among veterans. Since September 11, 2001, the Department of Veterans Affairs (VA) has witnessed a 270% increase in opioid prescriptions—including a 281% rise in methadone prescriptions and 578% increase in hydrocodone prescriptions. With these increases has come a sharp rise in overdose rates.1,2 According the VA, opioid-related overdoses have nearly doubled between 2001 and 2009.

How the military and the Department of Defense (DOD) handle the “undertreatment of pain” and the growing number of overdose deaths from prescription medications was a focus of the Army Surgeon General’s 2010 Pain Management Task Force (PMTF).3 The PMTF was chartered in response to the increasing recognition of the need for a comprehensive strategy for military pain management. Additionally, Section 711 of the National Defense Authorization Act for fiscal year 2010 tasked the Secretary of Defense to “develop and implement a comprehensive policy on pain management by the military healthcare system.” The PMTF report is unique in military medical history, representing the first systematic review of clinical policies and regulations from the DOD, regional medical commands, and military health care facilities regarding pain management.

A number of posters at this year’s AAPM meeting focused on pain management in the military. The first presentation set the stage by examining opioid use patterns among veterans. Information from over 1 million veterans who were prescribed an opioid was collected for the years 2009 to 2011 (Table 1).

According to investigator Mark Sullivan, MD, PhD, although the daily morphine equivalent dose (MED) was relatively low (average 20 mg MED, range 10 mg to 1,000 mg, with a mean of 33 mg/d), veterans have high rates of long-term opioid use (>90 days).1,2 “Once a veteran achieved 90 days of opioid use,” Dr. Sullivan said, “greater than 70% continued on opioids for years.”

Continuation of chronic opioid therapy was associated with multiple types of pain. The most common pain conditions seen included arthritis/joint pain, back pain, headache/migraine, neck pain, and neuropathic pain. Interestingly, chronic opioid therapy was not associated with multiple mental health disorders, substance abuse, traumatic brain injury disorders (except post-traumatic stress disorder), and/or tobacco use, but it was more common among veterans with at least one mental health diagnosis (anxiety, major depressive disorder, PTSD), said Dr. Sullivan. In addition, a higher daily opioid dose was associated with a greater risk for long-term opioid use.

These findings differed from patterns seen in the non-veteran population; in the veteran population the MED and rates of substance use disorders were lower than in civilian population of patients on long-term opioid therapy.

 

Reference

  1. Sullivan M, Hudson T, Martin BC, et al. National analysis of opioid use among veterans. Presented at the American Academy of Pain Medicine 30th Annual Conference, March 2014, Phoenix, Arizona. Abstract. 119.
  2. Sullivan M, Vanderlip E, Hudson T, et al. National study of discontinuation of chronic opioid therapy among veterans. Presented at the American Academy of Pain Medicine 30th Annual Conference, March 2014, Phoenix, Arizona. Abstract. 120.
  3. Pain Management Task Force—Final Report. Office of The Army Surgeon General. 2010. http://www.amedd.army.mil/reports/Pain_Management_Task_Force.pdf. Accessed April 14, 2014.
Next summary: Psychosocial Elements of Opioid Cessation
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