Not long ago doctors were so afraid of turning their patients into addicts that they sometimes refused opioids even to the dying. Nowadays, they are so afraid of not treating the pain of their patients that they are careless of whether or not they turn them into addicts.
A paper in the Journal of the American Medical Association for March 7 describes the pattern of opioid prescription for veterans returning from the wars in Iraq and Afghanistan. Of the 291,205 who enrolled for VA health care between October 2003 and December 2008, 141,029 received a diagnosis of a painful condition not caused by cancer; and of that number, 15,676 received a prescription of an opioid drug that lasted at least 20 days.
Of those veterans with pain who had no psychiatric diagnosis, only 6.5 per cent were prescribed such a drug; for those with post-traumatic stress disorder the figure was 17.8 per cent. Patients with non-PTSD psychiatric disorders had an intermediate rate of prescription, at 11.7 per cent.
The prescription of opioids was associated with a variety of unfortunate outcomes. It is hardly surprising that those prescribed the drugs were more likely to take deliberate or accidental overdoses of them than those not prescribed them; but they were also more likely to injure themselves deliberately, to suffer “violence-related” injuries, other forms of injury, or other kinds of overdose or alcohol-related harms. The difference was more marked among those with psychiatric diagnoses.
Of course, a statistical association does not establish causation. There is nothing in the paper that excludes the possibility that the patients prescribed opioids had a worse prognosis in a case than those not prescribed them. Physical injury is associated, not surprisingly, with the development of later psychological difficulties. Nevertheless, there is reason for unease.
The paper tells us in its introduction that:
Nationwide, the prescription of opioid analgesics has nearly doubled since 1994 because of a greater recognition of the importance of treating pain.