Use of Non-Pharmacological Pain Treatment Modalities Among Veterans with Chronic Pain: Results from a Cross-Sectional Survey

BACKGROUND

Despite strong evidence for the effectiveness of non-pharmacological pain treatment modalities (NPMs), little is known about the prevalence or correlates of NPM use.

OBJECTIVE

This study examined rates and correlates of NPM use in a sample of veterans who served during recent conflicts.

DESIGN

We examined rates and demographic and clinical correlates of self-reported NPM use (operationalized as psychological/behavioral therapies, exercise/movement therapies, and manual therapies). We calculated descriptive statistics and examined bivariate associations and multivariable associations using logistic regression.

PARTICIPANTS

Participants were 460 veterans endorsing pain lasting ≥ 3 months who completed the baseline survey of the Women Veterans Cohort Study (response rate 7.7%.

MAIN MEASURES

Outcome was self-reported use of NPMs in the past 12 months.

KEY RESULTS

Veterans were 33.76 years old (SD = 10.72), 56.3% female, and 80.2% White. Regarding NPM use, 22.6% reported using psychological/behavioral, 50.9% used exercise/movement and 51.7% used manual therapies. Veterans with a college degree (vs. no degree; OR = 2.51, 95% CI = 1.46, 4.30, p = 0.001) or those with worse mental health symptoms (OR = 2.88, 95% CI = 2.11, 3.93, p < 0.001) were more likely to use psychological/behavioral therapies. Veterans who were female (OR = 0.63, 95% CI = 0.43, 0.93, p = 0.02) or who used non-opioid pain medications (OR = 1.82, 95% CI = 1.146, 2.84, p = 0.009) were more likely to use exercise/movement therapies. Veterans who were non-White (OR = 0.57, 95% CI = 0.5, 0.94, p = 0.03), with greater educational attainment (OR = 2.11, 95% CI = 1.42, 3.15, p < 0.001), or who used non-opioid pain medication (OR = 1.71, 95% CI = 1.09, 2.68, p = 0.02) were more likely to use manual therapies.

CONCLUSIONS

Results identified demographic and clinical characteristics among different NPMs, which may indicate differences in veteran treatment preferences or provider referral patterns. Further study of provider referral patterns and veteran treatment preferences is needed to inform interventions to increase NPM utilization. Research is also need to identify demographic and clinical correlates of clinical outcomes related to NPM use.

Prescription contraception use and adherence by women with substance use disorders

BACKGROUND AND AIMS

Unintended pregnancy rates are high among women with substance use disorders (SUDs), which could be explained partly by lower use of and adherence to contraception. We aimed to test: (1) the association of SUD with prescription contraceptive use, contraceptive method selection and adherence; (2) whether practices participating in the Patient-Centered Medical Home Initiative (PCMHI) had better contraceptive use and adherence for patients with SUD; and (3) for differences in the association of SUD with adherence by type of contraceptive used.

DESIGN

Retrospective cohort analysis of claims and encounter data.

SETTING

Massachusetts, USA.

PARTICIPANTS

A total of 47 902 women aged 16-45 years enrolled in Medicaid or Commonwealth Care in Massachusetts between 2010 and 2014.

MEASUREMENTS

We examined three dependent variables: (1) use of a reversible prescription contraceptive during 2012; (2) the contraceptive methods used; and (3) the proportion of days covered by a prescription contraceptive in the year following the first prescription contraceptive claim. The primary predictor was diagnosed SUD, defined as at least one claim for an alcohol or drug use disorder.

FINDINGS

SUD was associated with lower rates of prescription contraceptive use during 2012 [19.2 versus 23.9%; adjusted odds ratio (aOR) = 0.79, P < 0.001]. SUD was associated with decreased selection of long-acting reversible contraception (LARC) compared with short-acting contraception (SARC) (42.8 versus 44.5%; aOR = 0.83, P = 0.011). There was no significant association between SUD and adherence (aOR = 0.84, P = 0.068). PCMHI enrollment did not alter the relationship between SUD and contraceptive use or adherence. Contraceptive method did not impact the relationship between SUD and adherence.

CONCLUSION

Women with substance use disorders are less likely to use prescription contraceptives, especially long-acting methods, but are not significantly less likely to adhere to them once prescribed than women without substance use disorders.

Implementing and Evaluating a Telephone-Based Centralized Maternity Care Coordination Program for Pregnant Veterans in the Department of Veterans Affairs

PURPOSE

The purpose of this study was to develop and evaluate a comprehensive, telephonic maternity care coordination (MCC) program for all pregnant veterans enrolled for care at New England Department of Veterans Affairs (VA) facilities that comprise the Veterans Integrated Service Network 1.

RESEARCH DESIGN

Telephone interviews were conducted with postpartum women veterans who had participated in the MCC program during their pregnancies. The program evaluation instrument assessed satisfaction and use of MCC services, prenatal education classes, and infant and maternal outcomes (e.g., newborn birthweight, insurance status, maternal depression) using both closed-ended and open-ended questions.

RESULTS

A substantial majority (95%) of women enrolled in the MCC program expressed satisfaction with the services they received in the program. Women were most satisfied with help understanding VA maternity benefits and acquiring VA services and equipment, such as breast pumps and pregnancy-related medications. More than one-third of women noted their infants had experienced health problems since delivery, including neonatal intensive care unit hospitalizations. A majority of women planned to return to VA care in the future.

CONCLUSIONS

Our findings suggest that MCC services play an important role for women veterans as they navigate both VA and non-VA care systems. MCC staff members coordinated maternity, medical, and mental health care services for women veterans. Additionally, by maintaining contact with the veteran during the postpartum period, MCC staff were able to assess the health of the mother and the infant, and refer women and their infants to medical and psychosocial services in the community as needed.

Hysterectomy and Bilateral Salpingo-Oophorectomy: Variations by History of Military Service and Birth Cohort

INTRODUCTION

Little is known about hysterectomy and bilateral salpingo-oophorectomy (BSO), which are associated with both health risks and benefits, among women Veterans.

PURPOSE OF THE STUDY

To compare the prevalence of hysterectomy with or without BSO, and early hysterectomy, between postmenopausal Veterans and non-Veterans.

DESIGN AND METHODS

We used baseline data from the Women's Health Initiative Clinical Trial and Observational Study. Multinomial logistic regression models examined differences in the prevalence of hysterectomy (neither hysterectomy nor BSO, hysterectomy without BSO, and hysterectomy with BSO) between Veterans and non-Veterans. Generalized linear models were used to determine whether early hysterectomy (before age 40) differed between Veterans and non-Veterans. Analyses were stratified by birth cohort (<65, ≥65 years at enrollment).

RESULTS

The unadjusted prevalence of hysterectomy without BSO was similar among Veterans and non-Veterans in both birth cohorts (<65: 22% vs 21%; ≥65: 22% vs 21%). The unadjusted prevalence of hysterectomy with BSO was equivalent among Veterans and non-Veterans in the >65 cohort (21%), but higher among Veterans in the <65 cohort (22% vs 19%). In adjusted analyses, although no differences were observed in the >65 cohort, Veterans in the <65 cohort had higher odds of hysterectomy without BSO (odds ratio [OR] 1.18, 95% confidence interval [CI] 1.03, 1.36) and with BSO (OR 1.26, 95% CI 1.10, 1.45), as well as elevated risk of early hysterectomy (relative risk 1.32, 95% CI 1.19, 1.47), compared with non-Veterans.

IMPLICATIONS

Aging women Veterans may have higher prevalence of hysterectomy and BSO than non-Veterans. This information contributes to understanding the health needs and risks of women Veterans and can inform clinical practice and policy for this population.

Smoking Status and Pain Intensity Among OEF/OIF/OND Veterans

OBJECTIVE

Pain and smoking are highly prevalent among Veterans. Studies in non-Veteran populations have reported higher pain intensity among current smokers compared with nonsmokers and former smokers. We examined the association of smoking status with reported pain intensity among Veterans of Operations Enduring Freedom, Iraqi Freedom, and New Dawn (OEF/OIF/OND).

DESIGN

The sample consisted of OEF/OIF/OND Veterans who had at least one visit to Veterans Affairs (2001-2012) with information in the electronic medical record for concurrent smoking status and pain intensity. The primary outcome measure was current pain intensity, categorized as none to mild (0-3); moderate (4-6); or severe (≥7); based on a self-reported 11-point pain numerical rating scale. Multivariable logistic regression analyses were used to assess the association of current smoking status with moderate to severe (≥4) pain intensity, controlling for potential confounders.

RESULTS

Overall, 50,988 women and 355,966 men Veterans were examined. The sample mean age was 30 years; 66.3% reported none to mild pain; 19.8% moderate pain; and 13.9% severe pain; 37% were current smokers and 16% former smokers. Results indicated that current smoking [odds ratio (OR) = 1.29 (95% confidence intervals (CI) = 1.27-1.31)] and former smoking [OR = 1.02 (95% CI = 1.01-1.05)] were associated with moderate to severe pain intensity, controlling for age, service-connected disability, gender, obesity, substance abuse, mood disorders, and Post Traumatic Stress Disorder.

CONCLUSIONS

We found an association between current smoking and pain intensity. This effect was attenuated in former smokers. Our study highlights the importance of understanding reported pain intensity in OEF/OIF/OND Veterans who continue to smoke.

Perceived Stigma, Discrimination, and Disclosure of Sexual Orientation Among a Sample of Lesbian Veterans Receiving Care in the Department of Veterans Affairs

PURPOSE

Many lesbian women experience stigma and discrimination from their healthcare providers as a result of their sexual orientation. Additionally, others avoid disclosure of their sexual orientation to their providers for fear of mistreatment. With the increasing number of lesbian, gay, bisexual, and transgender (LGBT) veterans seeking care from the Veterans Health Administration (VHA), it is important to understand lesbian veterans' experiences with stigma, discrimination, and disclosure of sexual orientation. This article examines lesbian veterans' experiences with perceived stigma and discrimination in VHA healthcare, their perspectives on disclosure of sexual orientation to VHA providers, and their recommendations for improvements in VHA healthcare to create a welcoming environment for lesbian veterans.

METHODS

This is a mixed methods study of twenty lesbian veterans at four VHA facilities. The women veterans participated in a one-hour interview and then completed an anonymous survey.

RESULTS

Ten percent of lesbian veterans had experienced mistreatment from VHA staff or providers, but nearly 50% feared that their Veterans Affairs (VA) providers would mistreat them if they knew about their sexual orientation. A majority of lesbian veterans (70%) believed that VHA providers should never ask about sexual orientation or should only ask if the veteran wanted to discuss it. A majority (80%) believed the VHA had taken steps to create a welcoming environment for LBGT veterans.

CONCLUSION

Though many lesbian veterans have fears of stigma and discrimination in the context of VHA care, few have experienced this. Most lesbian veterans believed the VHA was trying to create a welcoming environment for its LGBT veterans. Future research should focus on expanding this study to include a larger and more diverse sample of lesbian, gay, bisexual, and transgender veterans receiving care at VA facilities across the country.

Social support throughout the deployment cycle for women veterans returning from Iraq and Afghanistan

Social support throughout the deployment cycle and the challenges of readjustment to civilian life for veterans returning from Operation Iraqi Freedom and Operation Enduring Freedom were explored. Eighteen participants from the New England and Indiana Veterans Administration catchment area were interviewed using a semi-structured interview guide. All participants identified perceptions of social support but their utilization of these supports was compromised due to the need to protect family and friends from the strain of war, post-traumatic stress symptoms, and depressive symptoms. Resilience, fortitude, and commitment to their military mission were evidenced by all the women of this study. Implications for future service delivery are identified.

Improving care of chronic conditions for women veterans: identifying opportunities for comparative effectiveness research

This article aims to critically analyze research focused on the findings for five chronic conditions: chronic pain, diabetes, cardiovascular disease, HIV and cancer among women veterans to identify opportunities for comparative effectiveness research. We provide a descriptive analysis from the relevant articles in prior systematic reviews. In order to identify potential gaps in research for these specific conditions, we also conducted a literature search to highlight studies focusing on women veterans published since the last systematic review. While the scientific knowledge base has grown for these chronic conditions among women veterans, the vast majority of the published literature remains descriptive and/or observational, with only a few studies examining gender differences and even fewer clinical trials. There is a need to conduct comparative effectiveness research on chronic conditions among women veterans to improve health and healthcare.

Personal health record use and its association with antiretroviral adherence: survey and medical record data from 1871 US veterans infected with HIV

Patient electronic personal health record (PHR) use has been associated with improved patient outcomes in diabetes and depression care. Little is known about the effect of PHR use on HIV care processes and outcomes. We evaluated whether there was an association between patient PHR use and antiretroviral adherence. Data came from the Veterans Aging Cohort Study and included cross-sectional survey and medical record data from 1871 HIV+ veterans. Our adherence measure was an antiretroviral medication possession ratio, dichotomized at 0.90, and based on pharmacy refill data. In our sample 44 % did not use the internet, 14 % used internet but not for health, 27 % used internet for health but not the PHR, and 14 % used the PHR. In multivariable analysis PHR use was associated with ≥90 % adherence after controlling for socio-demographic variables. Findings provide support for longitudinal studies and studies that identify which PHR functions (e.g. online medication refills, viewing lab results, secure messaging with providers) are most closely associated with medication adherence.

High-risk behavior and sexually transmitted infections among U.S. active duty servicewomen and veterans

The number of women who are active duty service members or veterans of the U.S. military is increasing. Studies among young, unmarried, active duty servicewomen who are sexually active indicate a high prevalence of risky sexual behaviors, including inconsistent condom use, multiple sexual partners, and binge drinking, that lead to unintended and unsafe sex. These high-risk sexual practices likely contribute to chlamydia infection rates that are higher than the rates in the U.S. general population. Human papillomavirus (HPV) infection and cervical dysplasia may also be higher among young, active duty servicewomen. Little is known about the sexual practices and rates of sexually transmitted infections among older servicewomen and women veterans; however, women veterans with a history of sexual assault may be at high risk for HPV infection and cervical dysplasia. To address the reproductive health needs of military women, investigations into the prevalence of unsafe sexual behaviors and consequent infection among older servicewomen and women veterans are needed. Direct comparison of military and civilian women is needed to determine if servicewomen are a truly high-risk group. Additionally, subgroups of military women at greatest risk for these adverse reproductive health outcomes need to be identified.

Women at war: understanding how women veterans cope with combat and military sexual trauma

The wars in Iraq (Operation Iraqi Freedom, OIF) and Afghanistan (Operation Enduring Freedom, OEF) have engendered a growing population of US female veterans, with women now comprising 15% of active US duty military personnel. Women serving in the military come under direct fire and experience combat-related injuries and trauma, and are also often subject to in-service sexual assaults and sexual harassment. However, little is known regarding how women veterans cope with these combat and military sexual trauma experiences once they return from deployment. To better understand their experiences, we conducted semi-structured interviews with nineteen OEF/OIF women veterans between January-November 2009. Women veterans identified stressful military experiences and post-deployment reintegration problems as major stressors. Stressful military experiences included combat experiences, military sexual trauma, and separation from family. Women had varying abilities to address and manage stressors, and employed various cognitive and behavioral coping resources and processes to manage their stress.

Pregnancy and mental health among women veterans returning from Iraq and Afghanistan

BACKGROUND

Veterans of Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) may experience significant stress during military service that can have lingering effects. Little is known about mental health problems or treatment among pregnant OEF/OIF women veterans. The aim of this study was to determine the prevalence of mental health problems among veterans who received pregnancy-related care in the Veterans Health Administration (VHA) system.

METHODS

Data from the Defense Manpower Data Center (DMDC) deployment roster of military discharges from October 1, 2001, through April 30, 2008, were used to assemble an administrative cohort of female OEF/OIF veterans enrolled in care at the VHA (n = 43,078). Pregnancy and mental health conditions were quantified according to ICD-9-CM codes and specifications. Mental healthcare use and prenatal care were assessed by analyzing VHA stop codes.

RESULTS

During the study period, 2966 (7%) women received at least one episode of pregnancy-related care, and 32% of veterans with a pregnancy and 21% without a pregnancy received one or more mental health diagnoses (p < 0.0001). Veterans with a pregnancy were twice as likely to have a diagnosis of depression, anxiety, posttraumatic stress disorder (PTSD), bipolar disorder, or schizophrenia as those without a pregnancy.

CONCLUSIONS

Women OEF/OIF veterans commonly experience mental health problems after military service. The burden of mental health conditions is higher among women with an identified instance of pregnancy than among those without. Because women do not receive pregnancy care at the VHA, however, little is known about ongoing concomitant prenatal and mental healthcare or about pregnancy outcomes among these women veterans.

Drug toxicity, HIV progression, or comorbidity of aging: does tipranavir use increase the risk of intracranial hemorrhage?

The US Food and Drug Administration has issued a warning that tipranavir may be associated with increased risk of intracranial hemorrhage. We studied 2 large cohorts to estimate the background rate of intracranial hemorrhage and compared it with rates reported among persons who had been exposed to tipranavir.

Placebos, active control groups, and the unpredictability paradox

Randomized controlled trials often rely on placebo control groups to estimate treatment differences. Recently, the high frequency of negative trials and ethical concerns surrounding the use of placebos have brought the use of placebo control groups under increased scrutiny. Although many psychiatric researchers argue that placebo control groups should be replaced with active control groups, we argue that preferential use of active control groups will not reduce the number of negative trials. Rather, we suggest that some of the variation and contradiction in randomized controlled trial results arises from the clinical heterogeneity of patient characteristics, disease severity, comorbidity, and cotherapies. Further characterization of patient heterogeneity, through improved disease taxonomies, severity indices, and classification of comorbid diseases, will serve to reduce clinical heterogeneity among patients and reduce the number of negative trials produced by wide variation in treatment and control response rates.

Eradication of large colon tumor xenografts by targeted delivery of maytansinoids

The maytansinoid drug DM1 is 100- to 1000-fold more cytotoxic than anticancer drugs that are currently in clinical use. The immunoconjugate C242-DM1 was prepared by conjugating DM1 to the monoclonal antibody C242, which recognizes a mucin-type glycoprotein expressed to various extents by human colorectal cancers. C242-DM1 was found to be highly cytotoxic toward cultured colon cancer cells in an antigen-specific manner and showed remarkable antitumor efficacy in vivo. C242-DM1 cured mice bearing subcutaneous COLO 205 human colon tumor xenografts (tumor size at time of treatment 65-130 mm3), at doses that showed very little toxicity and were well below the maximum tolerated dose. C242-DM1 could even effect complete regressions or cures in animals with large (260- to 500-mm3) COLO 205 tumor xenografts. Further, C242-DM1 induced complete regressions of subcutaneous LoVo and HT-29 colon tumor xenografts that express the target antigen in a heterogeneous manner. C242-DM1 represents a new generation of immunoconjugates that may yet fulfill the promise of effective cancer therapy through antibody targeting of cytotoxic agents.

Enhancement of the selectivity and antitumor efficacy of a CC-1065 analogue through immunoconjugate formation

Bis-indolyl-(seco)-1,2,9a-tetrahydrocyclopropa[c]benz[e]indol-4-on e compounds are synthetic analogues of CC-1065 that are highly cytotoxic toward a broad spectrum of tumor cell lines. One of these compounds, called DC1, was conjugated to antibodies via novel cleavable disulfide linkers. Conjugates of DC1 with murine mAbs anti-B4 and N901 directed against tumor-associated antigens CD19 and CD56, respectively, proved to be extremely potent and antigen selective in killing target cells in culture. DC1 conjugates with humanized versions of anti-B4 and N901 antibodies were also constructed and demonstrated to be as cytotoxic and selective as the respective murine antibody conjugates. The anti-B4-DC1 conjugate showed antitumor efficacy in an aggressive metastatic human B-cell lymphoma survival model in SCID mice and completely cured animals hearing large tumors. Anti-B4-DC1 was considerably more effective in this tumor model than doxorubicin, cyclophosphamide, etoposide, or vincristine at their maximum tolerated doses.