On October 10, 2013, a Congressional hearing was held to address the issue of opioid medication prescribing within VHA facilities and clinics (House Veteran Affairs Subcommittee hearing “Between Peril and Promise: Facing the Dangers of VA’s Skyrocketing Use of Prescription Painkillers to Treat Veterans”). Several individuals testified, including the widows of 2 veterans; both their husbands had overdosed on prescribed opioid medications. One husband had been taking as many as 15 pills a day and was additionally prescribed oxycodone/acetaminophen, which led to his death.1
Alongside the widows were 2 veterans who had been treated for chronic back pain injuries sustained before and during deployment in Iraq. Both had been prescribed several pain medications, including oxycodone/acetaminophen, methadone, and morphine. One reported that as his pain increased, his doctors continued to provide him additional prescriptions; at one point he had more than 13 prescriptions and could no longer work from being so “doped up.”1
In the past 2 decades, health care professionals (HCPs) have placed greater emphasis on chronic pain management. As a result, the rate of opioid medication prescribing has increased dramatically. Since 1994, the number of opioid medication prescriptions has nearly doubled; this change has been accompanied by an increase in opioid misuse, which has resulted in accidental or intentional overdose and death.2
Based on a recent National Institute on Drug Abuse (NIDA) report, the greatest impact has been on armed forces personnel.3 Prescriptions for pain relievers quadrupled between 2001 and 2009 to almost 3.8 million within the military population. Although civilian populations are more likely to abuse illicit drugs, military personnel are at particular risk of prescription abuse, including opioid medications.3 In 2008, 11% of armed forces service members reported misusing prescription drugs, with opioid medications being the most abused. This is an approximate 5- to 6-fold increase since 2002 (2% reported misuse in 2002).3 Particularly concerning is the associated rise in suicide rates among armed forces personnel, which surpassed civilian suicide rates in 2004. In 2009, one-third of suicides among armed forces personnel involved prescription drugs.3
Certain patient characteristics or factors are related to greater overdose risk. These risk factors include prescription dosage and frequency, history of suicide attempts or self-harm behavior, history of depression or posttraumatic stress disorder (PTSD) among other mental health-related diagnoses, a history of substance and/or alcohol abuse, and within the context of opioid medication use, the concurrent use of other central nervous system (CNS) depressants.4,5 Additionally, the stresses of deployment during wartime, physical injuries sustained in combat, and the unique military culture play a particularly important role in access to substances with high abuse potential and the subsequent development of substance abuse.3
Opioid Use and Risk Factors
More than 3% of adults in the U.S. are now receiving opioid medications for chronic noncancer pain.6 Substance abuse among patients with chronic pain ranges from 14% to 40%.5 Prescription opioid medications are the fastest growing drugs of abuse and the most common cause of unintentional overdose in the U.S.4 About 17,000 deaths occur each year as a result of prescription opioid medication overdose.7 Opioid medication-related overdose deaths began to increase in the early 2000s and continue to increase. Between 1999 and 2007, the rate of unintentional overdose-related deaths in the U.S. increased by 124%, largely due to the increase of prescription opioid medications.8
High-Dose Opioid Medication Use
A study by Dunn and colleagues found that patients receiving higher doses of prescribed opioid medications were at an increased risk of overdose.6 Patients receiving 50 mg to 99 mg morphine equivalent daily dose (MEDD) had a 3.7-fold increase in overdose risk (0.7% annual overdose rate) as compared with patients who received < 50 mg MEDD (0.2% annual overdose rate). Patients receiving ≥ 100 mg MEDD had a 1.8% annual overdose rate and a 9.8-fold increase in overdose risk as compared with patients who received < 50 mg MEDD. Overall, 51 patients experienced ≥ 1 overdose event, 40 of whom experienced fatal or serious overdoses and 6 of whom attempted suicide. Patients receiving the highest doses were male, current smokers, and had a history of depression and substance abuse.6 Similarly, a study by Bohnert and colleagues found that opioid medication overdose was most likely to occur in those patients with psychiatric and substance use disorders compared with patients who had no psychiatric illness history.8
Depression
Mood disorders are common in people with chronic pain.4,5,9,10 In particular, patients with a history of depression are more likely to receive chronic opioid medication prescriptions and are at a higher risk for opioid medication abuse. A substance abuse history is the most consistent predictor of both chronic opioid medication use and abuse. However, depression without substance abuse is significantly associated with 2 forms of opioid medication abuse: self-medication for stress or sleep and overmedication (using a higher dose than prescribed). More severe cases of depression show a stronger association for potential abuse.4