Friday, January 15, 2010

Post Traumatic Stress Disorder And Morphine

The New York Times reported Wednesday about an article that appeared in the New England Journal of Medicine talking about post traumatic stress disorder and morphine. I do not get the New England Journal so I haven't seen the article itself yet but I want to make a few comments about what was reported.

A record review study of 696 servicemen and women who were wounded in Iraq between 2004 and 2006 noted that those who received prompt treatment with morphine had roughly half the chance of developing post traumatic stress symptoms (PTSD) within the first two years following the injury. Out of the 696 wounded 243 developed
PTSD which in itself is an alarming figure but those that received morphine within generally two hours after the injury fared better than those who did not.

Why does morphine help? My guess is that it works by inhibiting the excessive firing of the amygdala under stress. The amygdala is a group of cells in the front portion of both temporal lobes and as far as we know is responsible for the overall emotional tone we associate with events. It is also known as the "fear center" of the brain. The amygdala is next to and highly linked with the hippocampus which is responsible for encoding memories. Our current understanding then is that an event that gets encoded as a memory by the hippocampus will be encoded with a greater strength as well as with a connection to fear if the amygdala is highly active during the event.

There are some problems with this study though that need to be sorted out with further work before we can recommend morphine for non combat traumas. It has been noted that the same benefit of morphine has been seen in children at burn centers. The problems with this post traumatic stress disorder morphine study first of all is that it is a record review, a retrospective study which is never as beneficial as a prospective study. Secondly we may be confusing association with causation. These were men and women injured in combat. It may be that quick and adequate pain control is responsible for the effect on trauma. This makes sense with burned children as well. The trauma could be the pain itself especially as many of the wounded here did not get adequate morphine pain relief until well after two hours of the injury. It was also noted that many of the wounded received anti-anxiety medication as well so it may be length of time to receive help after a combat wound is the determining factor rather that the morphine itself.

I hope to be able to read the New England Journal article itself soon. Some of these issues may be addressed there. It is important that further work be carried out in this area as the symptoms of post traumatic stress disorder can be devastating and disabling and there are many more sorts of trauma than combat injuries and burn injuries.

Thought for the day

Every day is new with possibility.

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