Do postconcussive symptoms from traumatic brain injury in combat veterans predict risk for receiving opioid therapy for chronic pain?

Objectives: Opioid therapy is contraindicated in patients with traumatic brain injury (TBI) with neuropsychological impairment, yet guidelines do not consistently predict practice. We evaluated independent risk for initiation of opioid therapy among combat veterans with chronic pain diagnoses and persistent postconcussive symptoms.Methods: We assembled a retrospective cohort of 53124 Iraq and Afghanistan veterans in Veterans Affairs (VA) healthcare between October 2007 and March 2015 who received chronic pain diagnoses, completed a Comprehensive TBI Evaluation (CTBIE) and had not received opioid therapy in the prior year. Primary exposure variables were self-reported severe or very severe Emotional, Vestibular, Cognitive and Somatic/Sensory symptoms measured using the Neurobehavioral Symptom Inventory. Outcome measures were initiation of short-term and long-term opioid therapy within the year following CTBIE.Results: Self-reported severe and very severe postconcussive symptoms predicted initiation of long-term and short-term opioid use for chronic pain in both unadjusted and adjusted analyses. In adjusted analyses, all four postconcussive symptom domains significantly predicted initiation of long-term opioid therapy, with Emotional symptoms being the strongest predictor [ARR=1.68 (1.52, 1.86)].Conclusions: Increased opioid prescribing in veterans with self-reported severe persistent postconcussive symptoms indicates a need to educate prescribers and make non-opioid pain management options available for veterans with TBI and neuropsychological sequelae.