Texas Veteran Standard of Care - PTSD and Opiate Addiction
Post-traumatic Stress Disorder (PTSD) is normally treated with antidepressants, while opioids are never recommended therapy. Nonetheless, a significant number of veterans suffer from both PTSD and opioid addiction, because they are frequently prescribed the latter to treat chronic pain. A study of overdose deaths among Texas veterans found that 44.7% suffered from PTSD, a condition that affects only about 6% of the general population.
Because veteran's affairs are administered nationally, it is difficult to obtain robust data on a single state. After reviewing information from the Department of Veterans Affairs (VA), Texas State and reliable media sites, I was able to find some information specific to Texas, which I have noted below. Where no data for Texas was available, I have used information on the nation as a whole. Nothing in the course of my research suggested that the ratios for the nation vary significantly by state.
Although "opiates" and "opioids" are chemically distinct, they are both prescribed for the same conditions and both implicated in the problems of addiction for the same reasons. Therefore, I have used the terms interchangeably for the purposes of this research.
TREATMENTS FOR PTSD in veterans
Opiates are not recommended as therapy for the treatment of PTSD.
The Departments of Veterans Affairs and Defense recommend individual trauma therapy as a first line of treatment for PTSD, with pharmaceuticals used in cases where such therapy is not available, or has proven ineffective. The only pharmaceuticals they recommend are anti-depressants of the Selective Serotonin Reuptake Inhibitor or Serotonin Norepinephrine Reuptake Inhibitor class: fluoxetine (Prozac), paroxetine (Paxil) and venlafaxine (Effexor). These are the only medications that showed even moderate success (see p. 53) in treating PTSD (without the use of other drugs), based on a meta-analysis (see p. 52) of 55 studies with more than 6,000 participants.
If those drugs are not effective in the management of PTSD, the recommendation of the VA/DOD is to use certain tricyclic antidepressants. These have shown "modest" effectiveness, but have a worse side effect profile than SSRIs or SNRIs.
Benzodiazepines, which are often used to treat anxiety and depression in the short term in the general population, are specifically not recommended because of their addictive potential. There is a movement away from using these drugs to treat PTSD and other mental disorders among veterans because of this. Nonetheless, as of 2012 (the most recent year for which the VA gives data), 30% of veterans with PTSD were still prescribed benzodiazepines.
If none of the recommended pharmaceuticals work, doctors may choose to use other anti-depressants, anti-convulsants/ mood stabilizers or anti-psychotics.
A 2016 study by the South Texas Veterans Healthcare System found that veterans suffering from PTSD were more likely than those with other mental disorders to be taking five or more medications as treatment. The same study found that this practice, polypharmacy, was associated with drug overdose and suicide.
USES OF PRESCRIPTION OPIOIDS
Opioids are frequently used to treat chronic pain among veterans, and veterans with PTSD (or other mental disorders) are three times as likely to be prescribed opioids for pain as those seeking treatment for pain alone. Prescriptions of opioids to veterans peaked in 2012, after which the drugs were curtailed sharply. Since that time, the number of prescriptions has dropped by 56%. However, the speed of the shift has itself proven harmful to veterans' health.
A study conducted by the Austin-American Statesman in 2012 (the only one to provide such detail on veterans in Texas) found that the rate of deaths by overdose (accidental or suicide) in the state was 17.7%, compared to 3.3% in the general population. Among veterans who died by overdose, 44.7% had PTSD.
SEEKING HELP FOR ADDICTION and mental health
Substance abuse is a significant problem for veterans with PTSD; more than 20% of veterans with PTSD also have Substance Abuse Disorder. A third of veterans who seek treatment for substance abuse also have PTSD. Since opioids were used for years as first-line therapy for chronic pain (a health problem for 50-60% of veterans), this has lead to 68,000 cases of opioid abuse disorders among veterans (roughly 13% of all veterans taking opioids). Since 2010, there has been a 55% increase in the number of veterans seeking help for opioid addiction.
Although veterans have the option to seek care through the VA, in addition to the regular healthcare system, the wait times to get help can be very long. Lack of available services in a timely manner is the most common reason why veterans go without help for PTSD. For mental disorders in general, including both PTSD and addiction, the social stigma against admitting a problem is also a major factor in deterring veterans from seeking treatment. The VA has introduced improved telehealth services, which can help with both of these issues, but doctors acknowledge that this is a major cultural change.
OPINIONS OF VETERANS
There are no comprehensive studies on veterans' opinions on different treatment methods for PTSD and addiction, however the one treatment that many want to see implemented is prescription marijuana. A petition requesting that disabled veterans be allowed access to marijuana for treatment received 8,000 signatures, and experts note that veterans are among the most vocal groups calling for legalization/ decriminalization.
While 28 states now have some laws allowing marijuana for medical or recreational use, Texas is not among them; however veterans there are advocating for change. One veteran with PTSD, who spoke to a local news affiliate on condition of anonymity, described it as potentially being the difference between life and death based on his own experience. Texan David Bass, a 20-year veteran of the Army who suffers from both chronic pain and PTSD, conducted a public campaign in order to encourage state legislators to amend marijuana laws.
In late 2016, State Senator José Menéndez introduced a bill that would allow patients with debilitating illnesses, including PTSD, to receive prescriptions for marijuana from their doctors.
Other treatments that have met with anecdotal success are online counseling using artificial intelligence and eye motion desensitization reprocessing (EMDR). The former has showed promise because veterans are seemingly more comfortable speaking to a computer-generated assistant about their mental health than to another person. EMDR has shown some effectiveness, but the VA's current position is that there is not enough data for them to recommend it as therapy for PTSD.
The most commonly prescribed drugs for PTSD in veterans are SSRIs and SNRIs. Opiates, along with addictive antidepressants like benzodiazepines, are not recommended for PTSD treatment. However, veterans with PTSD are far more likely to receive opiate prescriptions for chronic pain, and there is a high rate of comorbidity of PTSD and substance abuse.
Because of delays in receiving treatment and the social stigma against revealing mental health issues, many veterans have been reluctant to seek care. There is some evidence that these problems are being addressed by improvements in distance medicine and artificial intelligence, however it is still very early to make definitive statements about the success of these initiatives.
For their part, veterans have been advocating for a relaxation of marijuana laws that would allow them to access the drug, claiming that it is effective in relieving PTSD symptoms with a low side effect profile.