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Research Letter |

Chronic Pain and Opioid Use in US Soldiers After Combat Deployment FREE

Robin L. Toblin, PhD, MPH1,2; Phillip J. Quartana, PhD1; Lyndon A. Riviere, PhD1; Kristina Clarke Walper, MPH1; Charles W. Hoge, MD1
[+] Author Affiliations
1Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Maryland
2Commissioned Corps of the US Public Health Service, Rockville, Maryland
JAMA Intern Med. 2014;174(8):1400-1401. doi:10.1001/jamainternmed.2014.2726.
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Published online

Chronic pain affects a quarter of people seeking primary health care.1,2 Opioid medications are prescribed for chronic pain, but recently, rates of opioid use and misuse have ballooned, leading to significant numbers of overdose-related hospitalizations and deaths.3 The prevalence of chronic pain and opioid use associated with deployment is not well known, despite large numbers of wounded service members. To our knowledge, this is the first study to assess chronic pain prevalence and opioid use in a non–treatment-seeking, active duty infantry population following deployment.

Institutional review board approval for the study was given by Walter Reed Army Institute of Research. Confidential surveys were collected in 2011 from 1 infantry brigade 3 months after return from Afghanistan under a protocol approved by the Walter Reed Army Institute of Research.4 Group recruitment briefings were attended by 80.3% of soldiers (3076 of 3832); 93.5% consented to participate (2876 of 3076). The final sample included 2597 soldiers who had been deployed to Afghanistan or Iraq. Participants provided written informed consent.

Chronic pain was defined by soldiers reporting pain duration of at least 3 months (Table 1).5 Past-month pain frequency and severity (range, 0-10; none [0], mild [1-4], moderate [5-6], and severe [7-10])6 were also assessed (Table 1). Opioids and other pain medications were assessed by past-month frequency of use (never, few or several days, more than half the days, nearly every day) (Table 1). Standardized scales assessed injuries during combat, combat intensity, posttraumatic stress disorder (PTSD), major depressive disorder (MDD) and alcohol misuse.4 Multiple logistic regressions examined correlates of chronic pain and opioid use.

Table Graphic Jump LocationTable 1.  Pain Characteristics and Medication Characteristics Among 2597 Army Infantry Soldiers, 2011

The 2597 participants were predominantly male (93.1%), 18 to 24 years old (41.3%), high school educated (48.2%), married (54.9%), and junior enlisted rank (56.1%). Nearly half (45.4%) reported injuries during combat. The prevalences of PTSD, MDD, and alcohol misuse screening were 9.1%, 5.8%, and 16.4%, respectively. Past-month opioid use was reported by 15.1% of soldiers (Table 1); among these, 5.6% reported no past-month pain, and 38.5%, 37.7%, and 18.2% reported mild, moderate, and severe pain, respectively. Most using opioids (62.6%) reported few or several days’ use.

Chronic pain was reported by 44.0%. Of these, 48.3% reported duration 1 year or longer, 55.6% reported nearly daily or constant frequency, and 51.2% reported severity of moderate to severe; 23.2% reported past-month opioid use, and 57.9% of those reported few or several days use (Table 1).

Chronic pain was significantly associated with age 30 years or older, being married or having been married previously, injury during combat, combat intensity, PTSD, and MDD (Table 2). Opioid use was associated with sex, age 25 years or older, being married, rank, injury during combat, chronic pain, and pain severity (Table 2).

Table Graphic Jump LocationTable 2.  Association of Demographic, Health, and Combat Factors With Chronic Pain and Opioid Use Among 2597 Army Soldiers, 2011

The prevalence of chronic pain (44.0%) and opioid use (15.1%) in this non–treatment-seeking infantry sample were higher than estimates in the general civilian population of 26.0% and 4.0%, respectively.2 These results are notable because this is an operational unit of young soldiers surveyed at their workplace and are likely, in part, related to deployment effects (including injuries, combat exposure, and mental health conditions). These findings suggest a large unmet need for assessment, management, and treatment of chronic pain and related opioid use and misuse in military personnel after combat deployments.

Notably, 44.1% of soldiers reporting opioid use reported no or mild past-month pain, including 5.6% with no pain. This might imply that opioids are working to mitigate pain, but it is also possible that soldiers are receiving or using these medications unnecessarily. This is cause for concern because opioids should be prescribed generally for moderate to severe pain1,3 and have high abuse and overdose potential.13 Prescription practices should be examined to ensure that opioid use is consistent with standards of care and practice guidelines and nonopioid alternatives are considered whenever possible.1,3 The benefits of opioids for treating pain, particularly in those with combat-related injuries, must be balanced by careful assessment of risks, including the potential for misuse.

Corresponding Author: Robin L. Toblin, PhD, MPH, Commissioned Corps of the US Public Health Service and Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, 503 Robert Grant Ave, Silver Spring, MD 20910 (robin.l.toblin.mil@mail.mil).

Published Online: June 30, 2014. doi:10.1001/jamainternmed.2014.2726.

Author Contributions: Dr Toblin had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Toblin, Hoge.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Toblin, Quartana.

Administrative, technical, or material support: Riviere, Walper.

Study supervision: Hoge.

Conflict of Interest Disclosures: None reported.

Funding/Support: The US Army Medical Research and Materiel Command (USAMRMC) provides intramural funding that supports enhancing the psychological resilience of the warfighter.

Role of the Sponsor: The USAMRMC had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The views reported herein are those of the authors only and do not represent the views of the US Army, Department of Defense, or any of the institutes listed.

Previous Presentation: Some data from this study were presented at the American Public Health Association Annual Meeting; October 29, 2012; San Francisco, California.

Additional Information: Dr Riviere was the principal investigator of the study.

Additional Contributions: We are grateful to the soldiers and leadership of the participating unit and the Land Combat Study team for assistance with data collection.

Department of Veteran Affairs; Department of Defense. VA/DoD Clinical practice guideline for management of opioid therapy for chronic pain. http://www.healthquality.va.gov/guidelines/Pain/cot/. Accessed January 31, 2014.
Toblin  RL, Mack  KA, Perveen  G, Paulozzi  LJ.  A population-based survey of chronic pain and its treatment with prescription drugs. Pain. 2011;152(6):1249-1255.
PubMed   |  Link to Article
Centers for Disease Control and Prevention. Prescription painkiller overdoses in the US. Vital Signs. http://www.cdc.gov/vitalsigns/painkilleroverdoses/. Accessed January 31, 2014.
Thomas  JL, Wilk  JE, Riviere  LA, McGurk  D, Castro  CA, Hoge  CW.  Prevalence of mental health problems and functional impairment among active component and National Guard soldiers 3 and 12 months following combat in Iraq. Arch Gen Psychiatry. 2010;67(6):614-623.
PubMed   |  Link to Article
International Association for the Study of Pain. Classification of Chronic Pain.2nd ed. Seattle, WA: International Association for the Study of Pain; 1994.
Anderson  KO.  Role of cutpoints: why grade pain intensity? Pain. 2005;113(1-2):5-6.
PubMed   |  Link to Article

Figures

Tables

Table Graphic Jump LocationTable 1.  Pain Characteristics and Medication Characteristics Among 2597 Army Infantry Soldiers, 2011
Table Graphic Jump LocationTable 2.  Association of Demographic, Health, and Combat Factors With Chronic Pain and Opioid Use Among 2597 Army Soldiers, 2011

References

Department of Veteran Affairs; Department of Defense. VA/DoD Clinical practice guideline for management of opioid therapy for chronic pain. http://www.healthquality.va.gov/guidelines/Pain/cot/. Accessed January 31, 2014.
Toblin  RL, Mack  KA, Perveen  G, Paulozzi  LJ.  A population-based survey of chronic pain and its treatment with prescription drugs. Pain. 2011;152(6):1249-1255.
PubMed   |  Link to Article
Centers for Disease Control and Prevention. Prescription painkiller overdoses in the US. Vital Signs. http://www.cdc.gov/vitalsigns/painkilleroverdoses/. Accessed January 31, 2014.
Thomas  JL, Wilk  JE, Riviere  LA, McGurk  D, Castro  CA, Hoge  CW.  Prevalence of mental health problems and functional impairment among active component and National Guard soldiers 3 and 12 months following combat in Iraq. Arch Gen Psychiatry. 2010;67(6):614-623.
PubMed   |  Link to Article
International Association for the Study of Pain. Classification of Chronic Pain.2nd ed. Seattle, WA: International Association for the Study of Pain; 1994.
Anderson  KO.  Role of cutpoints: why grade pain intensity? Pain. 2005;113(1-2):5-6.
PubMed   |  Link to Article

Correspondence

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