PTSD
Among Iraq and Afghanistan war veterans with ≥ 1 pain-related diagnosis, veterans with PTSD and veterans with a mental health disorder other than PTSD were significantly more likely to receive opioid medications for pain than were veterans without a mental health disorder (PTSD—17.8%, adjusted relative risk [RR] 2.58; other mental health disorder—11.7%, RR 1.74; no mental health disorder—6.5%).2 Although mental health disorders in general were related to a higher risk of opioid abuse, those with PTSD in particular were more likely to receive higher prescribed dosages; to continue taking opioids for a longer period; to receive concurrent prescriptions for opioid medications, sedative hypnotics, or both; to obtain early refills; and to have comorbid alcohol and substance use disorders. Based on these results, Seal and colleagues concluded that veterans with PTSD had the highest risk of alcohol, drug, and opioid-related accidents and overdose as well as self-inflicted injuries.2
Concurrent Use of Opioids and CNS Depressants
As mentioned earlier, studies suggest that people with PTSD are at a significantly higher risk for opioid medication overdose. One factor that may contribute to this higher risk is the concurrent use of CNS depressants/sedatives, particularly benzodiazepines and alcohol.
Benzodiazepines are often prescribed for people with PTSD. One study found that the concurrent use of benzodiazepines is significantly related to opioid overdose.5 Prescribing opioids for people already abusing or dependent on alcohol or other substances increases the risk of abuse and overdose. Furthermore, the concurrent use of multiple medications is associated with aberrant behaviors, cognitive impairment, and medication abuse, potentially leading to overdose. Overall, the combined administration of these medications is responsible for higher rates of adverse events, overdose, and death related to prescription opioid medication use.5,6,11
In summary, there are various risk factors that contribute to opioid medication overdose and more generally, risk of suicide, including (1) high-dose opioid medications; (2) history of psychiatric disorders, specifically depression and PTSD; (3) history of substance use disorders; and (4) concurrent use of opioid medications and prescription sedatives (specifically benzodiazepines) as well as alcohol and nonprescription drugs of abuse.
Suicide
Suicide is the tenth leading cause of death in the U.S., with 12.4 suicide deaths per 100,000 population.12 Suicide rates are even higher among veterans. According to the VHA, the age-adjusted rate of suicide for veterans using VHA facilities and clinics was 35.9 per 100,000 person-years for fiscal year 2009.13 Several risk factors for suicide attempts include depression and other mental health disorders, substance abuse, medical disorders, and prescription medications.
Prior suicide attempts or self-harm behavior is known to increase the risk of subsequent death by suicide. About 11 attempted suicides occur per suicide death where the medical severity of prior attempts increases the risk of future suicide, as does a history of multiple self-harm episodes.14,15 One study found that the single best predictor of suicide in a veteran population was an attempt in the previous 4 months.16
Among other risk factors, previous suicide attempts and violent behavior are major behavioral flags that warrant caution and require particular consideration when prescribing opioid medications. In a national survey on drug use and health, about 18% of prescription opioid users/abusers who experienced suicidal ideations actually attempted suicide. Only 11% of individuals who never used prescription opioid medications attempted suicide after reported suicidal ideations.17
Patient Data Aggregation
The early and widespread adoption of electronic medical records (EMRs) by the VHA allowed the aggregation of patient data for quality improvement. Initially, data were aggregated, and dashboards were designed retrospectively. However, the development of regional data warehouses that update patient information daily from the EMR allowed information to be aggregated prospectively, and dashboards were designed that provided real-time information.
The purpose of the current study is to demonstrate the efficacy and future potential of dashboard technology in assessing prospectively high-risk factors for opioid overdose. Dashboards are a user-friendly application that allows providers to isolate and calculate daily morphine equivalent opioid dosages and assess patients’ risk factors for overdose on an individual basis. By using this technology, providers who prescribe opioids can get a concise summary of opioid and other medications and adjust medications to decrease overdose risk on an individual basis.
What is the Dashboard?
The VISN 22 high-risk opioid dashboard is a business intelligence tool that serves as a report card, or progress report, to provide a global view of the number of veterans who are receiving opioid prescriptions totaling >120 mg MEDD and who have characteristics (history of depression, PTSD, substance abuse, or high-risk suicide flag) and prescriptions (concomitant CNS depressants) that may increase patient risk for overdose.
