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Morphine after Combat Injury and Post-Traumatic Stress Disorder
To the Editor: As medical providers currently deployed in Iraq, we read the article by Holbrook et al. (Jan. 14 issue)1 with great interest. If confirmed, the association of morphine use with reductions in post-traumatic stress disorder (PTSD)would provide another important indication for the administration of morphine to battlefield casualties. We note that the investigators analyzed morphine use in level 1 or 2 facilities and that the morphine was administered intravenously in 98% of recipients. First, clinicians would benefit from knowing whether morphine was associated with adverse outcomes among patients treated at the facilitiesstudied. Second, it is standard training for Navy corpsmen and Army medics to administer morphine and oral transmucosal fentanyl to patients before they reach these facilities.2 If opiates were commonly administered before the injured personnel in the study arrived at these facilities, this omission from analysis could significantly affect study conclusions. In addition, the “fragments from blast —NOS [not otherwise specified]” mechanism of injury was independently and strongly associated with the absence of PTSD in both models 1 and 2. Although we acknowledge that the numbers of injuries incurred through this mechanism were small, knowledge of the circumstances surrounding these injuries might lead to testable hypotheses for research aimed at elucidating factors associated with PTSD.Robert J. O’Connell, M.D. James P. Winstead, M.P.A.S., P.A.-C. Joseph M. Matthews, M.D., M.P.H.–T.M.
82nd Airborne Division U.S. Army Iraq roconnell@hivresearch.org No potential conflict of interest relevant to this letter was reported. The opinions expressed here are those of the authors and do not necessarily represent those of the Department of the Army or the Department of Defense.
1. HolbrookTL, Galarneau MR, Dye JL, Quinn K, Dougherty AL.

Morphine use after combat injury in Iraq and post-traumatic stress disorder. N Engl J Med 2010;362:110-7. 2. Black IH, McManus J. Pain management in current combat operations. Prehosp Emerg Care 2009;13:223-7.

To the Editor: We welcome the report from Holbrook and colleagues that the use of morphine during early resuscitation may reduce the riskof PTSD developing after trauma. This finding supports the intuitive use of multimodal analgesia (including fentanyl and ketamine) in military personnel with severe injuries. Although the authors found no association between the use of benzodiazepines and the onset of PTSD, at our deployed military hospital, midazolam is commonly used in small doses as an anesthetic co-induction agent,principally for its amnesic effects. Holbrook and colleagues suggest that the effect of morphine may not be specific in the secthis week’s letters 1341 Morphine after Combat Injury and PostTraumatic Stress Disorder 1342 Preoperative Drainage in Pancreatic Cancer 1346 Nosocomial Bacterial Meningitis 1348 Large Islets, Beta-Cell Proliferation, and a Glucokinase Mutation

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ondary prevention of PTSD. We encourage the authors to continue interrogating their database todetermine whether or not fentanyl and ketamine are as effective. Jonathan Schofield, M.R.C.P. Andrew M. Johnston, M.R.C.P.I. Winston F. de Mello, F.R.C.A.
Joint Force Medical Group Camp Bastion, Afghanistan jschofield@doctors.org.uk No potential conflict of interest relevant to this letter was reported.

To the Editor: It seems curious that a sizable proportion of troops injured on the...