Summer 2016

In this Issue: Improving the Safety of Prescription Opioid Use among Veterans » Table of Contents

Improving Opioid and Benzodiazepine Safety among Veterans with PTSD

Ongoing Study

Substantial numbers of Veterans with post-traumatic stress disorder (PTSD) present with multiple and complex symptoms such as co-occurring pain, anxiety, and insomnia, and are commonly prescribed opioid and benzodiazepine medications to treat these symptoms. Yet, potential interactions between opioids and benzodiazepines pose serious risks. The most serious risks to patients include fall-related injuries caused by over-sedation and death due to respiratory depression. Thus, specific aims of this ongoing HSR&D study (October 2014 – September 2016)include:

• Estimating the annual prevalence of concurrent opioid and benzodiazepine use among Veterans with PTSD in FY2011;
• Assessing the annual prevalence of alcohol misuse, suicide risk, and advanced age (>65 years old) among Veterans with PTSD who are prescribed benzodiazepines and opioids concurrently;
• Determining whether VA patients with PTSD receiving opioids and benzodiazepines concurrently are at increased risk of all-cause mortality and fractures, as compared to those receiving opioids only, benzodiazepines only, and non-users; and
• Evaluating whether alcohol misuse and advanced age are associated with increased risks of all-cause mortality and fractures among VA patients with PTSD who are prescribed opioids and benzodiazepines concurrently, as compared to those who screen negative for alcohol misuse, or who are younger than 65 years.

Veterans were eligible for this retrospective study if they received care at a VA facility and were diagnosed with PTSD during FY2010 and FY2011.

Thus far, findings show that the annual prevalence of any (>30 days) and long-term (>90 days) concurrent opioid and benzodiazepine use was 10% and 5%, respectively, among men, and 14% and 7%, respectively, among women with PTSD. In addition—

• Among Veterans who were co-prescribed these medications for >30 days and completed an AUDIT-C (screen for alcohol use) in the past 12 months (n=62,089), the prevalence of alcohol misuse was 11% and 9% among men and women, respectively.
• Of the Veterans in this study, 12% of men and 3% of women were older than 65 years, and 8% of men and 12% of women were at documented risk of suicide.
• Overall, 2% of the new concurrent opioid and benzodiazepine users and 1% of the propensity score matched new opioid only users died within 12 months of starting medications (n=6,291 per group). The 12-month relative risk of mortality was 1.9 times greater among new concurrent opioid and benzodiazepine users, as compared to propensity score matched new users of opioids only (n=6,280 per group).
• Over 12 months fractures were observed in 6% of new concurrent opioid and benzodiazepine users and 6% of new opioid-only users.

Impact

Study findings support VA efforts to reduce non-recommended prescribing practices, including concurrent prescribing of opioids and benzodiazepines, by identifying subsets of the population at greater risk of adverse events. Moreover, results will help educate patients and providers with respect to two of the most important adverse events – death and fractures – associated with these medications, thereby informing clinical care decisions.

Principal Investigator: Eric Hawkins, PhD, is part of HSR&D's Center of Innovation for Veteran-Centered and Value-Driven Care in Seattle WA and Denver, CO.