Veterans are an impacted community with a more challenging status quo than other communities and suffer high rates of chronic pain and co-morbidities. The loss of life among veterans prescribed opiates for chronic pain is staggering. Veterans impacted by opioids face a lifelong struggle.

Pain-relief medications, including controlled substances, are the most frequent form of medication used in suicide attempts via overdose. Service members are prescribed narcotic painkillers while serving in the military at three times the rate of civilians.

• An internal briefing from the Walter Reed’s Alcohol and Substance Abuse Program disclosed that nearly half of the soldiers in the Warrior Transition Units had narcotic prescriptions at the end of 2009, with roughly the same number having TBI and/or PTSD.

• In 2010, Army Surgeon General Lt. Gen. Eric Schoomaker estimated almost 14% of the force had been prescribed some form of opiate drug.

• By 2011, an estimated 25–35% of combat-wounded soldiers in WTUs experienced addiction or dependence on prescription drugs, particularly those provided in combat settings or military hospitals.

• Madigan Army Medical Center Pychiatrist Dr. Russell Hicks indicated 5% of the troops had two or more active prescriptions for opiates; 60% of the soldiers with PTSD seen in the Intensive Outpatient Program had a co-occurring substance use disorder.

Pain is the most frequent presenting complaint reported by service members in community and primary care settings, including nearly half of returning combat veterans signing into the VA with pain-related diagnoses from 2005–2008.

A VA study analyzing data on 123,946 veterans who received VA care in 2004–2005 and received opioids for non-cancer chronic pain found those being prescribed the highest doses were more than twice as likely to die by suicide between 2004–2009 compared to those with the lowest doses.

While opioid therapy was once largely in the domain of cancer and pain specialists, up to 80% of opioids were prescribed in VA primary care by 2010; the majority of long-acting opioids were prescribed for non-cancer pain.

Patients initiating therapy with long-acting opioids were more than twice as likely to overdose compared with persons initiating therapy with short-acting opioids, particularly within the first two weeks after initiation.

More than half of all veterans receiving care at VHA for chronic pain present with co-morbid mental health conditions. These veterans have a significantly greater risk of being prescribed the highest dose, highest risk opioid therapy by VA clinicians and for experiencing adverse outcomes.

• Veterans with PTSD experiencing chronic pain were more than twice as likely to be prescribed opioids.

• Veterans with PTSD and a history of substance use disorder were four times as likely to be prescribed opioids.

High dose, high risk opioid therapies had the worst outcomes for veterans with co-morbid mental health conditions, particularly those with PTSD. Around 75% of Vietnam veterans with PTSD have a co-occurring substance use disorder.

Veterans with co-morbid mental health conditions were the most likely to obtain early refills, to be prescribed higher doses, take opioids longer, and to receive concurrent opioid, sedative, and/or hypnotics prescriptions.

Long-term opioid therapy is associated with significant and well-known risks, particularly in vulnerable individuals experiencing chronic pain and co-morbid mental health and/or post-concussive conditions.

• Despite the risks and lack of evidence supporting the efficacy of long-term opioid therapy, opiate prescription rates at VA rose by 270% between 2001 and 2013. Of the more than a half million veterans receiving chronic or long-acting opioid therapy from the VA in 2016, more than a third were receiving sedatives concurrently; and

• Concurrent opioid and benzodiazepine prescription rates for veterans with PTSD in the VA were above 30%, despite the risk of their death from drug overdose increasing in a dose-response fashion.

As part of the 2013 Opioid Safety Initiative, VA stated its intent to leverage its electronic health record to identify patients with one or more risk factors, as well as providers whose prescribing practices are misaligned with medical evidence or best practices, in order to intervene.

With complete data, the VA’s electronic health record can alert providers of best practices, recommend evidence-based courses of treatment, and flag high-risk situations or potential violations of best practices, guidelines, and policy in order to improve quality and oversight and embed learning in care.

Matching of PDMP data to treatment records within the VA’s electronic health record has potential to improve care and patient safety while also opening up new opportunities for research, maximizing the value of the data at the point of care and developing best practices in data integration that can be applied across federal systems.

The VA has not yet leveraged the use of clinical alerts across the VA healthcare system to further mitigate the risk of potentially inappropriate prescribing and co-prescribing of CNS-acting medications and enhance patient safety and informed consent.

VA researchers have evaluated the impacts of veterans’ being prescribed multiple central nervous system (CNS) acting medications in multiple populations, noting that increases in the quantities prescribed have coincided with increases in overdoses and suicide-related behaviors. 

The researchers found past DoD reports of “potentially problematic use of [CNS-acting] drugs,” including a review of suicide-related events conducted by the Army Institute of Public Health that found in a review that at least one CNS-acting medication was prescribed in the year prior to:

• 90% of suicide attempts;

• 87% of suicidal ideation events, and

• 46% of suicide deaths.

TRICARE data from 2005–2011 reportedly demonstrated a shift in prescribing practices with a:

• 1,083% increase in use of antipsychotics (vs. a 22% increase within the civilian population);

• 996% increase in use of sedating anticonvulsants;

• 713% increase in use of benzodiazepines; and

• 682% increase in use of psychoactive medications.

In 2015, DoD’s Medical Command issued Policy Memorandum 15-039 to provide guidance on the management of polypharmacy involving psychotropic medications and CNS depressants specifically with the goal of reducing adverse events and optimizing the health of service members and families receiving care. 

In 2016, VA researchers examined experiences of more than 300,000 OIF/OEF veterans who received VA healthcare between 2009–2011. More than 8% were prescribed five or more CNS-acting drugs in 2011. CNS polypharmacy may independently increase the risk of overdose and suicide-related behavior. VA HSR&D released a Publication Brief about the findings here.

CNS polypharmacy was independently associated with documented overdose and suicide-related behaviors. OIF/OEF veterans with PTSD, depression, and TBI; women veterans; and veterans between ages 31–50 were more likely to have CNS polypharmacy. This may be a risk factor that could be used to “trigger” the evaluation of veterans’ care in order to decrease their risk of death.

In 2019, VA researchers evaluated menopausal symptoms and higher risk opioid prescribing. In a national sample of more than 100,000 women veterans aged 45–64 with chronic pain, menopausal symptoms were associated with potentially risky long-term opioid prescribing patterns, independent of other risk factors. Within this national sample, VA researchers found:

• 13% were prescribed high-dose long-term opioids;

• 35% were co-prescribed long-term opioids and CNS depressants; and

• 51% were prescribed long-term opioids.

The 17% of women veterans with documented menopausal symptoms were more likely to be prescribed high-dose long-term opioids, long-term opioids, and to have polypharmacy with long-term opioids co-prescribed with CNS depressants (sedative-hypnotics, gabapentin/ pregabalin, or muscle relaxants).

In 2022, VA researchers evaluated long-term psychoactive medications, polypharmacy, and risk of suicide and unintended overdose death in a national sample of more than 150,000 midlife and older women veterans. Long-term prescribing of psychoactive medications and psychoactive polypharmacy predicted their risk of suicide and/or overdose death above and beyond other factors:

• Long-term opioids and benzodiazepines were both associated with death by suicide.

• Opioids, benzodiazepines, sedative-hypnotics, antidepressants, antipsychotics, and antiepileptics were associated with unintended overdose death.

• Polypharmacy with three or more psychoactive medications was associated with a more than two-fold increased risk of both suicide and unintended overdose death.

Benzodiazepines are contraindicated with PTSD. Long-term use of benzodiazepines can increase symptoms of anxiety and depression. Women are more likely to be inappropriately prescribed benzodiazepines.

The VA has worked to de-implement benzodiazepine prescribing for PTSD, resulting in a decrease from over 31% in 2009 to just under 11% in 2019. The largest decreases were accounted for by new patients with PTSD not being prescribed benzodiazepines, as opposed to tapering and discontinuation among patients who were already prescribed benzodiazepines for PTSD.

From 2009 to 2019, the proportion of older veterans inappropriately prescribed benzodiazepines increased for both new and existing patients. The VA has not implemented clinical alerts within its electronic health record to mitigate risks of inappropriate prescribing at the point of service.

VA offers information about benzodiazepines here. In order to educate patients about the risks, VA published the pamphlet Benzodiazepines & PTSD: Do you know about this risky combination?.

In September 2020, the FDA updated the Boxed Warning for benzodiazepines to address serious risks of abuse, addiction, physical dependence, and withdrawal that may result in overdose or death. Risk is especially high when benzodiazepines are combined with opioids, alcohol, or illicit drugs – even when taken at recommended doses – even over the course of only days/weeks.

Akathisia may occur when stopping, starting, or changing the dosage or type of certain medications, and it may have a delayed onset. Akathisia is characterized by a feeling of inner restlessness and a compelling need or urge to be in constant movement (fidgeting, rocking, pacing, etc).​

Symptoms are often overlooked or mistaken as signs of new or worsening agitation, depression, or anxiety. It may be wrongly treated by raising the dose or adding new drugs as a result. It is important to learn about the causes and symptoms of akathisia to ensure it is promptly identified.

Patients with akathisia should be closely monitored due to suicide risk. Inner restlessness is experienced as distressing and may be expressed as impatience, apprehension, dysphoria, irritation, anger, rage, tension, confusion, fear, vague somatic complaints, dyspnea, or difficulty concentrating.

Other prominent symptoms may include exacerbation of hallucinations or delusions, manic activity, disruptive behavior, panic attacks, acting out, or self-destructive behaviors such as head banging. Such symptoms may be attributed to an underlying condition and/or mask akathisia.

Akathisia is most commonly understood and recognized in relation to the prescription of antipsychotic medications, but it can occur with medications prescribed for acne, depression, asthma, nausea, anxiety, malaria, insomnia, smoking cessation, high blood pressure, and others.

Akathisia has also been found more recently to occur as an adverse effect of calcium channel blockers, antiemetics, anti-vertigo drugs, and sedatives used in anesthesia. It may also occur with cocaine, methamphetamine, MDMA, ecstasy, and GHB.

People with any history of TBI may have an elevated suicide risk. TBI may also lead to akathisia. Other medical issues that may increase the risk for experiencing akathisia include hyperthyroidism, renal impairment, diabetes, iron deficiency anemia, Parkinson’s disease, and peripheral neuropathy.

Community Resources for Akathisia

• The Medication-Induced Suicide Prevention and Education Foundation (MISSD) offers educational materials and a training with CE credit focused on recognizing akathisia. MISSD works to raise awareness of medication-induced suicide.

• The Inner Compass Initiative offers information and a Help Hub for people having a psychiatric drug withdrawal journey and Quick Tips for coping with akathisia.

• The Akathisia Alliance offers general information about benzodiazepines and akathisia for clinicians, family, and friends.

The Benzodiazepine Information Coalition offers resources and information about akathisia and benzodiazepines, including Benzodiazepines: How They Work and How To Withdraw (ie, “The Ashton Manual”). 

The goal of AWP’s OpDD™ research is to:

• identify current/former service members with the highest probability of dying prematurely at a national/state/local level by correlating state death record data to detailed military experiences shared by DoD;

• identify community environments that contribute to lower or higher premature deaths (ie, overdose, asphyxiation, accidental gunshot, drowning, suicide by law enforcement, or high-speed, single-driver accident) through qualitative interviews with friends, families, and co-workers to re-construct the deceased veteran’s last year;

• identify the impact of adverse disciplinary actions on the premature death of current and former service members; and

• use the findings to develop national/state/local suicide and overdose prevention strategies and identify possible changes in clinical and public health practice for former service members.

OpDD™ uses the definition of Self Injury Mortality (SIM) cited by CDC and NIH, merging registered/known suicides with accidents and undetermined deaths aligned with self-harm or suicidal behavior, which have been attributed predominantly to overdose deaths. From 2014–18, the suicide rate was 37% greater than reported by VA; states undercounted deaths at an error rate of 25%.

Refer to the OpDD™ Methodology Report for more information on the study design, methodology, data, and limitations. State Data Sheets are expected to be released. OpDD™ Annual Reports are available for 2019, 2020, 2021, and 2023.