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The Journal of Pain Summary

Highlight from The Journal of Pain (Volume 19, No. 8, August 2018 Issue)

Traumatic Brain Injury and Receipt of Prescription Opioid Therapy for Chronic Pain in Iraq and Afghanistan Veterans: Do Clinical Practice Guidelines Matter?

Karen H. Seal, Daniel Berthenthal, Deborah E. Barnes, Amy L. Byers, Carolyn J. Gibson, Tessa L. Rife, Kristine Yaffe, and the Chronic Effects of Neurotrauma Consortium Study Group

Veterans have much higher rates of chronic pain than the general population, but for those with a traumatic brain injury (TBI), treatment with opioids can exacerbate mental health conditions and worsen psychological functioning. Despite this known risk, a new study published in The Journal of Pain shows that veterans with severe TBI are significantly more likely to receive long-and short-term opioid therapy than those with less severe or no TBI.

Researchers from San Francisco Veterans Health Care System and the University of California tested the hypothesis that among Iraq and Afghanistan veterans with a chronic pain diagnosis, greater TBI severity and mental health comorbidity independently predict subsequent initiation of short- and long-term opioid therapy.

For the study, data from 53,124 Iraq and Afghanistan veterans with chronic pain were evaluated between October 2007 and March 2015. The subjects completed a Comprehensive TBI Evaluation at Veterans Affairs (VA) health care facilities. To date, no study has reported on opioid prescribing patterns in individuals with chronic pain and TBI.

Results of the analysis showed that in more than 53,000 Iraq and Afghanistan veteran treated by the VA, 22 percent who were diagnosed with TBI received prescription opioids within the year after the TBI diagnosis. The authors noted that most veterans with chronic pain had tried non-opioid therapies prior to taking opioids, but 20 percent of those who received opioid therapy had no record of prior non-opioid therapies.

The authors concluded that the study exposes a paradox that risk for initiation of opioid therapy for chronic pain increases in association with increasing TBI severity and mental health comorbidity among Iraq and Afghanistan veterans. It was surmised that many physicians were prescribing opioids to avoid confrontations with patients and disrupting doctor-patient relationships. This contradicts current VA/Department of Defense clinical practice guidelines. However, many primary care physicians treating veterans with chronic pain and TBI do not use the clinical tools available for initiating non-opioid therapies. Therefore, a clear need exits for enhanced provider education and interdisciplinary behavioral support to primary care physicians who care from veterans with chronic pain and TBI.