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Xi D, Berger A, Shurtleff D, Zia FZ, Belouin S. National Institutes of Health psilocybin research speaker series: State of the science, regulatory and policy landscape, research gaps, and opportunities. Neuropharmacology 2023; 230:109467. [PMID: 36858149 PMCID: PMC10163373 DOI: 10.1016/j.neuropharm.2023.109467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 02/08/2023] [Accepted: 02/16/2023] [Indexed: 03/02/2023]
Abstract
The U.S. National Institutes of Health (NIH) convened a seminal first ever psychedelic drug substance-focused speaker series, from April 22 to June 10, 2021, titled the "NIH Psilocybin Research Speaker Series." This speaker series provided evidence-based scientific information to the public and the scientific community. Its aims were to assess the current state of the science, the regulatory and policy landscape, as well as to identify gaps in knowledge and understanding, ultimately serving to define future research needs. The highlights of the lectures and discussion from 26 national and international distinguished experts served as the basis for this Special Issue of Neuropharmacology. This article is part of the Special Issue on "National Institutes of Health Psilocybin Research Speaker Series".
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Affiliation(s)
- Dan Xi
- National Institutes of Health (NIH), National Cancer Institute (NCI), Division of Cancer Treatment and Diagnosis (DCTD), Office of Cancer Complementary and Alternative Medicine (OCCAM), Rockville, MD, USA.
| | - Ann Berger
- NIH Clinical Research Center, Pain and Palliative Care, Bethesda, MD, USA.
| | - David Shurtleff
- NIH, National Center for Complementary and Integrative Health (NCCIH), Bethesda, MD, USA.
| | - Farah Z Zia
- National Institutes of Health (NIH), National Cancer Institute (NCI), Division of Cancer Treatment and Diagnosis (DCTD), Office of Cancer Complementary and Alternative Medicine (OCCAM), Rockville, MD, USA.
| | - Sean Belouin
- NIH Clinical Research Center, Pain and Palliative Care, Bethesda, MD, USA; United States Public Health Service (USPHS), Germantown, MD, USA; Substance Abuse and Mental Health Services Administration (SAMHSA), Rockville, MD, USA.
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Saconi B, Kuna ST, Polomano RC, Compton PA, Keenan BT, Sawyer AM. Chronic pain is common and worsens daytime sleepiness, insomnia, and quality of life in veterans with obstructive sleep apnea. J Clin Sleep Med 2023; 19:1121-1132. [PMID: 36798982 PMCID: PMC10235723 DOI: 10.5664/jcsm.10516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 02/13/2023] [Accepted: 02/14/2023] [Indexed: 02/18/2023]
Abstract
STUDY OBJECTIVES Chronic noncancer pain (CP) commonly co-occurs with obstructive sleep apnea (OSA) and may contribute to greater symptom burden. The study aims were to (1) characterize CP among veterans with OSA and (2) examine differences in sleepiness (Epworth Sleepiness Scale), insomnia symptoms (Insomnia Severity Index), and quality of life (Short Form Health Survey-20) in veterans with OSA with or without pre-existing CP. METHODS An observational, cross-sectional, study of 111 veterans with newly diagnosed, untreated OSA was conducted. Descriptive statistics characterized the sample and comorbid CP outcomes. Regression analyses were performed to investigate associations between self-reported CP and sleep-related symptoms or quality of life while controlling for potential confounders. RESULTS CP was reported by 69.5% (95% confidence interval: 61.8%, 76.2%) of participants. Having CP was associated with increased Epworth Sleepiness Scale (12.7 ± 5.5 vs 10.2 ± 5.2; P = .021) and Insomnia Severity Index scores (18.1 ± 6.2 vs 13.7 ± 7.4; P = .002), and worse quality of life across all Short Form Health Survey-20 domains. CONCLUSIONS There is a high prevalence of CP among veterans with OSA and symptom burden is higher in patients with OSA and CP. Future investigations should address symptom response and burden to OSA treatment in comorbid OSA and CP to guide outcome expectancies and residual OSA symptom treatment plans. CITATION Saconi B, Kuna ST, Polomano RC, Compton PA, Keenan BT, Sawyer AM. Chronic pain is common and worsens daytime sleepiness, insomnia, and quality of life in veterans with obstructive sleep apnea. J Clin Sleep Med. 2023;19(6):1121-1132.
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Affiliation(s)
- Bruno Saconi
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Samuel T. Kuna
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
- University of Pennsylvania Perelman School of Medicine Center for Sleep and Circadian Neurobiology, Philadelphia, Pennsylvania
| | - Rosemary C. Polomano
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Peggy A. Compton
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Brendan T. Keenan
- Division of Sleep Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Amy M. Sawyer
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
- Division of Sleep Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Haun JN, Fowler CA, Venkatachalam HH, Saenger MS, Alman AC, Smith BM, Schneider T, Benzinger R, Stroupe K, French DD. Empower Veterans Program (EVP): a chronic pain management program demonstrates positive outcomes among veterans. BMC Health Serv Res 2023; 23:431. [PMID: 37138319 PMCID: PMC10155644 DOI: 10.1186/s12913-023-09327-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 03/22/2023] [Indexed: 05/05/2023] Open
Abstract
BACKGROUND Chronic pain is a highly prevalent health condition among veterans. Traditional pharmacological interventions present unique challenges for chronic pain management including prescription opioid addiction and overdose. In alignment with the 2016 Comprehensive Addiction and Recovery Act and VA's Stepped Care Model to meet veterans' pain management needs, the Offices of Rural Health and Pain Management, Opioid Safety, and Prescription Drug Monitoring Program (PMOP) funded an enterprise-wide initiative to implement a Step 3 integrated tele-pain program: Empower Veterans Program (EVP). EVP provides veterans with chronic pain self-care skills using a whole health driven approach to pain management. OBJECTIVES The Comprehensive Addiction and Recovery Act prompted the strategic approach to offer non-pharmacological options to meet veterans' pain management needs. EVP, a 10-week interdisciplinary group medical appointment, leverages Acceptance and Commitment Therapy, Mindful Movement, and Whole Health to provide veterans with chronic pain self-care skills. This evaluation was conducted to describe participant characteristics, graduation, and satisfaction rates; and assess pre-post patient-reported outcomes (PRO) associated with EVP participation. METHODS A sample of 639 veterans enrolled in EVP between May, 2015 and December, 2017 provided data to conduct descriptive analyses to assess participant demographics, graduation, and satisfaction rates. PRO data were analyzed using a within-participants pre-post design, and linear mixed-effects models were used to examine pre-post changes in PRO. RESULTS Of 639 participants, 444 (69.48%) graduated EVP. Participant median program satisfaction rating was 8.41 (Interquartile Range: 8.20-9.20). Results indicate pre-post EVP improvements (Bonferroni-adjusted p < .003) in the three primary pain outcomes (intensity, interference, catastrophizing), and 12 of 17 secondary outcomes, including physical, psychological, health-related quality of life (HRQoL), acceptance, and mindfulness measures. DISCUSSION Data suggest that EVP has significant positive outcomes in pain, psychological, physical, HRQoL, acceptance, and mindfulness measures for veterans with chronic pain through non-pharmacological means. Future evaluations of intervention dosing effect and long-term effectiveness of the program is needed.
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Grants
- OMAT ID# 16403,16404, 16405, 16489, 16490 U.S. Department of Veterans Affairs
- OMAT ID# 16403,16404, 16405, 16489, 16490 U.S. Department of Veterans Affairs
- OMAT ID# 16403,16404, 16405, 16489, 16490 U.S. Department of Veterans Affairs
- OMAT ID# 16403,16404, 16405, 16489, 16490 U.S. Department of Veterans Affairs
- OMAT ID# 16403,16404, 16405, 16489, 16490 U.S. Department of Veterans Affairs
- OMAT ID# 16403,16404, 16405, 16489, 16490 U.S. Department of Veterans Affairs
- OMAT ID# 16403,16404, 16405, 16489, 16490 U.S. Department of Veterans Affairs
- OMAT ID# 16403,16404, 16405, 16489, 16490 U.S. Department of Veterans Affairs
- OMAT ID# 16403,16404, 16405, 16489, 16490 U.S. Department of Veterans Affairs
- OMAT ID# 16403,16404, 16405, 16489, 16490 U.S. Department of Veterans Affairs
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Affiliation(s)
- Jolie N Haun
- Research and Development Service, James A. Haley Veterans' Hospital, 8900 Grand Oak Circle, Tampa, FL, 33637, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah, 295 Chipeta Way, Salt Lake City, UT, 84132, USA
| | - Christopher A Fowler
- Research and Development Service, James A. Haley Veterans' Hospital, 8900 Grand Oak Circle, Tampa, FL, 33637, USA.
- Department of Psychiatry and Behavioral Neurosciences, University of South Florida, 3515 E. Fletcher Ave, Tampa, FL, 33613, USA.
| | - Hari H Venkatachalam
- Research and Development Service, James A. Haley Veterans' Hospital, 8900 Grand Oak Circle, Tampa, FL, 33637, USA
| | - Michael S Saenger
- Anesthesia Service Line, Atlanta Veterans Administration Health Care System, 1670 Clairmont Rd, Decatur, GA, 30033, USA
- Division of Internal Medicine, School of Medicine, Emory University, 201 Dowman Dr, Atlanta, GA, 30322, USA
| | - Amy C Alman
- Research and Development Service, James A. Haley Veterans' Hospital, 8900 Grand Oak Circle, Tampa, FL, 33637, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah, 295 Chipeta Way, Salt Lake City, UT, 84132, USA
| | - Bridget M Smith
- Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital, 5000 South 5th Ave, Hines, IL, 60141, USA
| | - Tali Schneider
- Research and Development Service, James A. Haley Veterans' Hospital, 8900 Grand Oak Circle, Tampa, FL, 33637, USA
| | - Rachel Benzinger
- Research and Development Service, James A. Haley Veterans' Hospital, 8900 Grand Oak Circle, Tampa, FL, 33637, USA
| | - Kevin Stroupe
- Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital, 5000 South 5th Ave, Hines, IL, 60141, USA
| | - Dustin D French
- Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital, 5000 South 5th Ave, Hines, IL, 60141, USA
- Center for Health Services and Outcomes Research, Feinberg School of Medicine, Northwestern University, 633 N. St. Clair St. Suite 2000, Chicago, IL, 60611, USA
- Departments of Ophthalmology and Medical Social Sciences, Feinberg School of Medicine, Northwestern University, 645 N. Michigan Ave. Suite 440, Chicago, IL, 60611, USA
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Taylor KA, Kapos FP, Sharpe JA, Kosinski AS, Rhon DI, Goode AP. Seventeen-Year National Pain Prevalence Trends Among U.S. Military Veterans. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.03.27.23287408. [PMID: 37034604 PMCID: PMC10081421 DOI: 10.1101/2023.03.27.23287408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
Importance U.S. military veterans experience higher pain prevalence and severity than nonveterans. However, it is unclear how these differences have changed over time. Previous studies are limited to veterans receiving care from the Veterans Health Administration. Objective To characterize pain prevalence trends in the overall population of U.S. veterans compared to nonveterans, using nationally-representative data. Design Repeated cross-sectional study. Data: National Health Interview Survey, 2002-2018. Analysis: January 2023. Setting Population-based survey of noninstitutionalized U.S. adults. Participants Across the 17-year period, mean annual weighted population was 229.7 million adults (unweighted sample total: n=506,639; unweighted sample annual mean: n=29,802). Exposure Veteran status. Main Outcomes Crude and demographics-adjusted pain prevalence trend differences between veterans and nonveterans across five pain variables (severe headache or migraine, facial pain, neck pain, low back pain, and joint pain) and two composite variables (any pain [≥1 prevalent pain] and multiple pains [≥2 prevalent pains]). Results Weighted proportion of veterans varied from 11.48% in 2002 (highest) to 8.41% in 2017 (lowest). Across the study period, crude prevalence was generally similar or higher among veterans than nonveterans for all pain variables except for severe headache or migraine and facial pain. When equalizing age, sex, race, and ethnicity, pain prevalence among veterans remained similar or higher than nonveterans for all pain variables. From 2002 to 2018 there was an absolute increase (95% CI) in pain prevalence among veterans (severe headache or migraine: 2.0% [1.6% to 2.4%]; facial pain: 1.9% [1.4% to 2.4%]; neck pain: 4.7% [4.1% to 5.2%]; joint pain: 11.4% [10.8% to 11.9%]; low back pain: 10.3% [9.5% to 11.1%]; any pain: 10.0% [9.6% to 10.4%]; and multiple pains: 9.9% [9.2% to 10.6%]. Crude and adjusted analyses indicated prevalence of all pain variables increased more among veterans than nonveterans from 2002 to 2018. Conclusion and Relevance Veterans had similar or higher adjusted prevalence and higher rates of increase over time for all pain variables compared to nonveterans. Continued pain prevalence increase among veterans may impact healthcare utilization (within and outside of the VHA), underscoring the need for improved pain prevention and care programs for these individuals with disproportionate pain burden.
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Affiliation(s)
- Kenneth Adam Taylor
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Flavia Penteado Kapos
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington
| | - Jason Arthur Sharpe
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs (VA) Healthcare System, Durham, North Carolina
| | - Andrzej Stanislaw Kosinski
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Daniel I Rhon
- Department of Rehabilitation Medicine, School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Adam Payne Goode
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
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Ward R, Rauch SAM, Axon RN, Saenger MS. Evaluation of a non-pharmacological interdisciplinary pain rehabilitation and functional restoration program for chronic pain in veterans. Health Serv Res 2023; 58:365-374. [PMID: 36064854 PMCID: PMC10012215 DOI: 10.1111/1475-6773.14062] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To conduct a quality improvement evaluation of the Empower Veterans Program (EVP), an interdisciplinary pain rehabilitation/functional restoration program option for functional restoration for high-impact chronic pain, offered in a large metro-area Veterans Health Administration (VHA) system. DATA SOURCES VHA Corporate Data Warehouse electronic medical record data for patients treated by EVP between 2015 and 2019. EVALUATION DESIGN This retrospective design first compared EVP patients considered engaged or not engaged in completing treatment in terms of demographic characteristics and post-treatment changes in clinical measures related to opioid use and mental health. We then compared mortality risk between matched groups of treated and untreated patients with chronic pain and concurrent opioid prescriptions using propensity score matching and Cox proportional hazards methods. "Treated" in the matched groups was defined as any level of EVP participation (i.e., both engaged and not engaged). DATA COLLECTION/EXTRACTION METHODS We first identified 1053 EVP patients with 1 year of pre-and post-treatment follow-time and determined their engagement level. From those with chronic pain and prescription opioids, we matched 237 EVP patients to 375 untreated patients. PRINCIPAL FINDINGS Engaged patients (57.4% of treated patients), were somewhat older than the non-engaged (mean age 57.1 vs. 53.7, Cohen's D = 0.30), and achieved lower mean PHQ9 depression scores in the post-treatment year (9.2 vs. 10.6, Cohen's D = 0.20). Participation in EVP was associated with a 65% lower mortality risk among Veterans with chronic pain and opioid use when compared to the untreated patients: (HR: 0.35, 95% CI: 0.17, 0.75). CONCLUSIONS EVP was associated with a large reduction in mortality risk for Veterans with both chronic pain and opioid use. This result could inform the decision process in a VA station or region when considering providing or expanding access to an interdisciplinary rehabilitation/functional restoration program for chronic pain.
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Affiliation(s)
- Ralph Ward
- Health Equity and Rural Outreach Center of InnovationRalph H. Johnson Veterans Affairs Medical CenterCharlestonSouth CarolinaUSA
- Department of Public Health SciencesMedical University of South CarolinaCharlestonSouth CarolinaUSA
| | - Sheila A. M. Rauch
- Mental Health Service LineVA Atlanta Healthcare SystemAtlantaGeorgiaUSA
- Department of Psychiatry and Behavioral SciencesEmory University School of MedicineAtlantaGeorgiaUSA
| | - Robert Neal Axon
- Health Equity and Rural Outreach Center of InnovationRalph H. Johnson Veterans Affairs Medical CenterCharlestonSouth CarolinaUSA
- College of MedicineMedical University of South CarolinaCharlestonSouth CarolinaUSA
| | - Michael S. Saenger
- Anesthesia Service LineVA Atlanta Healthcare SystemAtlantaGeorgiaUSA
- Department of MedicineEmory University School of MedicineAtlantaGeorgiaUSA
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Edmond SN, Snow JL, Pomeranz J, Van Cleve R, Black AC, Compton P, Becker WC. Delphi study to explore a new diagnosis for "ineffective" long-term opioid therapy for chronic pain. Pain 2023; 164:870-876. [PMID: 36448976 DOI: 10.1097/j.pain.0000000000002783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 09/02/2022] [Indexed: 12/02/2022]
Abstract
ABSTRACT A challenge in clinical, research, and policy spheres is determining whether and how to apply the Diagnostic and Statistical Manual-5 Opioid Use Disorder criteria to patients receiving long-term opioid therapy (LTOT) for the management of chronic pain. This study explored perspectives on the merits of creating a new diagnostic entity to characterize the problems that arise for certain patients prescribed LTOT and develop consensus on its definition and diagnostic criteria. We conducted 3 rounds of online surveys and held one discussion-based workshop to explore a new diagnostic entity and generate consensus with subject matter experts (n = 51) in pain and opioid use disorder, including a wide range of professional disciplines. The first survey included open-ended questions and rapid qualitative analysis to identify potential diagnostic criteria. Rounds 2 and 3 involved rating potential diagnostic criteria on a Likert-type scale to achieve consensus. The workshop was a facilitated conversation aimed at further refining criteria. Three-quarters of Delphi panelists were in favor of a new diagnostic entity; consensus was reached for 19 potential diagnostic criteria including benefits of LTOT no longer outweighing harms and a criterion related to difficulty tapering. A subgroup of expert panelists further refined the new diagnostic entity definition and criteria. Consensus on potential criteria for the new diagnostic entity was reached and further refined by a subgroup of experts. This Delphi study represents the opinions of a small group of subject matter experts; perspectives from other experts and additional stakeholder groups (including patients) are warranted.
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Affiliation(s)
- Sara N Edmond
- Pain Research Informatics Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, United States
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States
| | - Jennifer L Snow
- Pain Research Informatics Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, United States
| | - Jamie Pomeranz
- Department of Occupational Therapy, University of Florida, Gainesville, FL, United States
| | - Raymond Van Cleve
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, CA, United States
- Stanford University, Stanford, CA, United States
| | - Anne C Black
- Pain Research Informatics Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, United States
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States
| | - Peggy Compton
- Department of Family and Community Health, University of Pennsylvania, Philadelphia, PA, United States
| | - William C Becker
- Pain Research Informatics Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, United States
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States
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Goldsmith ES, Miller WA, Koffel E, Ullman K, Landsteiner A, Stroebel B, Hill J, Ackland PE, Wilt TJ, Duan-Porter W. Barriers and facilitators of evidence-based psychotherapies for chronic pain in adults: A systematic review. THE JOURNAL OF PAIN 2023; 24:742-769. [PMID: 36934826 DOI: 10.1016/j.jpain.2023.02.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 02/20/2023] [Accepted: 02/24/2023] [Indexed: 03/21/2023]
Abstract
Cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), and mindfulness-based stress reduction (MBSR) have demonstrated effectiveness for improving outcomes in chronic pain. These evidence-based psychotherapies (EBPs) remain underutilized in clinical practice, however. To identify research gaps and next steps for improving uptake of EBPs, we conducted a systematic review of patient-, provider-, and system-level barriers and facilitators of their use for chronic pain. We searched MEDLINE, Embase, PsycINFO, and CINAHL databases databases from inception through September 2022. Prespecified eligibility criteria included outpatient treatment of adults with chronic pain; examination of barriers and facilitators and/or evaluation of implementation strategies; conducted in the United States (US), United Kingdom (UK), Ireland, Canada or Australia; and publication in English. Two reviewers independently assessed eligibility and rated quality. We conducted a qualitative synthesis of results using a best-fit framework approach building upon domains of the Consolidated Framework for Implementation Research (CFIR). We identified 34 eligible studies (33 moderate or high quality), most (n=28) of which addressed patient-level factors. Shared barriers across EBPs included variable patient buy-in to therapy rationale and competing responsibilities for patients; shared facilitators included positive group or patient-therapist dynamics. Most studies examining ACT and all examining MBSR assessed only group formats. No studies compared barriers, facilitators, or implementation strategies of group CBT to individual CBT, or of telehealth to in-person EBPs. Conceptual mismatches of patient knowledge and beliefs with therapy principles were largely analyzed qualitatively, and studies did not explore how these mismatches were addressed to support engagement. Future research on EBPs for chronic pain in real-world practice settings is needed to explore provider and system-level barriers and facilitators, heterogeneity of effects and uptake, and both effects and uptake of EBPs delivered in various formats, including group vs. individual therapy and telehealth or asynchronous digital approaches. Perspective This systematic review synthesizes evidence on barriers and facilitators to uptake of cognitive behavioral therapy, acceptance and commitment therapy, and mindfulness-based stress reduction for chronic pain. Findings can guide future implementation work to increase availability and use of evidence-based psychotherapies for treatment of chronic pain. Registration: PROSPERO number CRD42021252038.
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Affiliation(s)
- Elizabeth S Goldsmith
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA; Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA.
| | - Wendy A Miller
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA; Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Erin Koffel
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
| | - Kristen Ullman
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA; Veterans Affairs Evidence Synthesis Program, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
| | - Adrienne Landsteiner
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA; Veterans Affairs Evidence Synthesis Program, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
| | - Benjamin Stroebel
- Department of Dermatology, University of California - San Francisco School of Medicine, San Francisco, CA, USA
| | - Jessica Hill
- Department of Clinical Psychology, Binghamton University, Binghamton, NY, USA
| | - Princess E Ackland
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA; Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Timothy J Wilt
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA; Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA; Veterans Affairs Evidence Synthesis Program, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA; Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Wei Duan-Porter
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA; Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA; Veterans Affairs Evidence Synthesis Program, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
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58
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Reilly ED, Kathawalla UK, Robins HE, Heapy AA, Hogan TP, Waring ME, Quigley KS, Drebing CE, Bickmore T, Volonte M, Kelly MM. An Online Acceptance and Mindfulness Intervention for Chronic Pain in Veterans: Development and Protocol for a Pilot Feasibility Randomized Controlled Trial. JMIR Res Protoc 2023; 12:e45887. [PMID: 36881446 PMCID: PMC10031449 DOI: 10.2196/45887] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 01/27/2023] [Accepted: 01/29/2023] [Indexed: 03/08/2023] Open
Abstract
BACKGROUND In the veteran community, chronic pain is particularly prevalent and often debilitating. Until recently, veterans with chronic pain were offered primarily pharmacological intervention options, which rarely suffice and can also have negative health consequences. To better address chronic pain in veterans, the Veterans Health Administration has invested in novel, nonpharmacological behavior interventions that target both pain management and chronic pain-related functional issues. One approach, acceptance and commitment therapy (ACT) for chronic pain, is supported by decades of efficacy evidence for improving pain outcomes; however, ACT can be difficult to obtain owing to issues such as a lack of trained therapists or veterans having difficulty committing to the time and resources needed for the full clinician-led ACT protocol. Given the strong ACT evidence base combined with access limitations, we set out to develop and evaluate Veteran ACT for Chronic Pain (VACT-CP), an online program guided by an embodied conversational agent to improve pain management and functioning. OBJECTIVE The aims of this study are to develop, iteratively refine, and then conduct a pilot feasibility randomized controlled trial (RCT) of a VACT-CP group (n=20) versus a waitlist and treatment-as-usual control group (n=20). METHODS This research project includes 3 phases. In phase 1, our research team consulted with pain and virtual care experts, developed the preliminary VACT-CP online program, and conducted interviews with providers to obtain their feedback on the intervention. In phase 2, we incorporated feedback from phase 1 into the VACT-CP program and completed initial usability testing with veterans with chronic pain. In phase 3, we are conducting a small pilot feasibility RCT, with the primary outcome being assessment of usability of the VACT-CP system. RESULTS This study is currently in phase 3; recruitment for the RCT began in April 2022 and is expected to continue through April 2023. Data collection is expected to be completed by October 2023, with full data analysis completed by late 2023. CONCLUSIONS The findings from this research project will provide information on the usability of the VACT-CP intervention, as well as secondary outcomes related to treatment satisfaction, pain outcomes (pain-related daily functioning and pain severity), ACT processes (pain acceptance, behavioral avoidance, and valued living), and mental and physical functioning. TRIAL REGISTRATION ClinicalTrials.gov NCT03655132; https://clinicaltrials.gov/ct2/show/NCT03655132. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/45887.
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Affiliation(s)
- Erin D Reilly
- Mental Illness Research, Education, and Clinical Center, Veteran Affairs Bedford Healthcare System, Department of Veteran Affairs, Bedford, MA, United States
- Department of Psychiatry, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Ummul-Kiram Kathawalla
- Wheelock College of Education & Human Development, Boston University, Boston, MA, United States
| | | | - Alicia A Heapy
- Pain Research, Informatics, Multi-morbidities, and Education Center, Veterans Affairs Connecticut Healthcare System, Department of Veterans Affairs, West Haven, CT, United States
- Yale School of Medicine, New Haven, CT, United States
| | - Timothy P Hogan
- Center for Healthcare Organization and Implementation Research, Veterans Affairs Bedford Healthcare System, Department of Veterans Affairs, Bedford, MA, United States
- Peter O'Donnell Jr School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Molly E Waring
- Department of Allied Health Sciences, University of Connecticut, Storrs, CT, United States
| | - Karen S Quigley
- Khoury College of Computer Sciences, Northeastern University, Boston, MA, United States
| | - Charles E Drebing
- Cheyenne Veterans Affairs Medical Center, Department of Veterans Affairs, Cheyenne, WY, United States
| | - Timothy Bickmore
- Khoury College of Computer Sciences, Northeastern University, Boston, MA, United States
| | - Matias Volonte
- Khoury College of Computer Sciences, Northeastern University, Boston, MA, United States
| | - Megan M Kelly
- Mental Illness Research, Education, and Clinical Center, Veteran Affairs Bedford Healthcare System, Department of Veteran Affairs, Bedford, MA, United States
- Department of Psychiatry, University of Massachusetts Chan Medical School, Worcester, MA, United States
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Hadlandsmyth K, Driscoll MA, Mares JG, Au V, Miell KR, Lund BC. Rurality impacts pain care for female veterans similarly to male veterans. J Rural Health 2023; 39:313-319. [PMID: 35170073 DOI: 10.1111/jrh.12646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
PURPOSE Rural disparities exist in access to multidisciplinary pain care with higher rates of opioid prescribing in rural regions. Among Veterans, who have prevalent rates of chronic pain, women often evidence complex presentations, multiple comorbidities, and dissatisfaction with care. This study investigates the impact of rurality on pain care for women specifically, and whether this varies from the impact of rurality for men. METHODS A cohort of Veterans with chronic pain in 2018 was built utilizing VA administrative data. Variables of interest included: demographic, comorbidities, medications, and health care utilization for chronic pain. FINDINGS The cohort included 2,261,030 Veterans; 11% (n = 248,977) were women. Significantly fewer women (7%) compared to men (10.7%) received long-term opioids (adjusted OR = 0.77, 95% CI: 0.75-0.78). Men, relative to women, were also more likely to receive gabapentinoids and nonsteroidal ant-inflammatory drugs, whereas women, relative to men, were more likely to receive muscle relaxants and duloxetine. Women were more likely to receive most psychiatric medications. Rural women received more primary care visits compared to urban women (adjusted OR = 1.19, 95% CI: 1.15-1.22), but fewer women's clinic visits (a subset of primary care visits: adjusted OR = 0.69, 95% CI:0.67-0.71) and fewer pain specialty care visits (physical therapy, pain clinic, and mental health visits with pain codes). Rural effects did not vary substantially between women and men. CONCLUSIONS Rural-dwelling Veterans received more pain and psychiatric medications compared to urban Veterans and fewer specialty care visits. Rural Veterans may benefit from increased access to specialty chronic pain care.
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Affiliation(s)
- Katherine Hadlandsmyth
- Office of Rural Health, Veterans Rural Health Resource Center, Iowa City VA Health Care System, Iowa City, Iowa, USA
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa, USA
- Department of Anesthesia, University of Iowa, Carver College of Medicine, Iowa City, Iowa, USA
| | - Mary A Driscoll
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jasmine G Mares
- Department of Anesthesia, University of Iowa, Carver College of Medicine, Iowa City, Iowa, USA
| | - Vanessa Au
- Office of Rural Health, Veterans Rural Health Resource Center, Iowa City VA Health Care System, Iowa City, Iowa, USA
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa, USA
| | - Kelly Richardson Miell
- Office of Rural Health, Veterans Rural Health Resource Center, Iowa City VA Health Care System, Iowa City, Iowa, USA
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa, USA
| | - Brian C Lund
- Office of Rural Health, Veterans Rural Health Resource Center, Iowa City VA Health Care System, Iowa City, Iowa, USA
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa, USA
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Estacion M, Liu S, Cheng X, Dib-Hajj S, Waxman SG. Kv7-specific activators hyperpolarize resting membrane potential and modulate human iPSC-derived sensory neuron excitability. Front Pharmacol 2023; 14:1138556. [PMID: 36923357 PMCID: PMC10008904 DOI: 10.3389/fphar.2023.1138556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 02/13/2023] [Indexed: 03/02/2023] Open
Abstract
Chronic pain is highly prevalent and remains a significant unmet global medical need. As part of a search for modulatory genes that confer pain resilience, we have studied two family cohorts where one individual reported much less pain than other family members that share the same pathogenic gain-of-function Nav1.7 mutation that confers hyperexcitability on pain-signaling dorsal root ganglion (DRG) neurons. In each of these kindreds, the pain-resilient individual carried a gain-of-function variant in Kv7.2 or Kv7.3, two potassium channels that stabilize membrane potential and reduce excitability. Our observation in this molecular genetic study that these gain-of-function Kv7.2 and 7.3 variants reduce DRG neuron excitability suggests that agents that activate or open Kv7 channels should attenuate sensory neuron firing. In the present study, we assess the effects on sensory neuron excitability of three Kv7 modulators-retigabine (Kv7.2 thru Kv7.5 activator), ICA-110381 (Kv7.2/Kv7.3 specific activator), and as a comparator ML277 (Kv7.1 specific activator)-in a "human-pain-in-a-dish" model (human iPSC-derived sensory neurons, iPSC-SN). Multi-electrode-array (MEA) recordings demonstrated inhibition of firing with retigabine and ICA-110381 (but not with ML277), with the concentration-response curve indicating that retigabine can achieve a 50% reduction of firing with sub-micromolar concentrations. Current-clamp recording demonstrated that retigabine hyperpolarized iPSC-SN resting potential and increased threshold. This study implicates Kv7.2/Kv7.3 channels as effective modulators of sensory neuron excitability, and suggest that compounds that specifically target Kv7.2/Kv7.3 currents in sensory neurons, including human sensory neurons, might provide an effective approach toward pain relief.
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Affiliation(s)
- Mark Estacion
- Department of Neurology and Center for Neuroscience and Regeneration Research, Yale University School of Medicine, New Haven, CT, United States
- Rehabilitation Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, CT, United States
| | - Shujun Liu
- Department of Neurology and Center for Neuroscience and Regeneration Research, Yale University School of Medicine, New Haven, CT, United States
- Rehabilitation Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, CT, United States
| | - Xiaoyang Cheng
- Department of Neurology and Center for Neuroscience and Regeneration Research, Yale University School of Medicine, New Haven, CT, United States
- Rehabilitation Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, CT, United States
| | - Sulayman Dib-Hajj
- Department of Neurology and Center for Neuroscience and Regeneration Research, Yale University School of Medicine, New Haven, CT, United States
- Rehabilitation Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, CT, United States
| | - Stephen G. Waxman
- Department of Neurology and Center for Neuroscience and Regeneration Research, Yale University School of Medicine, New Haven, CT, United States
- Rehabilitation Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, CT, United States
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Mares JG, Lund BC, Adamowicz JL, Burgess DJ, Rothmiller SJ, Hadlandsmyth K. Differences in chronic pain care receipt among veterans from differing racialized groups and the impact of rural versus urban residence. J Rural Health 2023. [PMID: 36695646 DOI: 10.1111/jrh.12744] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
PURPOSE The current study aimed to identify differences in Veterans Affairs (VA) chronic pain care for Black, Asian, and Hispanic Americans, compared to non-Hispanic White Americans, and examine the intersection of race and rurality. METHODS Using national administrative data, all veterans who presented to the VA for chronic pain in 2018 were included. Demographic and comorbidity variables were built from 2018 data and health care utilization variables from 2019 data. Multivariate log-binomial regression models examined differences between racialized groups, and interactions with rural/urban residence, for each health care utilization variable. FINDINGS The full cohort included 2,135,216 veterans with chronic pain. There were no differences between racialized groups in pain-related primary care visits. Black Americans were less likely to receive pain clinic visits (aRR = 0.87, CI: 0.86-0.88). Rurality further decreased the likelihood of Black Americans visiting a pain clinic. Black, Hispanic, and Asian Americans were more likely to receive pain-related physical therapy visits relative to White Americans. Black and Hispanic Americans were more likely to present to emergency/urgent care for chronic pain. While there were no differences in pain-related primary care visits, the decreased likelihood of pain clinic visits and increased use of emergency department/urgent care among Black Americans could indicate inadequate management of chronic pain. CONCLUSIONS Tailored strategies are needed to provide equitable care that meets the needs of patients from racialized groups while accounting for systemic and cultural factors.
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Affiliation(s)
- Jasmine G Mares
- Office of Rural Health, Veterans Rural Resource Center, Iowa City VA Health Care System, Iowa City, Iowa, USA.,Department of Anesthesia, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Brian C Lund
- Office of Rural Health, Veterans Rural Resource Center, Iowa City VA Health Care System, Iowa City, Iowa, USA.,Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa, USA.,Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, Iowa, USA
| | - Jenna L Adamowicz
- Office of Rural Health, Veterans Rural Resource Center, Iowa City VA Health Care System, Iowa City, Iowa, USA.,Department of Psychological & Brain Sciences, University of Iowa, Iowa City, Iowa, USA
| | - Diana J Burgess
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA.,Center for Care Delivery and Outcomes Research, Veterans Affairs Medical Center, Minneapolis, Minnesota, USA
| | - Shamira J Rothmiller
- Office of Rural Health, Veterans Rural Resource Center, Iowa City VA Health Care System, Iowa City, Iowa, USA.,Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa, USA.,Department of Counselor Education, University of Iowa, Iowa City, Iowa, USA
| | - Katherine Hadlandsmyth
- Office of Rural Health, Veterans Rural Resource Center, Iowa City VA Health Care System, Iowa City, Iowa, USA.,Department of Anesthesia, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA.,Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa, USA
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Li H, Flynn DM, Highland KB, Burke LA, Mcquinn HM, Steffen AD, Doorenbos AZ. Pattern of Cumulative Treatment Hours on Pain Impact and PROMIS Outcomes. Mil Med 2023; 188:e278-e285. [PMID: 33885132 PMCID: PMC10040935 DOI: 10.1093/milmed/usab142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/31/2021] [Accepted: 04/06/2021] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION Participation in interdisciplinary treatments is associated with improvement in pain intensity, physical function, and additional pain-related outcome domains. However, the effect of cumulative treatment hours on outcomes remains unknown among military patients. The present analysis examined the relationship between cumulative interdisciplinary treatment hours and pain management outcomes at a single interdisciplinary pain management center (IPMC). MATERIALS AND METHODS This is a retrospective observational study of data previously collected as standard of care at the Madigan Army Medical Center, approved by the Institutional Review Board. We included patients who received treatment at the IPMC and completed at least two self-report assessment batteries: one at baseline and at least one between 90 and 180 days after baseline (n = 882). The primary outcome was pain impact. Secondary outcomes included fatigue, depression, anxiety, and sleep-related impairment. RESULTS Generalized additive models indicated that cumulative treatment hours were significantly associated with improvement in pain impact, fatigue, and depression. Patients who had higher baseline pain impact, who had mild or no depressive symptoms, and who were >40 years of age had greater improvements in pain impact following treatment, relative to those with lower pain impact, moderate-to-severe depressive symptoms, and were 40 years of age or younger, respectively. Additional research is needed to elucidate the effect of different therapies and additional patient factors in understanding the "therapeutic dose" of interdisciplinary pain management. CONCLUSIONS A higher number of cumulative treatment hours was associated with improvement of pain impact, fatigue, and depression among military personnel receiving interdisciplinary pain treatment. At least 30 hours of sustained interdisciplinary treatment appears to be the threshold for improvement in pain impact and related outcomes.
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Affiliation(s)
- Hongjin Li
- Department of Biobehavioral Nursing Science, College of Nursing, University of Illinois at Chicago, Chicago, IL 60607, USA
- Cancer Prevention and Control, University of Illinois Cancer Center, Chicago, IL 60612, USA
| | - Diane M Flynn
- Department of Rehabilitative Medicine, Madigan Army Medical Center, Tacoma, WA 98431, USA
| | - Krista B Highland
- Department of Biobehavioral Nursing Science, College of Nursing, University of Illinois at Chicago, Chicago, IL 60607, USA
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation, Rockville, MD 20852, USA
| | - Larisa A Burke
- Office of Research Facilitation, College of Nursing, University of Illinois at Chicago, Chicago, IL 60607, USA
| | - Honor M Mcquinn
- Department of Rehabilitative Medicine, Madigan Army Medical Center, Tacoma, WA 98431, USA
| | - Alana D Steffen
- Department of Population Health Nursing Science, College of Nursing, University of Illinois at Chicago, Chicago, IL 60607, USA
| | - Ardith Z Doorenbos
- Department of Biobehavioral Nursing Science, College of Nursing, University of Illinois at Chicago, Chicago, IL 60607, USA
- Cancer Prevention and Control, University of Illinois Cancer Center, Chicago, IL 60612, USA
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Zhang K, Zhang J, Robinson T, Sauer MC, Van Dorin S, Zabel L, De Sloover Koch Y, Soltys MD. Preventing Opioid-Related Toxicity at a Regional VA Medical Center: A Resident-Led Interprofessional Quality Improvement Project. Am J Med Qual 2023; 38:68-69. [PMID: 36367525 DOI: 10.1097/jmq.0000000000000100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Kathie Zhang
- Internal Medicine, The University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Jeremy Zhang
- Internal Medicine, The University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Tommy Robinson
- Internal Medicine, The University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Michael C Sauer
- Internal Medicine, The University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Sarah Van Dorin
- Internal Medicine, The University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Lauren Zabel
- Internal Medicine, The University of Iowa Hospitals and Clinics, Iowa City, IA
| | | | - Matthew D Soltys
- Internal Medicine, The University of Iowa Hospitals and Clinics, Iowa City, IA
- Iowa City VA Health Care System, Iowa City, IA
- VA Quality Scholars Fellowship, Washington, DC
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Subramaniam S, Chen J, Wilkerson TL, Stevenson L, Kincaid C, Firestone C, Ball SL. Refining the Implementation of a Hub-and-Spoke Model for TelePain Through Qualitative Inquiry. JOURNAL OF TECHNOLOGY IN BEHAVIORAL SCIENCE 2022; 8:1-11. [PMID: 36530381 PMCID: PMC9734451 DOI: 10.1007/s41347-022-00288-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 10/07/2022] [Accepted: 10/27/2022] [Indexed: 06/17/2023]
Abstract
The hub-and-spoke telehealth model leverages centrally located providers who utilize telehealth technology to bring specialized care to medically underserved areas. This model has the potential to promote equitable access to healthcare. However, few studies address how to facilitate the adoption and implementation of hub-and-spoke telehealth. We examined spoke site providers' experiences with TelePain, a national hub-and-spoke model of interdisciplinary chronic pain care, with a focus on improving future implementation. We conducted semi-structured individual interviews (20-45 min) with 27 VA spoke site providers via teleconferencing between August 2020 and February 2021. Interview transcripts were coded in Atlas.ti 8.0 using deductive (identified a priori and used to build the interview guide) and inductive (emerging) codes. Our analysis identified the following themes stressed by the spoke sites: (1) spoke sites needed to envision how TelePain services would work at their site before deciding to adopt; (2) TelePain implementation needed to fit into local existing care processes; (3) hub sites needed to understand spoke sites' context (e.g., via needs assessment) to tailor the services accordingly, and (4) hub-and-spoke sites needed to establish bidirectional communication. Our findings provide a practical guide to improve future rollout of hub-and-spoke telehealth models. Recommendations focus on the role of the hub site in promoting program adoption by (1) developing a clear and detailed marketing plan and (2) considering how the program can be adapted to fit the local spoke site context. To improve implementation, hub-and-spoke sites must establish ongoing and consistent bidirectional communication; this is particularly critical in the everchanging post-peak pandemic healthcare system. An important next step is the development of recommendations and guidelines for implementing hub-and-spoke telehealth, as well as examining pain outcomes for patients touched by this program.
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Affiliation(s)
- Soumya Subramaniam
- VA Northeast Ohio Healthcare System, 10701 East Blvd, Cleveland, OH 44106 USA
| | - Jessica Chen
- Puget Sound VA Healthcare System, 1660 S, Columbian Way, Seattle, WA 98108 USA
| | - Tai-Lyn Wilkerson
- VA Northeast Ohio Healthcare System, 10701 East Blvd, Cleveland, OH 44106 USA
| | - Lauren Stevenson
- VA Northeast Ohio Healthcare System, 10701 East Blvd, Cleveland, OH 44106 USA
| | - Carrie Kincaid
- Puget Sound VA Healthcare System, 1660 S, Columbian Way, Seattle, WA 98108 USA
| | - Christine Firestone
- VA Northeast Ohio Healthcare System, 10701 East Blvd, Cleveland, OH 44106 USA
| | - Sherry L. Ball
- VA Northeast Ohio Healthcare System, 10701 East Blvd, Cleveland, OH 44106 USA
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Davis JP, Prindle J, Saba SK, Tran DD, Lee DS, Sedano A, Castro CA, Pedersen ER. Changes in perceived stress during the COVID-19 pandemic among American veterans. Stress Health 2022; 38:1014-1028. [PMID: 35460535 PMCID: PMC9111081 DOI: 10.1002/smi.3153] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 03/16/2022] [Accepted: 04/12/2022] [Indexed: 12/16/2022]
Abstract
American veterans are a population that suffer from both context specific stressors as well as many population-specific major-life events. The present exploratory study utilises a longitudinal cohort of 1230 U.S. veterans surveyed from February 2020 through February 2021. We sought to understand heterogeneity in perceived stress, using growth mixture modelling, over this time period, how COVID-specific factors such as negative reactions to the pandemic, loneliness, and employment disruptions influence perceived stress trajectories, and how veterans vary across distal outcomes including posttraumatic stress disorder (PTSD), pain, depression, sleep problems, physical health, and alcohol use disorder. Results revealed a 4-class solution: Stable High, Stable Low, Steady Increasing, and Steady Decreasing classes. In terms of COVID specific factors, negative reactions to COVID were consistently associated with perceived stress for those in the Stable High and Steady Increasing classes whereas loneliness was associated with stress trajectories for all emergent classes. Finally, in terms of our distal outcomes, results showed a relatively robust pattern with veterans in the Stable High or Steady Increasing classes reporting worse scores across all outcomes including PTSD, pain, sleep problems, physical health, depression, and alcohol use disorder. Understanding the interplay between existing vulnerabilities, ongoing stressors, and behavioural health outcomes among veterans is crucial for prevention and intervention efforts.
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Affiliation(s)
- Jordan P. Davis
- Suzanne Dworak‐Peck School of Social WorkUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - John Prindle
- Suzanne Dworak‐Peck School of Social WorkUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Shaddy K. Saba
- Suzanne Dworak‐Peck School of Social WorkUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Denise D. Tran
- Department of Psychiatry and Behavioral SciencesUniversity of Southern CaliforniaKeck School of MedicineLos AngelesCaliforniaUSA
| | - Daniel S. Lee
- Department of Psychiatry and Behavioral SciencesUniversity of Southern CaliforniaKeck School of MedicineLos AngelesCaliforniaUSA
| | - Angeles Sedano
- Department of Psychiatry and Behavioral SciencesUniversity of Southern CaliforniaKeck School of MedicineLos AngelesCaliforniaUSA
| | - Carl A. Castro
- Suzanne Dworak‐Peck School of Social WorkUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Eric R. Pedersen
- Department of Psychiatry and Behavioral SciencesUniversity of Southern CaliforniaKeck School of MedicineLos AngelesCaliforniaUSA
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Ranney RM, Maguen S, Bernhard PA, Holder N, Vogt D, Blosnich JR, Schneiderman AI. Moral injury and chronic pain in veterans. J Psychiatr Res 2022; 155:104-111. [PMID: 36027646 DOI: 10.1016/j.jpsychires.2022.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 07/28/2022] [Accepted: 08/15/2022] [Indexed: 11/16/2022]
Abstract
Posttraumatic stress disorder (PTSD) and chronic pain are highly prevalent and co-morbid among veterans. Moral injury (MI), which results from traumatic experiences that conflict with deeply held moral beliefs, is also associated with pain. However, relationships between different types of exposures to potentially morally injurious events (PMIEs) and pain have not yet been investigated. In the current study, we investigated these relationships between exposure to PMIEs (betrayal, witnessing, and perpetration) and different types of pain (joint pain, muscle pain, and overall pain intensity), while controlling for other relevant variables (including PTSD symptoms, combat exposure, adverse childhood experiences, age, gender, and race/ethnicity). We also examined gender differences in these associations. Participants were 11,871 veterans drawn from a nationwide, population-based survey who self-reported exposure to PMIEs, PTSD symptoms, frequency of adverse childhood experiences, combat exposure, sociodemographic information, past six-month joint pain, past six-month muscle pain, and past week overall pain intensity. Population weighted regression models demonstrated that PMIEs were not significantly associated with joint or muscle pain, but that betrayal was associated with past week overall pain intensity, even when controlling for all other variables. Models investigating men and women separately found that for women, betrayal was associated with joint pain and pain intensity, but for men, betrayal was not associated with any pain outcome. These findings suggest that it may be especially important to assess betrayal when treating patients with a history of trauma and chronic pain.
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Affiliation(s)
- Rachel M Ranney
- San Francisco VA Health Care System, 4150 Clement St, San Francisco, CA, 94121, USA; University of California - San Francisco, 401 Parnassus Ave, San Francisco, CA, 94143, USA; Sierra Pacific Mental Illness Research Education, and Clinical Center, 4150 Clement St, San Francisco, CA, 94121, USA.
| | - Shira Maguen
- San Francisco VA Health Care System, 4150 Clement St, San Francisco, CA, 94121, USA; University of California - San Francisco, 401 Parnassus Ave, San Francisco, CA, 94143, USA
| | - Paul A Bernhard
- Health Outcomes of Military Exposures, Epidemiology Program, Office of Patient Care Services, Veterans Health Administration, 810 Vermont Ave NW, Washington, DC, 2057, USA
| | - Nicholas Holder
- San Francisco VA Health Care System, 4150 Clement St, San Francisco, CA, 94121, USA; University of California - San Francisco, 401 Parnassus Ave, San Francisco, CA, 94143, USA
| | - Dawne Vogt
- VA Boston Health Care System, 150 S Huntington Ave, Boston, MA, 02130, USA; Boston University School of Medicine, 72 E Concord St, Boston, MA, 02118, USA
| | - John R Blosnich
- University of Southern California, 669 W 34th St, Los Angeles, CA, 90089-0411, USA; VA Pittsburgh Healthcare System, 4100 Allequippa St, Pittsburgh, PA, 15240, USA
| | - Aaron I Schneiderman
- Health Outcomes of Military Exposures, Epidemiology Program, Office of Patient Care Services, Veterans Health Administration, 810 Vermont Ave NW, Washington, DC, 2057, USA
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Toor T, Murphy E, Simmons AN, Palyo S, Librodo SC, Strigo IA. Craving of prescription opioids among veterans with chronic pain. Pain 2022; 163:2021-2030. [PMID: 35297818 PMCID: PMC9329486 DOI: 10.1097/j.pain.0000000000002598] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 01/20/2022] [Indexed: 02/04/2023]
Abstract
ABSTRACT The United States faces a crisis because of the high prevalence of chronic pain, concurrent opioid use disorder, and overdose deaths. Prescription opioids remain a primary driver of opioid-related deaths. Craving is a core symptom of addiction, yet the degree to which craving plays a role in prescription opioid use among patients with chronic pain is unknown. Understanding the degree to which craving should be considered in patients with chronic pain is critical for developing effective interventions for supporting patients through opioid tapering. The current work combines data collected from (1) 2152 veterans screened for eligibility at a pain specialty care clinic at the San Francisco VA Health Care System and (2) medical records obtained from the VA Corporate Data Warehouse. We found that prescription opioid craving among veterans with chronic pain was low, with 66.4% of the sample reporting no craving and 33.6% reporting craving. We also found that craving had a small association with morphine equivalent daily dose and pain severity but was more strongly associated with depression. Craving of prescription opioids among veterans with chronic pain is complex. Findings are discussed in relation to chronic pain symptoms, psychiatric comorbidities, and demographics.
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Affiliation(s)
- Tiffany Toor
- Department of Veterans Affairs (VA) San Francisco Healthcare System, San Francisco, CA
| | - Emily Murphy
- Department of Veterans Affairs (VA) San Francisco Healthcare System, San Francisco, CA
| | - Alan N. Simmons
- Department of Veterans Affairs (VA) San Diego Healthcare System, San Diego, CA
- University of California, San Diego, CA
| | - Sarah Palyo
- Department of Veterans Affairs (VA) San Francisco Healthcare System, San Francisco, CA
- University of California, San Francisco, CA
| | - Sara C. Librodo
- Department of Veterans Affairs (VA) San Francisco Healthcare System, San Francisco, CA
- University of California, San Francisco, CA
| | - Irina A. Strigo
- Department of Veterans Affairs (VA) San Francisco Healthcare System, San Francisco, CA
- University of California, San Francisco, CA
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Williams RM, Day MA, Ehde DM, Turner AP, Ciol MA, Gertz KJ, Patterson D, Hakimian S, Suri P, Jensen MP. Effects of hypnosis vs mindfulness meditation vs education on chronic pain intensity and secondary outcomes in veterans: a randomized clinical trial. Pain 2022; 163:1905-1918. [PMID: 35082248 PMCID: PMC11089905 DOI: 10.1097/j.pain.0000000000002586] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 12/21/2021] [Indexed: 11/27/2022]
Abstract
ABSTRACT Effective, rigorously evaluated nonpharmacological treatments for chronic pain are needed. This study compared the effectiveness of training in hypnosis (HYP) and mindfulness meditation (MM) with an active education control (ED). Veterans (N = 328) were randomly assigned to 8 manualized, group-based, in-person sessions of HYP (n = 110), MM (n = 108), or ED (n = 110). Primary (average pain intensity [API]) and secondary outcomes were assessed at pretreatment, posttreatment, and 3 and 6 months posttreatment. Treatment effects were evaluated using linear regression, a generalized estimating equation approach, or a Fisher exact test, depending on the variable. There were no significant omnibus between-group differences in pretreatment to posttreatment change in API; however, pretreatment to posttreatment improvements in API and several secondary variables were seen for participants in all 3 conditions. Participation in MM resulted in greater decreases in API and pain interference at 6 months posttreatment relative to ED. Participation in HYP resulted in greater decreases in API, pain interference, and depressive symptoms at 3 and 6 months posttreatment compared with ED. No significant differences on outcomes between HYP and MM were detected at any time point. This study suggests that all 3 interventions provide posttreatment benefits on a range of outcomes, but the benefits of HYP and MM continue beyond the end of treatment, while the improvements associated with ED dissipate over time. Future research is needed to determine whether the between-group differences that emerged posttreatment are reliable, whether there are benefits of combining treatments, and to explore moderating and mediating factors.
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Affiliation(s)
- Rhonda M. Williams
- VA Puget Sound Health Care System, Seattle, Washington
- University of Washington School of Medicine, Department of Rehabilitation Medicine Seattle, Washington
| | - Melissa A. Day
- University of Washington School of Medicine, Department of Rehabilitation Medicine Seattle, Washington
- University of Queensland, School of Psychology, Australia
| | - Dawn M. Ehde
- University of Washington School of Medicine, Department of Rehabilitation Medicine Seattle, Washington
| | - Aaron P. Turner
- VA Puget Sound Health Care System, Seattle, Washington
- University of Washington School of Medicine, Department of Rehabilitation Medicine Seattle, Washington
| | - Marcia A. Ciol
- University of Washington School of Medicine, Department of Rehabilitation Medicine Seattle, Washington
| | - Kevin J. Gertz
- University of Washington School of Medicine, Department of Rehabilitation Medicine Seattle, Washington
| | - David Patterson
- University of Washington School of Medicine, Department of Rehabilitation Medicine Seattle, Washington
| | - Shahin Hakimian
- Department of Neurology, University of Washington, Seattle, Washington
| | - Pradeep Suri
- VA Puget Sound Health Care System, Seattle, Washington
- University of Washington School of Medicine, Department of Rehabilitation Medicine Seattle, Washington
- University of Washington Clinical Learning, Evidence and Research (CLEAR) Center, Seattle, Washington
| | - Mark P. Jensen
- University of Washington School of Medicine, Department of Rehabilitation Medicine Seattle, Washington
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69
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Story KM, Bravata DM, Robb SL, Wasmuth S, Slaven JE, Whitmire L, Barker B, Menen T, Bair MJ. Feasibility and Acceptability of Music Imagery and Listening Interventions for Analgesia: Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2022; 11:e38788. [PMID: 36136377 PMCID: PMC9539652 DOI: 10.2196/38788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 07/27/2022] [Accepted: 07/30/2022] [Indexed: 11/22/2022] Open
Abstract
Background Chronic pain and access to care are identified as critical needs of the Veterans Health Administration. Music imagery and music listening interventions have shown promise as effective nonpharmacological options for pain management. However, most studies have focused on acute pain, passive music experiences, and in-person delivery. Objective In this study, we aimed to examine the feasibility and acceptability of 2 music interventions delivered through telehealth for chronic musculoskeletal pain, trial design, and theoretical model before conducting a fully powered efficacy or comparative effectiveness trial. Methods FAMILIA (Feasibility and Acceptability of Music Imagery and Listening Interventions for Analgesia) is a 3-arm, parallel group, pilot trial. A total of 60 veterans will be randomized to one of the three conditions: music imagery, music listening, or usual care. Aim 1 is to test the feasibility and acceptability of a multicomponent, interactive music imagery intervention (8-weekly, individual sessions) and a single-component, minimally interactive music learning intervention (independent music listening). Feasibility metrics related to recruitment, retention, engagement, and completion of the treatment protocol and questionnaires will be assessed. Up to 20 qualitative interviews will be conducted to assess veteran experiences with both interventions, including perceived benefits, acceptability, barriers, and facilitators. Interview transcripts will be coded and analyzed for emergent themes. Aim 2 is to explore the effects of music imagery and music listening versus usual care on pain and associated patient-centered outcomes. These outcomes and potential mediators will be explored through changes from baseline to follow-up assessments at 1, 3, and 4 months. Descriptive statistics will be used to describe outcomes; this pilot study is not powered to detect differences in outcomes. Results Recruitment for FAMILIA began in March 2022, and as of July 2022, 16 participants have been enrolled. We anticipate that enrollment will be completed by May 2023. We expect that music imagery and music listening will prove acceptable to veterans and that feasibility benchmarks will be reached. We hypothesize that music imagery and music listening will be more effective than usual care on pain and related outcomes. Conclusions FAMILIA addresses four limitations in music intervention research for chronic pain: limited studies in veterans, evaluation of a multicomponent music intervention, methodological rigor, and internet-based delivery. Findings from FAMILIA will inform a fully powered trial to identify putative mechanisms and test efficacy. Trial Registration ClinicalTrials.gov NCT05426941; https://tinyurl.com/3jdhx28u International Registered Report Identifier (IRRID) DERR1-10.2196/38788
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Affiliation(s)
- Kristin M Story
- Center for Health Information and Communication (CHIC), Health Services Research & Development (HSRD), Richard L Roudebush Veterans Affairs Medical Center, Indianapolis, IN, United States
| | - Dawn M Bravata
- Center for Health Information and Communication (CHIC), Health Services Research & Development (HSRD), Richard L Roudebush Veterans Affairs Medical Center, Indianapolis, IN, United States.,Expanding Expertise through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Veterans Affairs Health Services Research and Development (HSR&D), Indianapolis, IN, United States.,Departments of Medicine and Neurology, Indiana University School of Medicine, Indianapolis, IN, United States.,Regenstrief Institute Inc, Indianapolis, IN, United States
| | - Sheri L Robb
- Indiana University School of Nursing, Indianapolis, IN, United States
| | - Sally Wasmuth
- Department of Occupational Therapy, Indiana University School of Health and Human Sciences, Indianapolis, IN, United States
| | - James E Slaven
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Leah Whitmire
- Creative Forces, National Endowment for the Arts, Henry M Jackson Foundation for the Advancement of Military Medicine Inc, Indianapolis, IN, United States
| | - Barry Barker
- Center for Health Information and Communication (CHIC), Health Services Research & Development (HSRD), Richard L Roudebush Veterans Affairs Medical Center, Indianapolis, IN, United States
| | - Tetla Menen
- Center for Health Information and Communication (CHIC), Health Services Research & Development (HSRD), Richard L Roudebush Veterans Affairs Medical Center, Indianapolis, IN, United States
| | - Matthew J Bair
- Center for Health Information and Communication (CHIC), Health Services Research & Development (HSRD), Richard L Roudebush Veterans Affairs Medical Center, Indianapolis, IN, United States.,Regenstrief Institute Inc, Indianapolis, IN, United States.,Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States
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70
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Taylor KA, Schwartz SW, Alman AC, Goode AP, Dagne GA, Sebastião YV, Foulis PR. Nightmare disorder and low back pain in veterans: cross-sectional association and effect over time. SLEEP ADVANCES : A JOURNAL OF THE SLEEP RESEARCH SOCIETY 2022; 3:zpac030. [PMID: 36387301 PMCID: PMC9648406 DOI: 10.1093/sleepadvances/zpac030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 07/29/2022] [Indexed: 12/15/2022]
Abstract
Low back pain (LBP) disproportionately impacts US military veterans compared with nonveterans. Although the effect of psychological conditions on LBP is regularly studied, there is little published to date investigating nightmare disorder (NMD) and LBP. The purpose of this study was to (1) investigate whether an association exists between NMD and LBP and (2) estimate the effect of NMD diagnosis on time to LBP. We used a retrospective cohort design with oversampling of those with NMD from the Veterans Health Administration (n = 15 983). We used logistic regression to assess for a cross-sectional association between NMD and LBP and survival analysis to estimate the effect of NMD on time to LBP, up to 60-month follow-up, conditioning on age, sex, race, index year, Charlson Comorbidity Index, depression, anxiety, insomnia, combat exposure, and prisoner of war history to address confounding. Odds ratios (with 95% confidence intervals [CIs]) indicated a cross-sectional association of 1.35 (1.13 to 1.60) and 1.21 (1.02 to 1.42) for NMD and LBP within 6 months and 12 months pre- or post-NMD diagnosis, respectively. Hazard ratios (HRs) indicated the effect of NMD on time to LBP that was time-dependent-HR (with 95% CIs) 1.27 (1.02 to 1.59), 1.23 (1.03 to 1.48), 1.19 (1.01 to 1.40), and 1.10 (0.94 to 1.29) in the first 3, 6, 9, and 12 months post-diagnosis, respectively-approximating the null (1.00) at >12 months. The estimated effect of NMD on LBP suggests that improved screening for NMD among veterans may help clinicians and researchers predict (or intervene to reduce) risk of future back pain.
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Affiliation(s)
- Kenneth A Taylor
- Corresponding author. Kenneth A. Taylor, Duke Clinical Research Institute, 300 West Morgan Street, Ste 800, Durham, NC 27701, USA.
| | - Skai W Schwartz
- College of Public Health, University of South Florida, Tampa, FL, USA
| | - Amy C Alman
- College of Public Health, University of South Florida, Tampa, FL, USA
| | - Adam P Goode
- Orthopaedic Surgery, Duke University School of Medicine, Durham, NC, USA,Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA,Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Getachew A Dagne
- College of Public Health, University of South Florida, Tampa, FL, USA
| | - Yuri V Sebastião
- Division of Global Women’s Health, Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Philip R Foulis
- Morsani College of Medicine, University of South Florida, Tampa, FL, USA,Pathology and Laboratory Medicine, James A. Haley Veterans’ Hospital, Tampa, FL, USA
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71
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Krause-Parello CA, Flynn L, Hibler DA, Presciutti RE, Pratt BA, Walsh P, Garvin JT, Morse CY, Carter L, Moreno SJ. Social and Chronic Pain: Veterans Sharing a Path in Developing a Patient-Centered Response to the COVID-19 Pandemic. JOURNAL OF VETERANS STUDIES 2022. [DOI: 10.21061/jvs.v8i1.331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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72
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Hadlandsmyth K, Burgess DJ, Leparski RF, Odom AS, Campbell EJ, Obrecht AA, Adamowicz JL, Cho H, Steffensmeier KS, Johnson NL, Richards CC, Vander Weg MW, Lund BC, Yoon P, Mosher HJ. The Perioperative Pain Self-Management (PePS) randomized controlled trial protocol: Preventing chronic post-surgical pain and prolonged opioid use. Contemp Clin Trials 2022; 118:106810. [PMID: 35660486 PMCID: PMC10498437 DOI: 10.1016/j.cct.2022.106810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 04/26/2022] [Accepted: 05/25/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Total joint arthroplasties are common orthopedic surgeries that carry risk for developing chronic post-surgical pain. In addition to pre- and post-operative pain severity, psychological distress (e.g., anxiety, pain catastrophizing) is a risk factor for chronic postsurgical pain. Cognitive behavioral therapy (CBT) for chronic pain is an empirically supported approach to managing chronic pain, functional impairment, and related distress. While CBT has been used extensively in patients with established chronic pain, using it as a preventive intervention targeting the transition from acute to chronic postsurgical pain is a novel application. OBJECTIVES The Perioperative Pain Self-Management (PePS) program is a pain self-management intervention based on the principles of CBT. This innovative intervention is brief, flexible, and is delivered remotely. The current study aims to determine the efficacy of PePS compared to standard care on reducing the incidence of significant surgical site pain at 6-months post-surgery. The current study also aims to evaluate the context for subsequent implementation. METHODS This study is a hybrid type I efficacy-preparing for implementation trial. It is a two-site, single-blind, two-arm, parallel, randomized control trial. Surgical patients will be randomized to either receive: 1) PePS plus standard care, or 2) Standard care. The primary end point will be surgical site pain severity at 6-months post-surgery. CONCLUSION Results from this study are expected to result in support for a brief scalable intervention (PePS) that can prevent the development of chronic pain and prolonged post-surgical opioid use, as well as key details to inform subsequent implementation. CLINICALTRIALS govIdentifier:NCT04979429.
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Affiliation(s)
- Katherine Hadlandsmyth
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA 52246, USA; University of Iowa, Carver College of Medicine, Department of Anesthesia, Iowa City, IA 52242, USA.
| | - Diana J Burgess
- Center for Care Delivery and Outcomes Research (CCDOR), Minneapolis VA Healthcare System, Minneapolis, MN 55417, USA
| | - Ryan F Leparski
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA 52246, USA
| | - Annie S Odom
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA 52246, USA
| | - Emily J Campbell
- Center for Care Delivery and Outcomes Research (CCDOR), Minneapolis VA Healthcare System, Minneapolis, MN 55417, USA
| | - Ashlie A Obrecht
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA 52246, USA; University of Iowa, Carver College of Medicine, Department of Anesthesia, Iowa City, IA 52242, USA
| | - Jenna L Adamowicz
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA 52246, USA; University of Iowa, College of Liberal Arts and Sciences, Department of Psychological and Brain Sciences, Iowa City, IA 52242, USA
| | - Hyunkeun Cho
- University of Iowa College of Public Health, Department of Biostatistics, Iowa City, IA 52242, USA
| | - Kenda Stewart Steffensmeier
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA 52246, USA
| | - Nicole L Johnson
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA 52246, USA
| | - Christopher C Richards
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA 52246, USA
| | - Mark W Vander Weg
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA 52246, USA; University of Iowa, College of Liberal Arts and Sciences, Department of Psychological and Brain Sciences, Iowa City, IA 52242, USA; University of Iowa College of Public Health, Department of Community and Behavioral Health, Iowa City, IA 52242, USA; University of Iowa, Carver College of Medicine, Department of Internal Medicine, Iowa City, IA 52242, USA
| | - Brian C Lund
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA 52246, USA; University of Iowa College of Public Health, Department of Epidemiology, Iowa City, IA 52242, USA
| | - Patrick Yoon
- Center for Care Delivery and Outcomes Research (CCDOR), Minneapolis VA Healthcare System, Minneapolis, MN 55417, USA
| | - Hilary J Mosher
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA 52246, USA; University of Iowa, Carver College of Medicine, Department of Internal Medicine, Iowa City, IA 52242, USA
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Nikpour J, Broome M, Silva S, Allen KD. Patient demographics and clinical characteristics influence opioid and nonopioid pain management prescriptions of primary care NPs, PAs, and physicians. J Am Assoc Nurse Pract 2022; 34:883-890. [PMID: 35544348 PMCID: PMC10201565 DOI: 10.1097/jxx.0000000000000728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 03/30/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Evidence exists on racial and gender disparities in chronic pain management among veterans. Most literature has described physicians' disparate opioid prescribing patterns, although it is unknown if prescribing disparities exist among nurse practitioners (NPs) and physician assistants (PAs) or among prescription of nonopioid analgesic strategies. PURPOSE To identify patient characteristics associated with opioid and nonopioid prescriptions among Veterans Affairs (VA) chronic pain patients by primary care physicians, NPs, and PAs. METHODOLOGY We used data from the VA's Survey of Health care Experience of Patients and Corporate Data Warehouse from October 2015 to September 2016. Outcomes included opioid and nonopioid analgesic prescriptions. Patient characteristics included race/ethnicity, gender, education level, age, and clinical characteristics (comorbidities, self-reported health, and self-reported mental health). Logistic regression was performed to test for associations of patient characteristics with outcomes. RESULTS Patients who were White, male, age 41-64 years, and with no postsecondary education had higher odds of receiving an opioid prescription (all p -values ≤ .01), whereas patients who were Black, female, and <65 years old had higher odds of a nonopioid prescription (all p -values < .01). Having 5+ comorbidities and fair/poor self-reported health increased the odds of opioid and nonopioid prescriptions (all p -values < .01). CONCLUSIONS Disparities in race, gender, and educational level significantly affect how primary care NPs, PAs, and physicians manage chronic pain. IMPLICATIONS NPs and other primary care providers should pursue training opportunities to identify and mitigate potential biases that may affect their practice. Future research should take an intersectional lens in examining the source of chronic pain disparities.
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Affiliation(s)
- Jacqueline Nikpour
- University of Pennsylvania School of Nursing, Durham Veterans Affairs Healthcare System, University of North Carolina-Chapel Hill
| | - Marion Broome
- Duke University School of Nursing, Durham Veterans Affairs Healthcare System, University of North Carolina-Chapel Hill
| | - Susan Silva
- Duke University School of Nursing, Durham Veterans Affairs Healthcare System, University of North Carolina-Chapel Hill
| | - Kelli D. Allen
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Healthcare System, University of North Carolina-Chapel Hill
- School of Medicine, University of North Carolina-Chapel Hill
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74
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Wang H, Cai S, Caprio T, Goulet J, Intrator O. Opioid administration trends among long-stay community living centers residents with dementia. J Am Geriatr Soc 2022; 70:2393-2403. [PMID: 35397116 DOI: 10.1111/jgs.17785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 03/14/2022] [Accepted: 03/22/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Pain assessment and management of Veterans with Alzheimer's disease and Related Dementia (ADRD) living in Community Living Centers (CLCs) is challenging. Safe and effective use of opioids in the treatment of pain is of great concern to patients and providers promulgating national policies and guidelines. METHODS This study examined long-stay CLC Veterans with ADRD identified in three regulatory periods (period 1: 10/2012-6/2013, n = 3347; period 2: 1/2014-11/2015, n = 4426; period 3: 1/2017-9/2018, n = 4444; Total N = 12,217).This population-based observational study used CLC Minimum Data Set (MDS) data in Fiscal Years (FYs) 2013-2018 and VA bar-code medication administration (BCMA) data. Opioid administration measures included: any opioids, long-term opioids, high-dose opioids, and co-administration with benzodiazepine. Measures were modeled using negative binomial regression with length of stay in CLC as offset adjusting for Veteran predisposing, enabling and need measures from the MDS. RESULTS Compared to period 1, any opioid administration was 26% lower in period 2, and 34% lower in period 3. Among Veterans who received any opioid medications over the three regulatory periods, high-dose and long-term opioid administration were more than 40% lower in periods 2 and 3 compared to period 1. Co-administration of opioid with benzodiazepine versus no opioid was 11% lower in period 2 and 34% lower in period 3 after adjusting for patient level covariates. CONCLUSIONS All patterns of opioid administration decreased over the four opioid regulations periods when guidelines were promulgated across the VA health system. Further research should clarify whether decreasing opioids among patients with ADRD impacted health outcomes.
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Affiliation(s)
- Huiying Wang
- Geriatrics and Extended Care Data and Analysis Center (GECDAC), Finger Lakes Healthcare System, Canandaigua, New York, USA.,Public Health Sciences, University of Rochester, Rochester, New York, USA
| | - Shubing Cai
- Geriatrics and Extended Care Data and Analysis Center (GECDAC), Finger Lakes Healthcare System, Canandaigua, New York, USA.,Public Health Sciences, University of Rochester, Rochester, New York, USA
| | - Thomas Caprio
- Department of Medicine, University of Rochester, Rochester, New York, USA
| | - Joseph Goulet
- VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Orna Intrator
- Geriatrics and Extended Care Data and Analysis Center (GECDAC), Finger Lakes Healthcare System, Canandaigua, New York, USA.,Public Health Sciences, University of Rochester, Rochester, New York, USA
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Pierce K, Troutner A, Rae L, Austin J. Provider-patient communication: an illustrative case report of how provider language can influence patient prognosis. THE JOURNAL OF THE CANADIAN CHIROPRACTIC ASSOCIATION 2022; 66:85-91. [PMID: 35655691 PMCID: PMC9103637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Patient-provider communication can lead to unhelpful ideas and beliefs about a patient's condition, negatively impacting their clinical outcome. A 34-year-old male Veteran presented for an evaluation of high impact chronic low back pain. Previous interactions with various healthcare providers resulted in the Veteran viewing his condition as ominous and in need of intervention, however clinical findings did not support these beliefs. Our Veteran underwent six visits in the chiropractic clinic with treatment consisting of pain education, utilization of cognitive behavioral principles, active home care exercises and spinal manipulation, resulting in improvements in functional and objective outcome measures. This case report highlights the impact of misalignment between an early contact healthcare provider and patient misunderstanding of their condition on long term outcomes. It serves as an example of how physicians utilizing pathoanatomic explanations to describe a patient's chronic low back pain diagnosis can alter the patient's beliefs about their condition.
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Affiliation(s)
| | - Alyssa Troutner
- VA Finger Lakes Healthcare System
- Northeast College of Health Sciences
| | - Lindsay Rae
- VA Finger Lakes Healthcare System
- Northeast College of Health Sciences
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Nikpour J, Broome M, Silva S, Allen KD. Influence of Primary Care Provider Type on Chronic Pain Management Among Veterans. JOURNAL OF NURSING REGULATION 2022; 13:35-44. [PMID: 35694638 PMCID: PMC9182699 DOI: 10.1016/s2155-8256(22)00032-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Chronic pain disproportionately impacts veterans and is often treated in primary care, where physician shortages in the Veterans Health Administration (VHA) healthcare system are well documented. Nurse practitioners (NPs) may represent a solution to the care shortage; however, concerns of NP opioid overprescribing have led to NP practice and prescribing restrictions in individual VHA facilities and at the state level. Little is known regarding the prescribing patterns of NPs and physician assistants (PAs) for veterans with chronic pain in the VHA. Purpose The purpose of this study was to compare opioid and non-opioid prescribing patterns of physicians, NPs, and PAs for chronic pain patients at VHA centers. Methods We used data from the U.S. Department of Veterans Affairs Survey of Healthcare Experience of Patients and Corporate Data Warehouse from October 2015 to September 2016. Patient medical records for the year were analyzed by provider type (physician, NP, or PA) for differences in providers' rates of prescribing opioid and non-opioid medications, as well as characteristics of the opioid prescriptions (e.g., high daily morphine milligram equivalent [90 MME/day] dose, long-term opioid therapy [90 days]). Results Medical records of a total of 39,936 patients were included. In FY 2016, 55% of patients received one opioid prescription, whereas 83.8% received one non-opioid prescription. Compared to patients of NPs and PAs, patients of physicians had higher odds of receiving opioid (vs. NPs: OR = 1.13, p < 0.01; vs. PAs: OR = 1.16, p < 0.01) and non-opioid prescriptions (vs. NPs: OR=1.08, p = 0.02; vs. PAs: OR=1.20, p < 0.01) after adjusting for patient characteristics. There were no differences in high MME/day dose (p = 0.59) or long-term opioid therapy (p = 0.99). Conclusion In a national sample of veterans with chronic pain, NPs and PAs did not have higher odds of opioid prescribing. Concerns of NP or PA opioid overprescribing may be addressed by considering evidence that patients of these providers are not at higher odds of receiving an opioid prescription.
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Affiliation(s)
| | - Marion Broome
- Ruby F. Wilson Distinguished Professor of Nursing, Duke University School of Nursing, Durham, North Carolina
| | | | - Kelli D Allen
- Associate Director, Durham (North Carolina) Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Healthcare System, and a Professor of Medicine, School of Medicine, University of North Carolina-Chapel Hill
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Werner AM, Schmalbach B, Zenger M, Brähler E, Hinz A, Kruse J, Kampling H. Measuring physical, cognitive, and emotional aspects of exhaustion with the BOSS II-short version - results from a representative population-based study in Germany. BMC Public Health 2022; 22:579. [PMID: 35331192 PMCID: PMC8943994 DOI: 10.1186/s12889-022-12961-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 03/08/2022] [Indexed: 11/23/2022] Open
Abstract
Background The aim of the present study was the construction and psychometric evaluation of a shortened version of the Burnout Screening Scales II (BOSS II), a measure for exhaustion and burnout. Methods To this end, among a representative sample of the German general population (N = 2429, 52.9% women), we shortened the scale from 30 to 15 items applying ant-colony-optimization, and calculated item statistics of the short version (BOSS II-short). To estimate its reliability, we used McDonald’s Omega (ω). To demonstrate validity, we compared the correlation between the BOSS II-short and the BOSS II, as well as their associations with depression, anxiety, and quality of life. Furthermore, we evaluated model fit and measurement invariance across respondent age and gender in confirmatory factor analyses (CFA). Finally, we present adapted norm values. Results The CFA showed an excellent model fit (χ2 = 223.037, df = 87, p < .001; CFI = .975; TLI = .970; RMSEA [90%CI] = .036 [.031;.040]) of the BOSS II-short, and good to very good reliability of the three subscales: ‘physical’ (ω = .76), ‘cognitive’ (ω = .89), and ‘emotional’ (ω = .88) symptoms. There was strict measurement invariance for male and female participants and partial strict invariance across age groups. Each subscale was negatively related to quality of life (‘physical’: r = −.62; ‘cognitive’: r = −.50; ‘emotional’: r = −.50), and positively associated with depression (‘physical’: r = .57; ‘cognitive’: r = .67; ‘emotional’: r = .73) and anxiety (‘physical’: r = .50; ‘cognitive’: r = .63; ‘emotional’: r = .71). Conclusions Overall, the BOSS II-short proved to be a valid and reliable instrument in the German general population allowing a brief assessment of different symptoms of exhaustion. Norm values can be used for early detection of exhaustion. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-022-12961-z.
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Affiliation(s)
- Antonia M Werner
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center of the Johannes Gutenberg University Mainz, Untere Zahlbacher Straße 8, 55131, Mainz, Germany. .,Department of Personality Psychology and Psychological Assessment, Goethe-University Frankfurt, Frankfurt, Germany.
| | - Bjarne Schmalbach
- Medical Psychology and Medical Sociology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Markus Zenger
- Faculty of Applied Human Studies, University of Applied Sciences Magdeburg and Stendal, Magdeburg, Germany.,Integrated Research and Treatment Center Adiposity Diseases, Behavioral Medicine Unit, Department of Psychosomatic Medicine and Psychotherapy, Leipzig University Medical Center, Leipzig, Germany
| | - Elmar Brähler
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center of the Johannes Gutenberg University Mainz, Untere Zahlbacher Straße 8, 55131, Mainz, Germany.,Integrated Research and Treatment Center Adiposity Diseases, Behavioral Medicine Unit, Department of Psychosomatic Medicine and Psychotherapy, Leipzig University Medical Center, Leipzig, Germany
| | - Andreas Hinz
- Department of Medical Psychology and Medical Sociology, University of Leipzig, Leipzig, Germany
| | - Johannes Kruse
- Department of Psychosomatic Medicine and Psychotherapy, Justus Liebig University Giessen, Giessen, Germany.,Department of Psychosomatic Medicine and Psychotherapy, Philipps University Marburg, Marburg, Germany
| | - Hanna Kampling
- Department of Psychosomatic Medicine and Psychotherapy, Justus Liebig University Giessen, Giessen, Germany
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Wilson M, Skeiky L, Muck RA, Honn KA, Williams RM, Jensen MP, Van Dongen HPA. Pain Catastrophizing Mediates the Relationship Between Pain Intensity and Sleep Disturbances in U.S. Veterans With Chronic Pain. Mil Med 2022; 188:usac065. [PMID: 35306565 PMCID: PMC10363005 DOI: 10.1093/milmed/usac065] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/29/2022] [Accepted: 02/24/2022] [Indexed: 07/25/2023] Open
Abstract
INTRODUCTION Veterans with chronic pain frequently report comorbid disruptions in sleep and psychological dysfunction. The purpose of this study was to investigate whether psychological function variables mediate the sleep-pain relationship. Knowledge regarding such contributing factors can inform the development and optimization of treatments for sleep disturbances and pain. MATERIALS AND METHODS In an IRB-approved, registered clinical trial, we collected objective sleep data from U.S. military Veterans with chronic pain (N = 184, ages 23-81) using wrist actigraphy for 7 days and self-reported survey data assessing sleep quality, pain intensity, and psychological function (depression, anxiety, post-traumatic stress disorder, and pain catastrophizing). We investigated the associations between objectively measured and self-reported sleep quality and self-reported pain intensity. In addition, using parallel mediation analyses, we examined whether psychological function variables mediated these associations. RESULTS Actigraphy showed suboptimal sleep duration (less than 7 hours) and sleep fragmentation for most participants. Self-reported poor sleep quality and pain intensity were significantly correlated. Pain catastrophizing was found to mediate the association between self-reported sleep quality and pain intensity. CONCLUSIONS Sleep disturbances in this sample of Veterans with chronic pain included insufficient sleep, fragmented sleep, and perceived poor sleep quality. Analyses suggest that poor perceived sleep quality and pain intensity are mediated via pain catastrophizing. The finding highlights the potential importance of pain catastrophizing in Veterans with chronic pain. Future longitudinal research is needed to determine the extent to which treatments that reduce pain catastrophizing might also improve both sleep and pain outcomes.
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Affiliation(s)
- Marian Wilson
- College of Nursing, Washington State University, Spokane, WA 99202, USA
- Sleep and Performance Research Center, Washington State University, Spokane, WA 99202, USA
| | - Lillian Skeiky
- Sleep and Performance Research Center, Washington State University, Spokane, WA 99202, USA
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA 99202, USA
| | - Rachael A Muck
- Sleep and Performance Research Center, Washington State University, Spokane, WA 99202, USA
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA 99202, USA
| | - Kimberly A Honn
- Sleep and Performance Research Center, Washington State University, Spokane, WA 99202, USA
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA 99202, USA
| | - Rhonda M Williams
- VA Puget Sound Health Care System, Seattle, WA 98108, USA
- Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, WA 98104, USA
| | - Mark P Jensen
- Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, WA 98104, USA
| | - Hans P A Van Dongen
- Sleep and Performance Research Center, Washington State University, Spokane, WA 99202, USA
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA 99202, USA
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79
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Bolton R, Ritter G, Highland K, Larson MJ. The relationship between capacity and utilization of nonpharmacologic therapies in the US Military Health System. BMC Health Serv Res 2022; 22:312. [PMID: 35255912 PMCID: PMC8900315 DOI: 10.1186/s12913-022-07700-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 02/24/2022] [Indexed: 11/17/2022] Open
Abstract
Background Nonpharmacologic therapies (NPTs) are recommended as first-line treatments for pain, however the impact of expanding professional capacity to deliver these therapies on use has not been extensively studied. We sought to examine whether an effort by the US Military Health System (MHS) to improve access to NPTs by expanding professional capacity increased NPT utilization in a cohort at higher risk for pain – Army soldiers returning from deployment. Methods Our study involved secondary analysis of MHS workforce data derived from the Defense Medical Human Resources System Internet (DMHRSi), and healthcare utilization data obtained from two ambulatory record systems of the Military Health System (MHS) for a sample of 863,855 Army soldiers previously deployed to Iraq or Afghanistan over a 10-year period (2008–2017). We measured clinical provider capacity in three occupational groups responsible for pain management at 130 military treatment facilities (MTFs): physical therapy, chiropractic, and behavioral health, measured annually as full-time equivalence per 100,000 patients served at each MTF. Utilization in both direct and purchased care settings was measured as annual mean NPT users per 1000 sample members and mean encounters per NPT user. Generalized estimating equation models estimated the associations of facility-level occupational capacity measures and facility-level utilization NPT measures. Results In 2008, nearly all MTFs had some physical therapist and behavioral health provider capacity, but less than half had any chiropractor capacity. The largest increase in capacity from 2008 to 2017 was for chiropractors (89%) followed by behavioral health providers (77%) and physical therapists (37%). Models indicated that increased capacity of physical therapists and chiropractors were associated with significantly increased utilization of six out of seven NPTs. Acupuncture initiation was associated with capacity increases in each occupation. Increased professional capacity in MTFs was associated with limited but positive effects on NPT utilization in purchased care. Conclusions Increasing occupational capacity in three professions responsible for delivering NPTs at MTFs were associated with growing utilization of seven NPTs in this Army sample. Despite increasing capacity in MTFs, some positive associations between MTF capacity and purchased care utilization suggest an unmet need for NPTs. Future research should examine if these changes lead to greater receipt of guideline-concordant pain management. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07700-4.
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Affiliation(s)
- Rendelle Bolton
- The Heller School for Social Policy and Management, Brandeis University, 415 South Street, MA, 02453, Waltham, USA. .,US Department of Veterans Affairs, VA Bedford Healthcare System, Center for Healthcare Organization and Implementation Research, 200 Springs Road, Bedford, MA, 01730, USA.
| | - Grant Ritter
- The Heller School for Social Policy and Management, Brandeis University, 415 South Street, MA, 02453, Waltham, USA
| | - Krista Highland
- Department of Anesthesiology, Defense and Veterans Center for Integrative Pain Management, Uniformed Services University, 11300 Rockville Pike, Suite 709, Rockville, MD, 20852, USA.,Henry M. Jackson Foundation, 11300 Rockville Pike, Suite 709, Rockville, MD, 20852, USA
| | - Mary Jo Larson
- The Heller School for Social Policy and Management, Brandeis University, 415 South Street, MA, 02453, Waltham, USA
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80
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Long CR, Salsbury SA, Vining RD, Lisi AJ, Corber L, Twist E, Abrams T, Wallace RB, Goertz CM. Care Outcomes for Chiropractic Outpatient Veterans (COCOV): a single-arm, pragmatic, pilot trial of multimodal chiropractic care for U.S. veterans with chronic low back pain. Pilot Feasibility Stud 2022; 8:54. [PMID: 35256010 PMCID: PMC8900358 DOI: 10.1186/s40814-022-01008-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 02/18/2022] [Indexed: 08/30/2023] Open
Abstract
Background Over 25% of veterans seeking care at U.S. Veterans Health Administration facilities have chronic low back pain (LBP), with high rates of mental health comorbidities. The primary objective of this study was to assess the feasibility of participant recruitment, retention, and electronic data collection to prepare for the subsequent randomized trial of multimodal chiropractic care for pain management of veterans with chronic low back pain. The secondary objectives were to estimate effect sizes and variability of the primary outcome and choose secondary outcomes for the full-scale trial. Methods This single-arm pilot trial enrolled 40 veterans with chronic LBP at one Veterans Health Administration facility for a 10-week course of pragmatic multimodal chiropractic care. Recruitment was by (1) provider referral, (2) invitational letter from the electronic health record pre-screening, and (3) standard direct recruitment. We administered patient-reported outcome assessments through an email link to REDCap, an electronic data capture platform, at baseline and 5 additional timepoints. Retention was tracked through adherence to the treatment plan and completion rates of outcome assessments. Descriptive statistics were calculated for baseline characteristics and outcome variables. Results We screened 91 veterans over 6 months to enroll our goal of 40 participants. Seventy percent were recruited through provider referrals. Mean age (range) was 53 (22–79) years and 23% were female; 95% had mental health comorbidities. The mean number of chiropractic visits was 4.5 (1–7). Participants adhered to their treatment plan, with exception of 3 who attended only their first visit. All participants completed assessments at the in-person baseline visit and 80% at the week 10 final endpoint. We had no issues administering assessments via REDCap. We observed clinically important improvements on the Roland-Morris Disability Questionnaire [mean change (SD): 3.6 (6.1)] and on PROMIS® pain interference [mean change (SD): 3.6 (5.6)], which will be our primary and key secondary outcome, respectively, for the full-scale trial. Conclusions We demonstrated the feasibility of participant recruitment, retention, and electronic data collection for conducting a pragmatic clinical trial of chiropractic care in a Veterans Health Administration facility. Using the pilot data and lessons learned, we modified and refined a protocol for a full-scale, multisite, pragmatic, National Institutes of Health-funded randomized trial of multimodal chiropractic care for veterans with chronic LBP that began recruitment in February 2021. Trial registration ClinicalTrials.gov NCT03254719 Supplementary Information The online version contains supplementary material available at 10.1186/s40814-022-01008-0.
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81
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Schulz-Heik RJ, Avery TJ, Jo B, Mahoney L, Bayley PJ. Posttraumatic Stress Disorder Does Not Compromise Behavioral Pain Treatment: Secondary Analysis of a Randomized Clinical Trial Among Veterans. Glob Adv Health Med 2022; 11:21649561221075578. [PMID: 35186445 PMCID: PMC8855456 DOI: 10.1177/21649561221075578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 01/06/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Individuals with posttraumatic stress disorder (PTSD) and chronic pain evince different presentations, coping strategies, and treatment utilization patterns than individuals with chronic pain alone. Theorists have suggested that comorbid PTSD may complicate chronic pain treatment, and that integrated pain and PTSD treatment may be preferable to pain treatment alone. OBJECTIVE Assess whether comorbid PTSD moderates Veterans' response to yoga and/or cognitive behavioral therapy (CBT) for pain. METHODS Veterans with Gulf War illness (n = 75) were assessed using the Brief Pain Inventory at baseline and posttreatment as part of a randomized clinical trial. PTSD status was abstracted from participants' medical records. RESULTS PTSD+ participants (n = 41) reported more pain at baseline than PTSD- participants (n = 34; d = .66, p < .01). PTSD+ participants experienced more improvement in pain from baseline to posttreatment than PTSD- participants by a small to moderate, marginally statistically significant amount (d = .39, p = .07). The relationship between PTSD and treatment outcome was not moderated by treatment type (yoga vs CBT; p = .99). Observation of treatment responses across PTSD status (+ vs -) and treatment (yoga vs CBT) revealed that PTSD+ participants responded well to yoga. CONCLUSION PTSD is not associated with reduced effectiveness of behavioral chronic pain treatment among Veterans with Gulf War illness. Therefore behavioral pain treatment should be made readily available to Veterans with pain and PTSD. Yoga deserves further consideration as a treatment for pain among individuals with PTSD.
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Affiliation(s)
- R. Jay Schulz-Heik
- War Related Illness and Injury Study
Center, VA Palo Alto Healthcare System, Palo Alto, CA, USA
| | - Timothy J. Avery
- War Related Illness and Injury Study
Center, VA Palo Alto Healthcare System, Palo Alto, CA, USA
- Department of Psychiatry and Behavioral
Sciences, Stanford University School of
Medicine, Stanford, CA, USA
| | - Booil Jo
- Department of Psychiatry and Behavioral
Sciences, Stanford University School of
Medicine, Stanford, CA, USA
| | - Louise Mahoney
- War Related Illness and Injury Study
Center, VA Palo Alto Healthcare System, Palo Alto, CA, USA
| | - Peter J. Bayley
- War Related Illness and Injury Study
Center, VA Palo Alto Healthcare System, Palo Alto, CA, USA
- Department of Psychiatry and Behavioral
Sciences, Stanford University School of
Medicine, Stanford, CA, USA
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82
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Friedman DR, Patil V, Li C, Rassmussen KM, Burningham Z, Hamilton-Hill S, Kelley MJ, Halwani AS. Integration of Patient-Reported Outcome Measures in the Electronic Health Record: The Veterans Affairs Experience. JCO Clin Cancer Inform 2022; 6:e2100086. [PMID: 35290072 PMCID: PMC8932492 DOI: 10.1200/cci.21.00086] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
PURPOSE There are growing efforts to integrate patient-reported outcome (PRO) data into electronic health records (EHRs) to bring together disparate sources of patient information and improve medical care. PRO measures can be used to assess cancer symptom presence and severity. Integrating PRO tools in EHRs can alert providers to address symptoms, which is an essential component of comprehensive oncology care. METHODS We modified a PRO used to measure cancer and end-of-life symptoms, the Edmonton Symptom Assessment System to create the Veteran Symptom Assessment System (VSAS). VSAS was implemented as an integrated PRO as part of the Veterans Administration EHR system and was used at hematology-oncology clinics in Veteran Administration (VA) medical centers in the Southeast. RESULTS From 2013 to 2014, VSAS was introduced, underwent usability testing and modifications, and was finally implemented in the EHR. Between 2015 and 2019, VSAS was administered 43,883 times in 9,058 patients. Eighty-nine percent of Veterans were male, 11% were female, 52% identified as non-Hispanic White, and 43% identified as African American. Fatigue, shortness of breath with exertion, and pain were most frequently reported initially (68%, 48%, and 45%, respectively) and were most frequently rated as severe (27%, 16%, and 17%, respectively). In patients diagnosed with stage IV cancer, higher symptom burden was significantly associated with shorter overall survival. The majority of Veterans with longitudinal measurements experienced improvement in symptoms, most frequently in severe symptoms. CONCLUSION To our knowledge, this is the first large-scale implementation of a PRO system, integrated in the VA EHR, in ambulatory patients with cancer and blood disorders. The integration of VSAS within the VA EHR is a significant demonstration and a necessary requirement for current and future systemic initiatives in cancer symptom management.
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Affiliation(s)
- Daphne R Friedman
- Division of Medical Oncology, Duke University School of Medicine, Durham, NC.,Durham Veterans Administration Health Care System, Durham, NC
| | - Vikas Patil
- George E. Wahlen Veterans Health Administration, Salt Lake City, UT.,Division of Epidemiology, VERITAS, University of Utah, Salt Lake City, UT
| | - Chunyang Li
- George E. Wahlen Veterans Health Administration, Salt Lake City, UT.,Division of Epidemiology, VERITAS, University of Utah, Salt Lake City, UT
| | - Kelli M Rassmussen
- George E. Wahlen Veterans Health Administration, Salt Lake City, UT.,Division of Epidemiology, VERITAS, University of Utah, Salt Lake City, UT
| | - Zachary Burningham
- George E. Wahlen Veterans Health Administration, Salt Lake City, UT.,Division of Epidemiology, VERITAS, University of Utah, Salt Lake City, UT
| | - Susan Hamilton-Hill
- National Oncology Program Office, Department of Veterans Administration, Durham, NC
| | - Michael J Kelley
- Division of Medical Oncology, Duke University School of Medicine, Durham, NC.,Durham Veterans Administration Health Care System, Durham, NC.,National Oncology Program Office, Department of Veterans Administration, Durham, NC
| | - Ahmad S Halwani
- George E. Wahlen Veterans Health Administration, Salt Lake City, UT.,Division of Epidemiology, VERITAS, University of Utah, Salt Lake City, UT.,Division of Hematology and Hematologic Malignancies, Huntsman Cancer Institute, Salt Lake City, UT
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83
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Griffin SC, Young JR, Naylor JC, Allen KD, Beckham JC, Calhoun PS. Reciprocal Effects Between Depressive Symptoms and Pain in Veterans over 50 Years of Age or Older. PAIN MEDICINE (MALDEN, MASS.) 2022; 23:295-304. [PMID: 34643735 PMCID: PMC9123932 DOI: 10.1093/pm/pnab294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Depression and chronic pain are major problems in American veterans, yet there is limited long-term research examining how they relate to one another in this population. This study examined the relationship between depressive symptoms and pain in U.S. veterans 50 years of age or older. METHODS This study used data on veterans from the 2002-2016 waves of the Health and Retirement Study (n = 4,302), a large-scale observational study of Americans 50 years of age or older. Measures included a short form of the Center for Epidemiologic Studies Depression scale and two items assessing the presence and degree of pain. Analyses included random-intercept cross-lagged panel models (RI-CLPM). RESULTS In the RI-CLPM, there were roughly equivalent cross-lagged effects between depressive symptoms and pain. There was also evidence that depressive symptoms and pain have a trait-like component and that these trait-like characteristics are associated. CONCLUSIONS These findings indicate that depressive symptoms and pain in veterans are stable characteristics in American veterans 50 years of age or older. There appear to be reciprocal effects between the two, whereby deviations in one's typical depressive symptoms predict subsequent deviations in one's pain level and vice versa; however, the size of these effects is very small. These findings suggest that clinicians should treat both depressive symptoms and pain, rather than assume that treatment benefits in one domain will lead to major benefits in another.
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Affiliation(s)
- Sarah C Griffin
- Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MIRECC), Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Jonathan R Young
- Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MIRECC), Durham Veterans Affairs Health Care System, Durham, North Carolina
- Division of Behavioral Medicine and Neurosciences, Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Jennifer C Naylor
- Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MIRECC), Durham Veterans Affairs Health Care System, Durham, North Carolina
- Division of Behavioral Medicine and Neurosciences, Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Kelli D Allen
- Division of Behavioral Medicine and Neurosciences, Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina
- Allergy and Immunology & Thurston Arthritis Research Center, Division of Rheumatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Department of Veterans Affairs Health Care Center, Durham, North Carolina, USA
| | - Jean C Beckham
- Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MIRECC), Durham Veterans Affairs Health Care System, Durham, North Carolina
- Division of Behavioral Medicine and Neurosciences, Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Patrick S Calhoun
- Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MIRECC), Durham Veterans Affairs Health Care System, Durham, North Carolina
- Division of Behavioral Medicine and Neurosciences, Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina
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84
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Hall AL, Sweet J, Tweel M, MacLean MB. Comparing negative health indicators in male and female veterans with the Canadian general population. BMJ Mil Health 2022; 168:82-87. [PMID: 32868291 PMCID: PMC8788043 DOI: 10.1136/bmjmilitary-2020-001526] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/17/2020] [Accepted: 07/18/2020] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Sex-based information on differences between Canadian veterans and the general population is important to understand veterans' unique health needs and identify areas requiring further research. This study compared various health indicators in male and female veterans with their Canadian counterparts. METHODS Health indicators for recent-era Regular Force veterans (released between 1998 and 2015) were obtained from the 2016 Life After Service Survey and compared with the general population in the 2015-16 Canadian Community Health Survey using a cross-sectional approach. Age-adjusted rates and 95% CIs were calculated for males and females separately. RESULTS Compared with Canadians, veterans (both sexes) reported higher prevalence of fair or poor health and mental health, needing help with one or more activity of daily living, lifetime suicidal ideation and being diagnosed with mood and anxiety disorders, post-traumatic stress disorder, migraines, back problems, chronic pain, arthritis, ever having cancer, hearing problems, chronic pain and gastrointestinal problems. A higher prevalence of cardiovascular disease (all types) and high blood pressure was observed in male veterans compared with their Canadian counterparts. Within veterans only, males reported a higher prevalence of diagnosed hearing problems and cardiovascular disease compared with females; conversely females reported a higher prevalence of diagnosed migraines, mood, anxiety and gastrointestinal disorders, and needing help with activities of daily living. These sex differences are similar to the Canadian general population. Some similarities in reporting prevalence between male and female veterans (eg, fair or poor mental health, lifetime suicidal ideation, arthritis, asthma, lifetime cancer incidence, chronic pain and diabetes) were not observed in other Canadians. CONCLUSION Male and female veterans differed from comparable Canadians, and from each other, in various areas of health. Further research is needed to explore these findings, and veteran-based policies and services should consider sex differences.
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Affiliation(s)
- Amy L Hall
- Veterans Affairs Canada, Government of Canada, Charlottetown, Prince Edward Island, Canada
| | - J Sweet
- Veterans Affairs Canada, Government of Canada, Charlottetown, Prince Edward Island, Canada
| | - M Tweel
- Veterans Affairs Canada, Government of Canada, Charlottetown, Prince Edward Island, Canada
| | - M B MacLean
- Veterans Affairs Canada, Government of Canada, Charlottetown, Prince Edward Island, Canada
- School of Rehabilitation Therapy, Queen's University, Kingston, Ontario, Canada
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Enkema MC, Hasin DS, Browne KC, Stohl M, Shmulewitz D, Fink DS, Olfson M, Martins SS, Bohnert KM, Sherman SE, Cerda M, Wall M, Aharonovich E, Keyhani S, Saxon AJ. Pain, cannabis use, and physical and mental health indicators among veterans and nonveterans: results from the National Epidemiologic Survey on Alcohol and Related Conditions-III. Pain 2022; 163:267-273. [PMID: 34108436 PMCID: PMC8985055 DOI: 10.1097/j.pain.0000000000002345] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 04/15/2021] [Indexed: 02/03/2023]
Abstract
ABSTRACT Chronic pain is associated with mental and physical health difficulties and is prevalent among veterans. Cannabis has been put forth as a treatment for chronic pain, and changes in laws, attitudes, and use patterns have occurred over the past 2 decades. Differences in prevalence of nonmedical cannabis use and cannabis use disorder (CUD) were examined across 2 groups: veterans or nonveterans and those reporting or not reporting recent pain. Data from the National Epidemiologic Survey on Alcohol and Related Conditions-III (2012-2013; n = 36,309) were analyzed using logistic regression. Prevalence differences (PDs) for 3 cannabis outcomes (1) past-year nonmedical cannabis use, (2) frequent (≥3 times a week) nonmedical use, and (3) DSM-5 CUD were estimated for those reporting recent moderate to severe pain (veterans or nonveterans) and veterans reporting or not reporting recent pain. Difference in differences was calculated to investigate PDs on outcomes associated with residence in a state with medical cannabis laws (MCLs). Associations between physical and mental health and cannabis variables were tested. The results indicated that the prevalence of recent pain was greater among veterans (PD = 7.25%, 95% confidence interval (CI) [4.90-9.60]). Among veterans, the prevalence of frequent cannabis use was greater among those with pain (PD = 1.92%, 98% CI [0.21-3.63]), and among veterans residing in a state with MCLs, the prevalence of CUD was greater among those reporting recent pain (PD = 3.88%, 98% CI [0.36-7.39]). Findings failed to support the hypothesis that cannabis use improves mental or physical health for veterans with pain. Providers treating veterans with pain in MCL states should monitor such patients closely for CUD.
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Affiliation(s)
- Matthew C. Enkema
- VA Puget Sound Health Care System, Centers of Excellence in Substance Addiction Treatment and Education (CESATE), VA Puget Sound Health Care System, Seattle, WA, US
| | - Deborah S. Hasin
- New York State Psychiatric Institute, New York, NY, US
- Department of Psychiatry, Columbia University Medical Center, New York, NY, US
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, US
| | - Kendall C. Browne
- VA Puget Sound Health Care System, Centers of Excellence in Substance Addiction Treatment and Education (CESATE), VA Puget Sound Health Care System, Seattle, WA, US
- Department of Psychiatry, University of Washington, Seattle, WA, US
| | - Malki Stohl
- VA Puget Sound Health Care System, Centers of Excellence in Substance Addiction Treatment and Education (CESATE), VA Puget Sound Health Care System, Seattle, WA, US
| | | | - David S. Fink
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, US
| | - Mark Olfson
- New York State Psychiatric Institute, New York, NY, US
| | - Silvia S. Martins
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, US
| | | | - Scott E. Sherman
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, US
| | - Magdalena Cerda
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, US
| | - Melanie Wall
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, US
| | | | | | - Andrew J. Saxon
- VA Puget Sound Health Care System, Centers of Excellence in Substance Addiction Treatment and Education (CESATE), VA Puget Sound Health Care System, Seattle, WA, US
- Department of Psychiatry, University of Washington, Seattle, WA, US
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86
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Murphy JL, Cordova MJ, Dedert EA. Cognitive behavioral therapy for chronic pain in veterans: Evidence for clinical effectiveness in a model program. Psychol Serv 2022; 19:95-102. [PMID: 32986454 PMCID: PMC10009772 DOI: 10.1037/ser0000506] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The U.S. Department of Veterans Affairs (VA) has been training clinicians in its cognitive behavioral therapy for chronic pain (CBT-CP) structured protocol since 2012. The aim of this project was to review patient outcomes to determine the effectiveness of the VA's CBT-CP treatment. From 2012-2018, 1,331 Veterans initiated individual CBT-CP treatment as part of the training program. Patient outcomes were assessed with measures of patient-reported pain intensity, pain catastrophizing, depression, pain interference, and quality of life (physical, psychological, social, and environmental). Mixed models of the effects of time indicated significant changes across pretreatment, midtreatment, and treatment conclusion on all outcomes. There was a large effect size (Cohen's d = 0.78) for pain catastrophizing, and there were medium to large effect sizes (d > 0.60) for worst pain intensity, pain interference, depression, and physical quality of life. Systematic training of therapists and implementation of the VA's CBT-CP protocol yielded significant patient improvements across multiple domains. This offers strong support for the VA's CBT-CP as an effective, safe treatment for Veterans with chronic pain and highlights it as a model to increase the availability of training in standardized, pain-focused, evidence-based, behavioral interventions. The findings suggest that the broad dissemination of such training, including in routine, nonpain specialty settings, would improve patient access to effective, nonpharmacological treatment options in both the public and private sectors. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
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87
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Burdick R, Corcoran KL, Zhao X, Lisi A. The rate of use of Veterans Affairs chiropractic care: a 5-year analysis. Chiropr Man Therap 2022; 30:4. [PMID: 35062971 PMCID: PMC8781440 DOI: 10.1186/s12998-022-00413-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 01/17/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The US Department of Veterans Affairs (VA) has initiated various approaches to provide chiropractic care to Veterans. Prior work has shown substantial increase in use of VA chiropractic care between fiscal years (FY) 2005-2016. However, the extent of the availability of these services to the Veteran population remains unclear. The purpose of this study was to analyze the rate of Veteran use of VA chiropractic services, both from on-site care at VA facilities and VA purchased care from community care providers. This study analyzed facility characteristics associated with chiropractic use by both care delivery mechanisms (on-site and in the community). METHODS Cross-sectional analyses of administrative data were conducted for FY 2014-2019. Data were obtained from VA's Corporate Data Warehouse. The variables extracted included number of unique Veterans receiving VA chiropractic care on-site and in the community, total Veteran population of the VA facilities, size of the VA chiropractic workforce (measured as Full-Time Equivalent, FTE), and facility characteristics (geographic region and the facility complexity). Descriptive statistics, mixed model, and multivariant models were used to analyze data. RESULTS Use of VA chiropractic care increased over the six-year period for both on-site and community care. National average for on-site use of the population was 1.27% in FY14 and 1.48% in FY19. Community care use was 0.29% and 1.76% for the same years. Use at individual facilities varied widely in each FY. Factors such as chiropractor FTE, geographic locations, and the complexity of the VA facility are associated with use of chiropractic services. CONCLUSION The VA has expanded the non-pharmacologic treatments available to Veterans by providing chiropractic services, yet chiropractic use remains low compared to other US populations. As Veterans have a high prevalence of pain and musculoskeletal conditions, continued work to assess and achieve the optimal levels of chiropractic use in this population is warranted.
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Affiliation(s)
- Ryan Burdick
- Center for Medical Informatics, Yale School of Medicine, Yale University, 300 George St, New Haven, CT, 06511, USA. .,Department of Physical Medicine and Rehabilitation, VA Connecticut Healthcare System, 950 Campbell Ave., West Haven, CT, 06516, USA.
| | - Kelsey L. Corcoran
- grid.47100.320000000419368710Center for Medical Informatics, Yale School of Medicine, Yale University, 300 George St, New Haven, CT 06511 USA ,grid.281208.10000 0004 0419 3073Department of Physical Medicine and Rehabilitation, VA Connecticut Healthcare System, 950 Campbell Ave., West Haven, CT 06516 USA ,grid.281208.10000 0004 0419 3073Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, 950 Campbell Ave., West Haven, CT 06516 USA
| | - Xiwen Zhao
- grid.47100.320000000419368710Center for Analytical Sciences, Yale School of Public Health, Yale University, 300 George St, New Haven, CT 06511 USA
| | - Anthony Lisi
- grid.47100.320000000419368710Center for Medical Informatics, Yale School of Medicine, Yale University, 300 George St, New Haven, CT 06511 USA ,grid.281208.10000 0004 0419 3073Department of Physical Medicine and Rehabilitation, VA Connecticut Healthcare System, 950 Campbell Ave., West Haven, CT 06516 USA ,grid.281208.10000 0004 0419 3073Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, 950 Campbell Ave., West Haven, CT 06516 USA
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88
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Hogan TP, Etingen B, McMahon N, Bixler FR, Am L, Wacks RE, Shimada SL, Reilly ED, Frisbee KL, Smith BM. Understanding Adoption and Preliminary Effectiveness of a Mobile App for Chronic Pain Management Among US Military Veterans: Pre-Post Mixed Methods Evaluation. JMIR Form Res 2022; 6:e33716. [PMID: 35049515 PMCID: PMC8814923 DOI: 10.2196/33716] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 10/17/2021] [Accepted: 11/22/2021] [Indexed: 12/21/2022] Open
Abstract
Background The Veterans Health Administration Pain Coach mobile health app was developed to support veterans with chronic pain. Objective Our objective was to evaluate early user experiences with the Pain Coach app and preliminary impacts of app use on pain-related outcomes. Methods Following a sequential, explanatory, mixed methods design, we mailed surveys to veterans at 2 time points with an outreach program in between and conducted semistructured interviews with a subsample of survey respondents. We analyzed survey data using descriptive statistics among veterans who completed both surveys and examined differences in key outcomes using paired samples t tests. We analyzed semistructured interview data using thematic analysis. Results Of 1507 veterans invited and eligible to complete the baseline survey, we received responses from 393 (26.1%). These veterans received our outreach program; 236 (236/393, 60.1%) completed follow-up surveys. We conducted interviews with 10 app users and 10 nonusers. Among survey respondents, 10.2% (24/236) used Pain Coach, and 58% (14/24) reported it was easy to use, though interviews identified various app usability issues. Veterans who used Pain Coach reported greater pain self-efficacy (mean 23.1 vs mean 16.6; P=.01) and lower pain interference (mean 34.6 vs mean 31.8; P=.03) after (vs before) use. The most frequent reason veterans reported for not using the app was that their health care team had not discussed it with them (96/212, 45.3%). Conclusions Our findings suggest that future efforts to increase adoption of Pain Coach and other mobile apps among veterans should include health care team endorsement. Our findings regarding the impact of Pain Coach use on outcomes warrant further study.
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Affiliation(s)
- Timothy P Hogan
- eHealth Partnered Evaluation Initiative, Veterans Affairs Bedford Healthcare System, Bedford, MA, United States.,Center for Healthcare Organization and Implementation Research, Veterans Affairs Bedford Healthcare System, Bedford, MA, United States.,Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Bella Etingen
- eHealth Partnered Evaluation Initiative, Veterans Affairs Bedford Healthcare System, Bedford, MA, United States.,Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. Veterans Affairs Hospital, Hines, IL, United States
| | - Nicholas McMahon
- eHealth Partnered Evaluation Initiative, Veterans Affairs Bedford Healthcare System, Bedford, MA, United States.,Center for Healthcare Organization and Implementation Research, Veterans Affairs Bedford Healthcare System, Bedford, MA, United States
| | - Felicia R Bixler
- eHealth Partnered Evaluation Initiative, Veterans Affairs Bedford Healthcare System, Bedford, MA, United States.,Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. Veterans Affairs Hospital, Hines, IL, United States
| | - Linda Am
- eHealth Partnered Evaluation Initiative, Veterans Affairs Bedford Healthcare System, Bedford, MA, United States.,Center for Healthcare Organization and Implementation Research, Veterans Affairs Bedford Healthcare System, Bedford, MA, United States
| | - Rachel E Wacks
- eHealth Partnered Evaluation Initiative, Veterans Affairs Bedford Healthcare System, Bedford, MA, United States.,Center for Healthcare Organization and Implementation Research, Veterans Affairs Bedford Healthcare System, Bedford, MA, United States
| | - Stephanie L Shimada
- eHealth Partnered Evaluation Initiative, Veterans Affairs Bedford Healthcare System, Bedford, MA, United States.,Center for Healthcare Organization and Implementation Research, Veterans Affairs Bedford Healthcare System, Bedford, MA, United States.,Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA, United States.,Division of Health Informatics and Implementation Science, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States
| | - Erin D Reilly
- Mental Illness Research, Education, and Clinical Center (MIRECC), Veterans Affairs Bedford Healthcare System, Bedford, MA, United States.,Social and Community Reintegration Research (SoCRR), Veterans Affairs Bedford Healthcare System, Bedford, MA, United States
| | - Kathleen L Frisbee
- eHealth Partnered Evaluation Initiative, Veterans Affairs Bedford Healthcare System, Bedford, MA, United States.,Office of Connected Care, Veterans Health Administration, Washington, DC, United States
| | - Bridget M Smith
- eHealth Partnered Evaluation Initiative, Veterans Affairs Bedford Healthcare System, Bedford, MA, United States.,Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. Veterans Affairs Hospital, Hines, IL, United States.,Northwestern University Feinberg School of Medicine, Chicago, IL, United States
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89
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Ashrafioun L, Saulnier KG, Allan NP, Bishop TM, Stecker T. Pain intensity trajectories among veterans seeking mental health treatment: Association with mental health symptoms and suicidal thoughts and behaviors. J Affect Disord 2022; 297:586-592. [PMID: 34728278 DOI: 10.1016/j.jad.2021.10.082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 07/21/2021] [Accepted: 10/23/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND The purpose of this study was to identify classes of pain intensity trajectories among veterans reporting suicidal ideation with no prior mental health treatment experience. We were interested in also assessing factors associated with the pain trajectory classes. METHODS A total 747 participants completed measures of pain, depression, suicide ideation and behaviors, insomnia, substance use, and PTSD. Follow-up assessments were completed at 1-, 3-, 6-, and 12-months post-baseline. Growth mixture modeling was conducted, and pain trajectories were modeled from baseline to month 12. RESULTS Three classes were identified: mild pain intensity that increased over time to severe pain intensity (Increasing-Severe; n = 9), low pain intensity that decreased over time (Mild-Decreasing; n = 172), and moderate pain intensity that remained relatively stable over time (Moderate-Stable; n = 566). The Moderate-Stable trajectory had more severe PTSD symptoms, more frequent depression symptoms, and more severe insomnia. The odds of endorsing suicide ideation at month 12 were significantly higher in the Moderate-Stable trajectory compared to the Mild-Decreasing trajectory. CONCLUSIONS This was the first study to assess classes of pain intensity trajectories among individuals who were treatment naïve for mental health issues. The findings suggest that a moderate stable trajectory of pain intensity over the course of 12 months is common and associated with a more severe clinical profile, including suicide ideation. This study underscores the importance of addressing pain intensity among individuals seeking mental health treatment, particularly for those with pain intensity that is moderate and stable over time.
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Affiliation(s)
- Lisham Ashrafioun
- VA Center of Excellence for Suicide Prevention, VA Finger Lakes Healthcare System, 400 Fort Hill Avenue, Canandaigua, NY, United States; Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, United States.
| | - Kevin G Saulnier
- Department of Psychology, Ohio University, Athens, OH, United States
| | - Nicholas P Allan
- VA Center of Excellence for Suicide Prevention, VA Finger Lakes Healthcare System, 400 Fort Hill Avenue, Canandaigua, NY, United States; Department of Psychology, Ohio University, Athens, OH, United States
| | - Todd M Bishop
- VA Center of Excellence for Suicide Prevention, VA Finger Lakes Healthcare System, 400 Fort Hill Avenue, Canandaigua, NY, United States; Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, United States
| | - Tracy Stecker
- VA Center of Excellence for Suicide Prevention, VA Finger Lakes Healthcare System, 400 Fort Hill Avenue, Canandaigua, NY, United States; College of Nursing, Medical University of South Carolina, Charleston, SC, United States
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90
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Subramaniam S, Stryczek KC, Ball S, Stevenson L, Ho PM, Aron DC. Workforce Development to Improve Access to Pain Care for Veterans: A Qualitative Analysis of VA-ECHO Participant Experiences. Health Serv Res Manag Epidemiol 2022; 9:23333928221124806. [PMID: 36093259 PMCID: PMC9452798 DOI: 10.1177/23333928221124806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 08/08/2022] [Accepted: 08/19/2022] [Indexed: 11/16/2022] Open
Abstract
Background/Objective The prevalence of chronic pain and its links to the opioid epidemic have given way to widespread aims to improve pain management care and reduce opioid use, especially in rural areas. Pain Management Specialty Care Access Network-Extension for Community Health Outcomes (VA-ECHO) promotes increased pain care access to rural Veterans through knowledge sharing from specialists to primary care providers (PCPs). We explored PCP participants’ experiences in VA-ECHO and pain management care. Methods This qualitative study is based on a descriptive secondary analysis of semi-structured interviews (n = 10) and 3 focus groups with PCPs participating in VA-ECHO from 2017–2019. A rapid matrix analysis approach was used to analyze participants’ responses. Results VA-ECHO was an effective workforce development strategy for meeting PCPs’ training needs by providing pain management knowledge and skills training (eg alternative care approaches and communicating treatment options). Having protected time to participate in VA-ECHO was a challenge for many PCPs, mitigated by leadership and administrative support. Participants who volunteer to participate had more positive experiences than those required to attend. Conclusions VA-ECHO could be used for meeting the workforce development needs of PCPs. Respondents were satisfied with the program citing improvement in their practice and increased confidence in providing pain management care to Veterans despite some challenges to participation. These findings offer insight into using VA-ECHO to meet the VHA’s workforce development to improve Veterans’ access to pain management care. The ECHO model presents opportunities for workforce development in large complex healthcare systems and garnering ongoing support for this training model is necessary for promoting workforce development for PCPs.
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Affiliation(s)
| | | | - Sherry Ball
- VA Northeast Ohio Healthcare System, Cleveland, OH, USA
| | | | - P. Michael Ho
- VA Eastern Colorado Health Care System, Center of Innovation for Veteran-Centered and Value-Driven Care, Aurora, CO, USA
| | - David C. Aron
- VA Northeast Ohio Healthcare System, Cleveland, OH, USA
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91
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Sellinger JJ, Martino S, Lazar C, Mattocks K, Rando K, Serowik K, Ablondi K, Fenton B, Gilstad-Hayden K, Brummett B, Holtzheimer PE, Higgins D, Reznik TE, Semiatin AM, Stapley T, Ngo T, Rosen MI. The acceptability and feasibility of screening, brief intervention, and referral to treatment for pain management among new England veterans with chronic pain: A pilot study. Pain Pract 2022; 22:28-38. [PMID: 33934499 PMCID: PMC9084457 DOI: 10.1111/papr.13023] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 04/09/2021] [Accepted: 04/23/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Musculoskeletal disorders often lead to chronic pain in Veterans. Chronic pain puts sufferers at risk for substance misuse, and early intervention is needed for both conditions. This pilot study tested the feasibility and acceptability of a Screening, Brief Intervention, and Referral to Treatment for Pain Management intervention (SBIRT-PM) to help engage Veterans seeking disability compensation for painful musculoskeletal disorders in multimodal pain treatment and to reduce risky substance use, when indicated. METHODS This pilot study enrolled 40 Veterans from 8 medical centers across New England in up to 4 sessions of telephone-based counseling using a motivational interviewing framework. Counseling provided education about, and facilitated engagement in, multimodal pain treatments. Study eligibility required Veterans be engaged in no more than 2 Veteran Affairs (VA) pain treatment modalities, and study participation involved a 12-week postassessment and semistructured interview about the counseling process. RESULTS Majorities of enrolled Veterans screened positive for comorbid depression and problematic substance use. Regarding the offered counseling, 80% of participants engaged in at least one session, with a mean of 3 sessions completed. Ninety percent of participants completed the postassessment. Numerically, most measures improved slightly from baseline to week 12. In semistructured interviews, participants described satisfaction with learning about new pain care services, obtaining assistance connecting to services, and receiving support from their counselors. DISCUSSION It was feasible to deliver SBIRT-PM to Veterans across New England to promote engagement in multimodal pain treatment and to track study outcomes over 12 weeks. Preliminary results suggest SBIRT-PM was well-received and has promise for the targeted outcomes.
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Affiliation(s)
- John J Sellinger
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Steve Martino
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Christina Lazar
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Kristin Mattocks
- VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts, USA
- University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Kenneth Rando
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Kristin Serowik
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Karen Ablondi
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Brenda Fenton
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Yale University School of Medicine, New Haven, Connecticut, USA
| | | | - Bradley Brummett
- VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts, USA
| | - Paul E Holtzheimer
- White River Junction VA Medical Center, White River Junction, Vermont, USA
- Dartmouth School of Medicine, Hanover, New Hampshire, USA
| | - Diana Higgins
- VA Boston Healthcare System, Boston, Massachusetts, USA
- Boston University School of Medicine, Boston, Massachusetts, USA
| | - Thomas E Reznik
- Providence VA Medical Center, Providence, Rhode Island, USA
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | | | | | - Tu Ngo
- Bedford VA Medical Center, Bedford, Massachusetts, USA
| | - Marc I Rosen
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Yale University School of Medicine, New Haven, Connecticut, USA
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92
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Murphy CA, Roig RL, Trimble WB, Bennett M, Doughty J. Review of Efficacy and Safety of Spinal Cord Stimulation in Veterans. Fed Pract 2022; 39:32-36a. [PMID: 35185318 PMCID: PMC8849029 DOI: 10.12788/fp.0204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Spinal cord stimulation (SCS) has been shown to be an effective and safe option to treat patients with intractable pain in the general population. Our study examined the experience of US veterans with SCS. METHODS We reviewed electronic health records and conducted phone interviews with 65 veterans who had SCS from 2008 to 2020 at the Southeastern Louisiana Veterans Health Care System (SLVHCS). Our primary outcome measure was veteran would recommend SCS to peers. Secondary outcomes were improvements in activities of daily living and ability to decrease opioid pain medications. RESULTS A majority (77%) of veterans recommended SCS to their peers. Statistical difference was seen in 16 of 18 categories of activities of daily living based on the Pain Outcomes Questionnaire. No permanent neurologic deficits or deaths were associated with SCS use. There were no neurological sequelae. Three patients (5%) developed skin dehiscence postimplant and were treated with explant surgery but all were eager to get a new SCS implanted. CONCLUSION Veterans at SLVHCS were satisfied with their experience using SCS and few experienced adverse effects.
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Affiliation(s)
- Casey A Murphy
- Veterans Affairs Medical Center, New Orleans, Louisiana
- Louisiana State University School of Medicine, New Orleans
- Tulane University School of Medicine, New Orleans
| | - Randolph L Roig
- Veterans Affairs Medical Center, New Orleans, Louisiana
- Louisiana State University School of Medicine, New Orleans
- Tulane University School of Medicine, New Orleans
| | | | | | - Justin Doughty
- Louisiana State University School of Medicine, New Orleans
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93
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Green BN, Dunn AS. An Essential Guide to Chiropractic in the United States Military Health System and Veterans Health Administration. JOURNAL OF CHIROPRACTIC HUMANITIES 2021; 28:35-48. [PMID: 35002576 PMCID: PMC8720651 DOI: 10.1016/j.echu.2021.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 10/19/2021] [Accepted: 10/19/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVE The purpose of this article is to provide an essential overview of chiropractic services in United States military and veterans' health care systems. METHODS We reviewed literature, legislation, and policies from 1936 through September 2021 pertaining to chiropractic services in the United States military and veterans' health systems. Using these sources and our combined experience in these systems, we identified fundamental themes in the delivery of chiropractic care in the health care systems of the Department of Defense (providing health care for active duty service members) and the Department of Veterans Affairs (providing health care for veterans) in main topic areas. RESULTS We identified 7 main topic areas relevant to the 2 systems: populations served by chiropractors; health care systems; integration; utilization and supply of chiropractic care; vetting of chiropractors; roles and evaluation of chiropractors; and oversight and leadership. Key information about chiropractic care in these systems was synthesized into the main topic areas. Benefits of high-quality within-system chiropractic care to active-duty service members and veterans are presented. The assets that within-system chiropractors bring to the Department of Defense and Department of Veterans Affairs health care systems are discussed for each main topic area. CONCLUSION This article contains an essential overview of chiropractic services in the Department of Defense and the Department of Veterans Affairs. It offers clarity regarding the integration of chiropractic services into these health care systems and includes a 1-page brief of talking points that may help better inform ongoing discussions of chiropractic services in these 2 different but intertwined environments.
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Affiliation(s)
- Bart N. Green
- National University of Health Sciences, Lombard, Illinois
| | - Andrew S. Dunn
- Chiropractic Department, VA Western New York Healthcare System, Buffalo, New York
- Department of Chiropractic Clinical Sciences, New York Chiropractic College, Seneca Falls, New York
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94
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Sidiq M, Alenazi W, Kashoo FZ, Qasim M, Lopez MP, Ahmad M, Mani S, Shaphe MA, Khodairi O, Almutairi A, Mir SA. Prevalence of non-specific chronic low-back pain and risk factors among male soldiers in Saudi Arabia. PeerJ 2021; 9:e12249. [PMID: 34721972 PMCID: PMC8519176 DOI: 10.7717/peerj.12249] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 09/13/2021] [Indexed: 11/20/2022] Open
Abstract
Background Non-specific chronic low back pain (NSCLBP) is the most common musculoskeletal disorder affecting health and work among the military population. NSCLBP is a complex disorder with several risk factors contributing to its occurrence. Therefore, the objective of our study was to estimate the prevalence and contribution of risk factors towards NSCLBP among male soldiers in Saudi Arabia. Methods A cross-sectional study was conducted from March 2020 to January 2021 among the military personnel at Hafar Al-Batin military base, Saudi Arabia. The entire population (n = 62, 000) at the military base were invited to participate in the study. The participants were invited to participate in the study either through direct referral from in-patient and out-patient departments of the military hospital or by invitation through pamphlets, email, and advertisement across the offices and residential areas. Soldiers reporting lower back pain for at least 12 weeks were screened for inclusion criteria at the physical therapy department of the military hospital. Inclusion criteria included pain or discomfort originating from the lower back without any known spinal diseases. Participants with a systemic inflammatory disorder, trauma, neurological symptoms, and recent spinal surgery were excluded. All eligible participants were assessed for demographic variables and risk factors and complete the Rolland Morris Disability Questionnaire and WHO-Five Well-Being Index. Results This study identified a 46.3% prevalence of pain originating from the spine with a 2.7% prevalence of NSCLBP. Spearman's rho correlation between the severity of disability due to NSCLBP was strongly associated with age (rs = 0.834, p < 0.01), quality of sleep (rs = 0.790, p < 0.01), body mass index (BMI) (rs = 0.617, p < 0.01), smoking (rs = 0.520, p < 0.01), co-morbidity (rs = 0.357, p < 0.01), but not with the level of physical activity (rs = 0.044, p = 0.07). Conclusion There was a high prevalence of pain originating from the spine among male Saudi soldiers with a relatively low prevalence of NSCLBP. However, the prevalence of disability due to NSCLBP was strongly associated with age, sleep quality, BMI, smoking habit, and co-morbidity.
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Affiliation(s)
- Mohammad Sidiq
- Department of Rehabilitation Medicine, Northern Area Armed Force Hospital, Hafer Al-Batin, Hafer, Saudi Arabia.,Faculty of Physiotherapy, Madhav University, Abu Road, Rajasthan, India
| | - Wadha Alenazi
- Department of Rehabilitation Medicine, Northern Area Armed Force Hospital, Hafer Al-Batin, Hafer, Saudi Arabia
| | - Faizan Z Kashoo
- Department of Physical Therapy and Health Rehabilitation, College of Applied Medical Sciences, Mjamaah University, Al Majmaah, Saudi Arabia
| | - Mohammad Qasim
- Department of Rehabilitation Medicine, Northern Area Armed Force Hospital, Hafer Al-Batin, Hafer, Saudi Arabia
| | - Marisia Paz Lopez
- Department of Rehabilitation Medicine, Northern Area Armed Force Hospital, Hafer Al-Batin, Hafer, Saudi Arabia
| | - Mehrunnisha Ahmad
- Department of Nursing, College of Applied Medical Sciences, Majmaah University, Almajmaah, Saudi Arabia
| | - Suresh Mani
- Department of Physiotherapy, Lovely Professional University, Phagwara, Punjab, India
| | - Mohammad Abu Shaphe
- College of Applied Medical Sciences, Physical Therapy Department, Jazan University, Jazan, Saudi Arabia
| | - Omaymah Khodairi
- Department of Physical Therapy, College of Applied Medical science, Jazan University, Jazan, Saudi Arabia
| | - Abdulqader Almutairi
- Department of Physical Therapy, College of Applied Medical science, Jazan University, Jazan, Saudi Arabia
| | - Shabir Ahmad Mir
- Department of Medical Laboratory Sciences, College of Applied Medical Sciences, Majmaah University, Majmaah, Riyadh, Saudi Arabia
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95
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Ward R, Weeda E, Taber DJ, Axon RN, Gebregziabher M. Advanced models for improved prediction of opioid-related overdose and suicide events among Veterans using administrative healthcare data. HEALTH SERVICES AND OUTCOMES RESEARCH METHODOLOGY 2021; 22:275-295. [PMID: 34744496 PMCID: PMC8561350 DOI: 10.1007/s10742-021-00263-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 08/21/2021] [Accepted: 10/19/2021] [Indexed: 11/29/2022]
Abstract
Veterans suffer disproportionate health impacts from the opioid epidemic, including overdose, suicide, and death. Prediction models based on electronic medical record data can be powerful tools for identifying patients at greatest risk of such outcomes. The Veterans Health Administration implemented the Stratification Tool for Opioid Risk Mitigation (STORM) in 2018. In this study we propose changes to the original STORM model and propose alternative models that improve risk prediction performance. The best of these proposed models uses a multivariate generalized linear mixed modeling (mGLMM) approach to produce separate predictions for overdose and suicide-related events (SRE) rather than a single prediction for combined outcomes. Further improvements include incorporation of additional data sources and new predictor variables in a longitudinal setting. Compared to a modified version of the STORM model with the same outcome, predictor and interaction terms, our proposed model has a significantly better prediction performance in terms of AUC (84% vs. 77%) and sensitivity (71% vs. 66%). The mGLMM performed particularly well in identifying patients at risk for SREs, where 72% of actual events were accurately predicted among patients with the 100,000 highest risk scores compared with 49.7% for the modified STORM model. The mGLMM’s strong performance in identifying true cases (sensitivity) among this highest risk group was the most important improvement given the model’s primary purpose for accurately identifying patients at most risk for adverse outcomes such that they are prioritized to receive risk mitigation interventions. Some predictors in the proposed model have markedly different associations with overdose and suicide risks, which will allow clinicians to better target interventions to the most relevant risks.
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Affiliation(s)
- Ralph Ward
- Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC USA.,Department of Public Health Science, Medical University of South Carolina, Charleston, SC USA
| | - Erin Weeda
- Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC USA.,College of Pharmacy, Medical University of South Carolina, Charleston, SC USA
| | - David J Taber
- Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC USA.,Division of Transplant Surgery, College of Medicine, Medical University of South Carolina, Charleston, SC USA
| | - Robert Neal Axon
- Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC USA.,College of Medicine, Medical University of South Carolina, Charleston, SC USA
| | - Mulugeta Gebregziabher
- Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC USA.,Department of Public Health Science, Medical University of South Carolina, Charleston, SC USA
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96
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Silvestrini M, Indresano J, Zeliadt SB, Chen JA. "There's a huge benefit just to know that someone cares:" a qualitative examination of rural veterans' experiences with TelePain. BMC Health Serv Res 2021; 21:1111. [PMID: 34656133 PMCID: PMC8520618 DOI: 10.1186/s12913-021-07133-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 10/01/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Veterans in the United States are at an increased risk of chronic pain and have higher reported pain prevalence and severity than nonveterans. This qualitative study aims to examine veterans' perspectives on the acceptability of receiving pain care through TelePain, a telehealth program implemented by the Veterans Health Administration (VA) that offers specialty pain care to rural veterans in their homes or in a video conferencing room at a nearby outpatient clinic. METHODS The VA electronic health record was used to identify patients who were referred to TelePain from rural clinics located in Washington, Oregon, and Alaska between 12/01/2019 and 03/31/2020. The study team completed 16 semi-structured interviews with rural veterans about their experiences with TelePain. After interview transcripts were recorded digitally and transcribed, Atlas.ti was used to organize data and facilitate qualitative coding. Interview transcripts were analyzed using thematic analysis. RESULTS Veterans reported general satisfaction with receiving pain care through telehealth and valued having supportive, knowledgeable providers who provided useful information and resources. In addition, veterans appreciated the convenience of telehealth. Barriers to care included problems with program follow-up, negative perceptions of mental health care for pain, and preference for in-person care. Although some patients suggested that telehealth audio and video could be improved, most patients did not have any significant problems with telehealth technology. CONCLUSIONS In this sample of rural veterans who used TelePain, many reported satisfaction with the program and positive experiences with providers. Targets for quality improvement include streamlining the program's referral and scheduling process and improving patient motivation to engage in psychological pain treatments. Results indicate that delivering pain services over telehealth is an acceptable modality for this patient population.
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Affiliation(s)
- Molly Silvestrini
- Department of Veterans Affairs Puget Sound Health Care System, Seattle, USA.
- Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, USA.
| | - Jess Indresano
- Department of Veterans Affairs Puget Sound Health Care System, Seattle, USA
| | - Steven B Zeliadt
- Department of Veterans Affairs Puget Sound Health Care System, Seattle, USA
- Department of Health Services, University of Washington, Seattle, USA
| | - Jessica A Chen
- Department of Veterans Affairs Puget Sound Health Care System, Seattle, USA
- Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, USA
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Ward R, Tang YL, Axon RN, Casarella J, Whitfield N, Rauch SAM. Effectiveness of a substance use treatment program for veterans with chronic pain and opioid use disorder. J Subst Abuse Treat 2021; 132:108635. [PMID: 34607731 DOI: 10.1016/j.jsat.2021.108635] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 08/17/2021] [Accepted: 09/21/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Veterans suffer disproportionately from the combined adverse health impacts of chronic pain and hazardous opioid use. This evaluation involved a substance use treatment program that included medication for opioid use disorder (SATP-MOUD) in a large metro-area Veterans Health Administration (VHA). This form of treatment has become increasingly important during the opioid crisis and is among several important Department of Veteran's Affairs (VA) initiatives to improve treatment for opioid use disorder (OUD), for which chronic pain is often a comorbid condition. METHODS We compared clinical measures related to substance use and mental health between groups who were considered either engaged or not engaged in completing treatment. The study used propensity score matching methods and Cox proportional hazards models to compare the mortality risk for treated and untreated veterans who had chronic pain with concurrent opioid use. RESULTS We identified 1559 SATP-MOUD patients with 1 year of pre- and post-treatment follow-time. From those with chronic pain and concurrent opioid use, we matched 478 SATP-MOUD patients to 647 untreated patients. Engaged patients (at least 4 visits in the first 8 weeks of treatment) had significant improvements in Brief Addiction Monitor (BAM) scores and in PHQ-9 depression screening scores compared to those who started treatment but did not meet the engagement threshold. In Cox proportional hazards analysis, participation in SATP-MOUD was associated with a 38% lower mortality risk among veterans with chronic pain and opioid use when compared to the untreated group: (HR: 0.62, 95% CI: 0.47, 0.82). CONCLUSIONS SATP-MOUD, as delivered in actual practice, was associated with significant improvements in depression and addiction severity scores, and was associated with reduced mortality risk for veterans with chronic pain and OUD.
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Affiliation(s)
- Ralph Ward
- Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA; Medical University of South Carolina, Department of Public Health Science, Charleston, SC, USA.
| | - Yi-Lang Tang
- Emory University School of Medicine, Department of Psychiatry and Behavioral Sciences, Atlanta, GA, USA; Atlanta VA Medical Center, Substance Abuse Treatment Program, Decatur, GA, USA
| | - Robert Neal Axon
- Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA; Medical University of South Carolina, College of Medicine, Charleston, SC, USA
| | - Jennifer Casarella
- Emory University School of Medicine, Department of Psychiatry and Behavioral Sciences, Atlanta, GA, USA; Atlanta Healthcare System, Mental Health Service Line, Atlanta, GA, USA
| | - Natasha Whitfield
- Emory University School of Medicine, Department of Psychiatry and Behavioral Sciences, Atlanta, GA, USA; Atlanta Healthcare System, Mental Health Service Line, Atlanta, GA, USA
| | - Sheila A M Rauch
- Emory University School of Medicine, Department of Psychiatry and Behavioral Sciences, Atlanta, GA, USA; Atlanta Healthcare System, Mental Health Service Line, Atlanta, GA, USA
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98
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Ashrafioun L, Bishop TM, Pigeon WR. The Relationship Between Pain Severity, Insomnia, and Suicide Attempts Among a National Veteran Sample Initiating Pain Care. Psychosom Med 2021; 83:733-738. [PMID: 34297006 DOI: 10.1097/psy.0000000000000975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We assessed the longitudinal association of suicide attempts by moderate to severe pain and insomnia before and after the initiation of pain services among veterans. METHODS A cohort of 221,817 veterans initiating pain care was divided into four subgroups: a) no/mild pain + no insomnia (LowPain-NoINS), b) no/mild pain + insomnia (LowPain-INS), c) moderate/severe pain + no insomnia (HighPain-NoINS), and d) moderate/severe pain + insomnia (HighPain-INS). Data on diagnoses, pain severity, demographics, medications, and suicide attempts were extracted from Veterans Health Administration data sets. RESULTS Overall, there were 2227 (1.0%) suicide attempts before initiating pain services and 1655 (0.8%) after initiating pain services. Cox proportional hazard models accounting for key covariates revealed that patients in the HighPain-INS group were significantly more likely to attempt suicide in the year after the initiation of pain services relative to all subgroups (versus LowPain-NoINS: hazard ratio [HR] = 1.44, 95% confidence interval [CI] = 1.21-1.72; versus LowPain-INS: HR = 1.71, 95% CI = 1.23-2.38; versus HighPain-NoINS: HR = 1.17, 95% CI = 1.01-1.34) even after accounting for prior attempts. Adjusted logistic regression analyses found that patients with moderate/severe pain and insomnia had higher odds of attempting suicide in the year before initiating pain services compared to all subgroups (versus LowPain-NoINS: HR = 1.75, 95% CI = 1.50-2.05; versus LowPain-INS: HR = 1.41, 95% CI = 1.09-1.82; versus HighPain-NoINS: HR = 1.21, 95% CI = 1.07-1.37). CONCLUSIONS These results suggest that those with both moderate/severe pain and insomnia are more likely to have a history of suicide attempts and are at greater risk of a suicide attempt relative to those with insomnia with low/mild pain and those with moderate/severe pain with no insomnia. Suicide prevention efforts for chronic pain and insomnia could address pain and insomnia within the same intervention or in parallel.
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Affiliation(s)
- Lisham Ashrafioun
- From the VA Center of Excellence for Suicide Prevention, VA Finger Lakes Healthcare System (Ashrafioun, Bishop, Pigeon), Canandaigua; and Department of Psychiatry (Ashrafioun, Bishop, Pigeon), University of Rochester School of Medicine and Dentistry, Rochester, New York
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Gilmore-Bykovskyi A, Markart M, Imig K, Hunt K, Murray D, Block L, Dhein J. Implementation and Evaluation of an Acute Care Multicomponent Intervention for Dementia-Related Behavioral Expressions. J Gerontol Nurs 2021; 47:21-30. [PMID: 34432573 DOI: 10.3928/00989134-20210803-02] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Despite the high prevalence and negative outcomes associated with poorly managed dementia-related behavioral expressions (BE) during hospitalization, evidence-based interventions for BE management in acute care environments are lacking. To address this gap, we designed, implemented, and evaluated feasibility, utility, and exploratory nurse and patient outcomes associated with a low-cost, nurse-led multicomponent decision support intervention-the Personalized Approach and Targeted Interventions (PROACTIVE) Treatment Approach-which was implemented as a quality improvement program and evaluated with a historical matched comparison group. The intervention was feasibly implemented and improved nurse-sensitive outcomes (stress, confidence), practices (use of nonpharmacological approaches) for BE management, and perceived utility of intervention resources. Patients receiving the PROACTIVE Treatment Approach (N = 40) had higher rates of acetaminophen use, and shorter lengths of stay (N = 40). More rigorous evaluation is needed to better determine optimal implementation strategies and intervention impact. [Journal of Gerontological Nursing, 47(9), 21-30.].
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Donahue ML, Dunne EM, Gathright EC, DeCosta J, Balletto BL, Jamison RN, Carey MP, Scott-Sheldon LAJ. Complementary and integrative health approaches to manage chronic pain in U.S. military populations: Results from a systematic review and meta-analysis, 1985-2019. Psychol Serv 2021; 18:295-309. [PMID: 32134305 PMCID: PMC7483193 DOI: 10.1037/ser0000417] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The objective of this study was to examine the efficacy of complementary and integrative health (CIH) approaches for reducing pain intensity (primary outcome) and depressive symptoms (secondary outcome) as well as improving physical functioning (secondary outcome) among U.S. military personnel living with chronic pain. Studies were retrieved from bibliographic databases, databases of funded research, and reference sections of relevant articles. Studies that (a) evaluated a CIH approach to promote chronic pain management among military personnel, (b) used a randomized controlled trial design, and (c) assessed pain intensity were included. Two coders extracted data from each study and calculated effect sizes. Discrepancies between coders were resolved through discussion. Comprehensive searches identified 12 studies (k = 15 interventions) that met inclusion criteria. CIH practices included cognitive-behavioral therapies (k = 5), positive psychology (k = 3), yoga (k = 2), acupuncture (k = 2), mindfulness-based interventions (k = 2), and biofeedback (k = 1). Across these studies, participants who received the intervention reported greater reductions in pain intensity (d+ = 0.44, 95% CI [0.21, 0.67], k = 15) compared to controls. Statistically significant improvements were also observed for physical functioning (d+ = 0.36, 95% CI [0.11, 0.61], k = 11) but not for depressive symptoms (d+ = 0.21, 95% CI [-0.15, 0.57], k = 8). CIH approaches reduced pain intensity and improved physical functioning. These approaches offer a nonpharmacological, nonsurgical intervention for chronic pain management for military personnel. Future studies should optimize interventions to improve depressive symptoms in military populations experiencing chronic pain. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Affiliation(s)
- Marissa L. Donahue
- Centers for Behavioral and Preventive Medicine, The Miriam Hospital, Providence, RI
| | - Eugene M. Dunne
- Centers for Behavioral and Preventive Medicine, The Miriam Hospital, Providence, RI
- Department of Psychiatry and Human Behavior, Alpert School of Medicine, Brown University, Providence, RI
| | - Emily C. Gathright
- Centers for Behavioral and Preventive Medicine, The Miriam Hospital, Providence, RI
- Department of Psychiatry and Human Behavior, Alpert School of Medicine, Brown University, Providence, RI
| | - Julie DeCosta
- Centers for Behavioral and Preventive Medicine, The Miriam Hospital, Providence, RI
| | - Brittany L. Balletto
- Centers for Behavioral and Preventive Medicine, The Miriam Hospital, Providence, RI
| | - Robert N. Jamison
- Pain Management Center, Brigham and Women’s Hospital, Chestnut Hill, MA
- Harvard Medical School, Boston, MA
| | - Michael P. Carey
- Centers for Behavioral and Preventive Medicine, The Miriam Hospital, Providence, RI
- Department of Psychiatry and Human Behavior, Alpert School of Medicine, Brown University, Providence, RI
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI
| | - Lori A. J. Scott-Sheldon
- Centers for Behavioral and Preventive Medicine, The Miriam Hospital, Providence, RI
- Department of Psychiatry and Human Behavior, Alpert School of Medicine, Brown University, Providence, RI
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI
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