Traumatic stress is common in American life. 80% of adult Americans will experience one or more traumatic events in their lifetimes. Of these, 13% of women and 6% of men will develop post-traumatic stress disorder. Think of trauma as any event where one is exposed to actual or threatened death, serious injury, or sexual violence. Moreover, post-traumatic stress can occur when one witnesses trauma in a loved one, or repeated exposure to a level of trauma in the workplace. Post-traumatic stress disorder (PTSD) manifests as re-experiencing of the traumatic event, avoidance of anything that reactivates the trauma in memory, blunted emotional responsiveness, and changes in triggering or severity of arousal and/or reactivity. It is helpful to see PTSD as a chronic disease, as up to 50% of individuals with PTSD will have it for their lifetimes.
Individuals with PTSD have numerous associated co-morbidities including higher rates of diabetes, cardiovascular disease, and dementia, as well as psychiatric hospitalizations, unemployment, and suicide. A PTSD-afflicted individual is also much more likely to engage in substance use, up to 14 times more likely. Conversely, in patients seeking substance use disorder treatment, 30-60% will have PTSD. Several theories have been offered to explain the strikingly strong relationship between PTSD and substance use. The most common is that PTSD patients use substances such as opioids to self-medicate, to manage their symptoms of anxiety and depression. A second theory is that substance users are predisposed because of lifestyle to encounter more traumatic events.
How do you diagnose PTSD? Beyond clinical suspicions that arise from the history, two screening tools are very useful. The Primary Care PTSD Screen (PC-PTSD) is a four item questionnaire. If any three items are answered “yes,” the individual probably has PTSD. It has a positive predictive value (PPV) of 62% and a negative predictive value (NPV) of 94%. It can be found on the Substance Abuse and Mental Health Services Administration website at: http://www.integration.samhsa.gov/clinical-practice/PC-PTSD.pdf
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Four Questions to Screen for PTSD
1. Have you nightmares about the event or thought about it when you did not want to?
2. Have you tried hard not to think about it or went out of your way to avoid situations that reminded you of it?
3. Are you constantly on guard, watchful, or easily startled?
4. Have you felt numb or detached from others, activities, or your surroundings?
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A second valuable diagnostic tool is the PTSD Checklist developed by the Veterans Administration with a civilian version available at http://www.mirecc.va.gov/docs/visn6/3_PTSD_CheckList_and_Scoring.pdf. This is 17 item, self-administered instrument. Scores can range from 17-85. Scores over 50 predict PTSD. The PPV is 58 and the NPV is 98, very similar to the PC-PTSD instrument.
How is opioid use managed in patients with PTSD? The key is to recognize that these two conditions are intimately linked, and benefit from integrated behavioral-pain management. Rather than only continuing to write chronic opioid prescriptions or wrestle with difficult opioid taper regimens, screen for PTSD and, if present, refer patients to behavioral therapy as well. Where there are truly integrated services that bring together behavioral and pain management specialists, refer your patients to them early after diagnosis.
Scott Endsley, MD