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Shukla A, Chaudhary R, Nayyar N, Gupta B. Drugs used for pain management in gastrointestinal surgery and their implications. World J Gastrointest Pharmacol Ther 2024; 15:97350. [PMID: 39281265 PMCID: PMC11401020 DOI: 10.4292/wjgpt.v15.i5.97350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Revised: 07/28/2024] [Accepted: 07/31/2024] [Indexed: 09/03/2024] Open
Abstract
Pain is the predominant symptom troubling patients. Pain management is one of the most important aspects in the management of surgical patients leading to early recovery from surgical procedures or in patients with chronic diseases or malignancy. Various groups of drugs are used for dealing with this; however, they have their own implications in the form of adverse effects and dependence. In this article, we review the concerns of different pain-relieving medicines used postoperatively in gastrointestinal surgery and for malignant and chronic diseases.
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Affiliation(s)
- Ankit Shukla
- Department of Surgery, Dr Rajendra Prasad Government Medical College, Kangra 176001, Himachal Pradesh, India
| | - Rajesh Chaudhary
- Department of Renal Transplant Surgery, Dr Rajendra Prasad Government Medical College, Kangra 176001, India
| | - Nishant Nayyar
- Department of Radiology, Dr Rajendra Prasad Government Medical College, Kangra 176001, Himachal Pradesh, India
| | - Bhanu Gupta
- Department of Anaesthesia, Dr Rajendra Prasad Government Medical College, Tanda, Kangra 176001, Himachal Pradesh, India
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Johnson NL, Steffensmeier KS, Garvin LA, Adamowicz JL, Obrecht AA, Rothmiller SJ, Sibenaller Z, Stout L, Driscoll MA, Hadlandsmyth K. "It Made Me Not Want to See him…": The Role of Patient-Provider Communication in Influencing Rural-Dwelling Women Veterans' Motivation to Seek Health Care for Managing Chronic Pain. HEALTH COMMUNICATION 2024; 39:1161-1174. [PMID: 37161286 DOI: 10.1080/10410236.2023.2207280] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Despite being high health care utilizers, many women Veterans perceive their pain condition to be poorly understood by their providers, which can be a strong demotivator for seeking care. We set out to understand the priorities rural-dwelling women Veterans have for using health care for their chronic pain, and interviewed participants about their experiences with (and priorities for seeking) health care for their chronic pain. Self-Determination Theory identifies three sources of motivation (autonomy, competence, relatedness), all of which were represented through two themes that reflect rural women Veterans' rationale for decision-making to obtain health care for chronic pain: role of trust and competing priorities. Women described their priorities for chronic pain management in terms of their competing priorities for work, education, and supporting their family, but most expressed a desire to function in their daily life and relationships. Second, women discussed the role of trust in their provider as a source of motivation, and the role of patient-provider communication skills and gender played in establishing trust. Rural women Veterans often discussed core values that stemmed from facets of their identity (e.g. gender, military training, ethnicity) that also influenced their decision-making. Our findings provide insight for how providers may use Motivational Interviewing and discuss chronic pain treatment options so that rural-dwelling women Veterans feel autonomous, competent, and understood in their decision-making about their chronic pain. We also discuss importance of acknowledging the effects of disenfranchising talk and perpetuating gendered stereotypes related to chronic pain and theoretical implications of this work.
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Affiliation(s)
- Nicole L Johnson
- Office of Rural Health, Veterans Rural Health Resource Center, Iowa City VA Health Care System
- Center for Access & Delivery Research and Evaluation, Iowa City VA Health Care System
| | - Kenda Stewart Steffensmeier
- Office of Rural Health, Veterans Rural Health Resource Center, Iowa City VA Health Care System
- Center for Access & Delivery Research and Evaluation, Iowa City VA Health Care System
| | | | - Jenna L Adamowicz
- Office of Rural Health, Veterans Rural Health Resource Center, Iowa City VA Health Care System
- Center for Access & Delivery Research and Evaluation, Iowa City VA Health Care System
- Department of Psychological and Brain Sciences, University of Iowa
| | - Ashlie A Obrecht
- Department of Primary Care, Veteran Affairs Central Iowa Health Care System
| | - Shamira J Rothmiller
- Office of Rural Health, Veterans Rural Health Resource Center, Iowa City VA Health Care System
- Center for Access & Delivery Research and Evaluation, Iowa City VA Health Care System
| | - Zita Sibenaller
- Department of Psychological and Brain Sciences, University of Iowa
| | - Lori Stout
- Department of Anesthesia, University of Iowa
| | - Mary A Driscoll
- Pain Research, Informatics, Multimorbidities, and Education Center, VA Connecticut Healthcare System
| | - Katherine Hadlandsmyth
- Office of Rural Health, Veterans Rural Health Resource Center, Iowa City VA Health Care System
- Center for Access & Delivery Research and Evaluation, Iowa City VA Health Care System
- Department of Anesthesia, University of Iowa
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Dursa EK, Cao G, Culpepper WJ, Schneiderman A. Comparison of Health Outcomes Over Time Among Women 1990-1991 Gulf War Veterans, Women 1990-1991 Gulf Era Veterans, and Women in the U.S. General Population. Womens Health Issues 2023; 33:643-651. [PMID: 37495424 DOI: 10.1016/j.whi.2023.06.006] [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: 10/19/2022] [Revised: 06/15/2023] [Accepted: 06/16/2023] [Indexed: 07/28/2023]
Abstract
INTRODUCTION The aim of this study is to examine health over almost 20 years of follow-up among women Gulf War veterans and women Gulf Era veterans and compare their health to that of women in the U.S. general population. METHODS We used data from a health survey of 1,274 women Gulf War veteran and Gulf Era veteran participants of the Gulf War Longitudinal Study who responded to all three waves. Data on the U.S. population of women came from the 1999-2000, 2005-2006, and 2011-2014 National Health and Nutrition Examination Survey (NHANES). Generalized estimating equations (GEEs) were used to compare the report of disease over time in women Gulf War and Gulf Era veterans. Differences in prevalence at the three survey timepoints were calculated between women Gulf War veterans and the NHANES women population, and women Gulf War Era veterans and the NHANES women population. RESULTS Women veterans who deployed to the 1990-1991 Gulf War report poorer health than women veterans who served during the same time but did not deploy. Women veterans reported a lower prevalence of hypertension, stroke, and diabetes than women in the NHANES sample. Women veterans also reported a higher prevalence of arthritis, chronic obstructive pulmonary disease, and skin cancer than women in the NHANES sample. CONCLUSIONS This study is the first to characterize the health of a population-based cohort of women Gulf War and women Gulf Era veterans over time and compare it with women's health in a civilian NHANES population. This demonstrates the value of epidemiological research on women veterans and the importance of developing longitudinal cohorts across genders.
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Affiliation(s)
- Erin K Dursa
- Health Outcomes Military Exposures, U.S. Department of Veterans Affairs, Washington, District of Columbia; Hines VA Medical Center Cooperative Studies Coordinating Center, Hines, Illinois.
| | - Guichan Cao
- Hines VA Medical Center Cooperative Studies Coordinating Center, Hines, Illinois
| | - William J Culpepper
- Health Outcomes Military Exposures, U.S. Department of Veterans Affairs, Washington, District of Columbia
| | - Aaron Schneiderman
- Health Outcomes Military Exposures, U.S. Department of Veterans Affairs, Washington, District of Columbia
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Ballengee LA, King HA, Simon C, Lentz TA, Allen KD, Stanwyck C, Gladney M, George SZ, Hastings SN. Partner engagement for planning and development of non-pharmacological care pathways in the AIM-Back trial. Clin Trials 2023; 20:463-472. [PMID: 37269070 PMCID: PMC10524642 DOI: 10.1177/17407745231178789] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND/AIMS Embedded pragmatic clinical trials are increasingly recommended for non-pharmacological pain care research due to their focus on examining intervention effectiveness within real-world settings. Engagement with patients, health care providers, and other partners is essential, yet there is limited guidance for how to use engagement to meaningfully inform the design of interventions to be tested in pain-related pragmatic clinical trials. This manuscript aims to describe the process and impacts of partner input on the design of two interventions (care pathways) for low back pain currently being tested in an embedded pragmatic trial in the Veterans Affairs health care system. METHODS Sequential cohort design for intervention development was followed. Engagement activities were conducted with 25 participants between November 2017 and June 2018. Participants included representatives from multiple groups: clinicians, administrative leadership, patients, and caregivers. RESULTS Partner feedback led to several changes in each of the care pathways to improve patient experience and usability. Major changes to the sequenced care pathway included transitioning from telephone-based delivery to a flexible telehealth model, increased specificity about pain modulation activities, and reduction of physical therapy visits. Major changes to the pain navigator pathway included transitioning from a traditional stepped care model to one that offers care in a feedback loop, increased flexibility regarding pain navigator provider type, and increased specificity for patient discharge criteria. Centering patient experience emerged as a key consideration from all partner groups. CONCLUSION Diverse input is important to consider before implementing new interventions in embedded pragmatic trials. Partner engagement can increase acceptability of new care pathways to patients and providers and enhance uptake of effective interventions by health systems. TRIAL REGISTRATION NCT#04411420. Registered on 2 June 2020.
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Affiliation(s)
- Lindsay A Ballengee
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Heather A King
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Corey Simon
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Trevor A Lentz
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Kelli D Allen
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Medicine and Thurston Arthritis Research Center, University of North Carolina, Chapel Hill, NC, USA
| | - Catherine Stanwyck
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Micaela Gladney
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Steven Z George
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - S Nicole Hastings
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Center for the Study of Aging, Duke University School of Medicine, Durham, NC, USA
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Hasin DS, Wall MM, Alschuler D, Mannes ZL, Malte C, Olfson M, Keyes KM, Gradus JL, Cerdá M, Maynard CC, Keyhani S, Martins SS, Fink DS, Livne O, McDowell Y, Sherman S, Saxon AJ. Chronic Pain, Cannabis Legalization and Cannabis Use Disorder in Veterans Health Administration Patients, 2005 to 2019. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.07.10.23292453. [PMID: 37503049 PMCID: PMC10370240 DOI: 10.1101/2023.07.10.23292453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
Background The risk for cannabis use disorder (CUD) is elevated among U.S. adults with chronic pain, and CUD rates are disproportionately increasing in this group. Little is known about the role of medical cannabis laws (MCL) and recreational cannabis laws (RCL) in these increases. Among U.S. Veterans Health Administration (VHA) patients, we examined whether MCL and RCL effects on CUD prevalence differed between patients with and without chronic pain. Methods Patients with ≥1 primary care, emergency, or mental health visit to the VHA and no hospice/palliative care within a given calendar year, 2005-2019 (yearly n=3,234,382 to 4,579,994) were analyzed using VHA electronic health record (EHR) data. To estimate the role of MCL and RCL enactment in the increases in prevalence of diagnosed CUD and whether this differed between patients with and without chronic pain, staggered-adoption difference-in-difference analyses were used, fitting a linear binomial regression model with fixed effects for state, categorical year, time-varying cannabis law status, state-level sociodemographic covariates, a chronic pain indicator, and patient covariates (age group [18-34, 35-64; 65-75], sex, and race and ethnicity). Pain was categorized using an American Pain Society taxonomy of painful medical conditions. Outcomes In patients with chronic pain, enacting MCL led to a 0·14% (95% CI=0·12%-0·15%) absolute increase in CUD prevalence, with 8·4% of the total increase in CUD prevalence in MCL-enacting states attributable to MCL. Enacting RCL led to a 0·19% (95%CI: 0·16%, 0·22%) absolute increase in CUD prevalence, with 11·5% of the total increase in CUD prevalence in RCL-enacting states attributable to RCL. In patients without chronic pain, enacting MCL and RCL led to smaller absolute increases in CUD prevalence (MCL: 0·037% [95%CI: 0·03, 0·05]; RCL: 0·042% [95%CI: 0·02, 0·06]), with 5·7% and 6·0% of the increases in CUD prevalence attributable to MCL and RCL. Overall, MCL and RCL effects were significantly greater in patients with than without chronic pain. By age, MCL and RCL effects were negligible in patients age 18-34 with and without pain. In patients age 35-64 with and without pain, MCL and RCL effects were significant (p<0.001) but small. In patients age 65-75 with pain, absolute increases were 0·10% in MCL-only states and 0·22% in MCL/RCL states, with 9·3% of the increase in CUD prevalence in MCL-only states attributable to MCL, and 19.4% of the increase in RCL states attributable to RCL. In patients age 35-64 and 65-75, MCL and RCL effects were significantly greater in patients with pain. Interpretation In patients age 35-75, the role of MCL and RCL in the increasing prevalence of CUD was greater in patients with chronic pain than in those without chronic pain, with particularly pronounced effects in patients with chronic pain age 65-75. Although the VHA offers extensive behavioral and non-opioid pharmaceutical treatments for pain, cannabis may seem a more appealing option given media enthusiasm about cannabis, cannabis commercialization activities, and widespread public beliefs about cannabis efficacy. Cannabis does not have the risk/mortality profile of opioids, but CUD is a clinical condition with considerable impairment and comorbidity. Because cannabis legalization in the U.S. is likely to further increase, increasing CUD prevalence among patients with chronic pain following state legalization is a public health concern. The risk of chronic pain increases as individuals age, and the average age of VHA patients and the U.S. general population is increasing. Therefore, clinical monitoring of cannabis use and discussion of the risk of CUD among patients with chronic pain is warranted, especially among older patients. Research in Context Evidence before this study: Only three studies have examined the role of state medical cannabis laws (MCL) and/or recreational cannabis laws (RCL) in the increasing prevalence of cannabis use disorder (CUD) in U.S. adults, finding significant MCL and RCL effects but with modest effect sizes. Effects of MCL and RCL may vary across important subgroups of the population, including individuals with chronic pain. PubMed was searched by DH for publications on U.S. time trends in cannabis legalization, cannabis use disorders (CUD) and pain from database inception until March 15, 2023, without language restrictions. The following search terms were used: (medical cannabis laws) AND (pain) AND (cannabis use disorder); (recreational cannabis laws) AND (pain) AND (cannabis use disorder); (cannabis laws) AND (pain) AND (cannabis use disorder). Only one study was found that had CUD as an outcome, and this study used cross-sectional data from a single year, which cannot be used to determine trends over time. Therefore, evidence has been lacking on whether the role of state medical and recreational cannabis legalization in the increasing US adult prevalence of CUD differed by chronic pain status.Added value of this study: To our knowledge, this is the first study to examine whether the effects of state MCL and RCL on the nationally increasing U.S. rates of adult cannabis use disorder differ by whether individuals experience chronic pain or not. Using electronic medical record data from patients in the Veterans Health Administration (VHA) that included extensive information on medical conditions associated with chronic pain, the study showed that the effects of MCL and RCL on the prevalence of CUD were stronger among individuals with chronic pain age 35-64 and 65-75, an effect that was particularly pronounced in older patients ages 65-75.Implications of all the available evidence: MCL and RCL are likely to influence the prevalence of CUD through commercialization that increases availability and portrays cannabis use as 'normal' and safe, thereby decreasing perception of cannabis risk. In patients with pain, the overall U.S. decline in prescribed opioids may also have contributed to MCL and RCL effects, leading to substitution of cannabis use that expanded the pool of individuals vulnerable to CUD. The VHA offers extensive non-opioid pain programs. However, positive media reports on cannabis, positive online "information" that can sometimes be misleading, and increasing popular beliefs that cannabis is a useful prevention and treatment agent may make cannabis seem preferable to the evidence-based treatments that the VHA offers, and also as an easily accessible option among those not connected to a healthcare system, who may face more barriers than VHA patients in accessing non-opioid pain management. When developing cannabis legislation, unintended consequences should be considered, including increased risk of CUD in large vulnerable subgroups of the population.
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Affiliation(s)
- Deborah S Hasin
- Columbia University Irving Medical Center, 630 West 168th Street, New York, NY 10032, USA
- Columbia University Mailman School of Public Health, 722 W 168th St, New York, NY 10032, USA
- New York State Psychiatric Institute, 1051 Riverside Dr, New York, NY 10032, USA
| | - Melanie M Wall
- Columbia University Irving Medical Center, 630 West 168th Street, New York, NY 10032, USA
- New York State Psychiatric Institute, 1051 Riverside Dr, New York, NY 10032, USA
| | - Dan Alschuler
- New York State Psychiatric Institute, 1051 Riverside Dr, New York, NY 10032, USA
| | - Zachary L Mannes
- New York State Psychiatric Institute, 1051 Riverside Dr, New York, NY 10032, USA
| | - Carol Malte
- Health Services Research & Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, 1660 S Columbian Way, Seattle, WA 98108, USA
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care System, 1660 S Columbian Way, Seattle, WA 98108, USA
| | - Mark Olfson
- Columbia University Irving Medical Center, 630 West 168th Street, New York, NY 10032, USA
| | - Katherine M Keyes
- Columbia University Mailman School of Public Health, 722 W 168th St, New York, NY 10032, USA
| | - Jaimie L Gradus
- Boston University School of Public Health, 715 Albany St, Boston, MA 02118, USA
| | - Magdalena Cerdá
- New York University, 50 West 4th Street, New York, NY 10012, USA
| | - Charles C Maynard
- Health Services Research & Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, 1660 S Columbian Way, Seattle, WA 98108, USA
- University of Washington, 1400 Ne Campus Parkway, Seattle, WA 98195, USA
| | - Salomeh Keyhani
- San Francisco VA Health System, 4150 Clement St, San Francisco, CA 94121, USA
- University of California at San Francisco, 505 Parnassus Ave, San Francisco, CA 94143, USA
| | - Silvia S Martins
- Columbia University Mailman School of Public Health, 722 W 168th St, New York, NY 10032, USA
| | - David S Fink
- New York State Psychiatric Institute, 1051 Riverside Dr, New York, NY 10032, USA
| | - Ofir Livne
- New York State Psychiatric Institute, 1051 Riverside Dr, New York, NY 10032, USA
| | - Yoanna McDowell
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care System, 1660 S Columbian Way, Seattle, WA 98108, USA
| | - Scott Sherman
- New York University, 50 West 4th Street, New York, NY 10012, USA
- VA Manhattan Harbor Healthcare, 423 E 23rd St, New York, NY 10010, USA
| | - Andrew J Saxon
- Health Services Research & Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, 1660 S Columbian Way, Seattle, WA 98108, USA
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care System, 1660 S Columbian Way, Seattle, WA 98108, USA
- University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA 98195, USA
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Murphy SL, Zick SM, Harris RE, Smith SN, Sen A, Alexander NB, Caldararo J, Roman P, Firsht E, Belancourt P, Maciasz R, Perzhinsky J, Mitchinson A, Krein SL. Self-administered acupressure for veterans with chronic back pain: Study design and methodology of a type 1 hybrid effectiveness implementation randomized controlled trial. Contemp Clin Trials 2023; 130:107232. [PMID: 37207810 PMCID: PMC11017920 DOI: 10.1016/j.cct.2023.107232] [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: 03/06/2023] [Revised: 05/11/2023] [Accepted: 05/15/2023] [Indexed: 05/21/2023]
Abstract
BACKGROUND Chronic low back pain is prevalent and disabling in Veterans, but effective pain management is challenging. Clinical practice guidelines emphasize multimodal pain management including evidence-based complementary and integrative health treatments such as acupressure as a first line of care. Unfortunately, the ability to replicate interventions, cost, resources, and limited access are implementation barriers. Self-administered acupressure has shown positive effects on pain and can be practiced anywhere with little to no side effects. METHODS/DESIGN The aims of this Type 1 hybrid effectiveness implementation randomized controlled trial are 1) to determine effectiveness of a self-administered acupressure protocol at improving pain interference and secondary outcomes of fatigue, sleep quality, and disability in 300 Veterans with chronic low back pain, and 2) evaluate implementation barriers and facilitators to scale-up acupressure utilization within Veterans Health Administration (VHA). Participants randomized to the intervention will receive instruction on acupressure application using an app that facilitates daily practice for 6 weeks. During weeks 6 through 10, participants will discontinue acupressure to determine sustainability of effects. Participants randomized to waitlist control will continue their usual care for pain management and receive study materials at the end of the study period. Outcomes will be collected at baseline and at 6- and 10-weeks post baseline. The primary outcome is pain interference, measured by the PROMIS pain interference scale. Using established frameworks and a mixed methods approach, we will evaluate intervention implementation. DISCUSSION If acupressure is effective, we will tailor strategies to support implementation in the VHA based on study findings. TRIAL REGISTRATION NUMBER NCT05423145.
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Affiliation(s)
- Susan L Murphy
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, USA; Department of Internal Medicine, Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA
| | - Suzanna M Zick
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA; Department of Nutritional Sciences, School of Public Health, University of Michigan, Ann Arbor, MI, ISA, USA.
| | - Richard E Harris
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA; Susan Samueli Integrative Health Institute, School of Medicine, University of California at Irvine, Irvine, CA, USA.
| | - Shawna N Smith
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI, USA.
| | - Ananda Sen
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA.
| | - Neil B Alexander
- Department of Internal Medicine, Division of Geriatric Medicine, University of Michigan, Ann Arbor, MI, USA; VA Ann Arbor Healthcare System, Geriatric Research Education Clinical Center, Ann Arbor, MI, USA.
| | - Jennifer Caldararo
- VA Ann Arbor Healthcare System, Center for Clinical Management Research, Ann Arbor, MI, USA.
| | - Pia Roman
- VA Ann Arbor Healthcare System, Center for Clinical Management Research, Ann Arbor, MI, USA.
| | - Elizabeth Firsht
- VA Ann Arbor Healthcare System, Center for Clinical Management Research, Ann Arbor, MI, USA.
| | - Patrick Belancourt
- VA Ann Arbor Healthcare System, Center for Clinical Management Research, Ann Arbor, MI, USA.
| | - Rachael Maciasz
- VA Ann Arbor Healthcare System, Department of Ambulatory Care, Ann Arbor, MI, USA; Department of Internal Medicine, Division of General Medicine, University of Michigan, Ann Arbor, MI, USA.
| | - Juliette Perzhinsky
- VA Ann Arbor Healthcare System, Department of Ambulatory Care, Ann Arbor, MI, USA.
| | - Allison Mitchinson
- VA Ann Arbor Healthcare System, Center for Clinical Management Research, Ann Arbor, MI, USA.
| | - Sarah L Krein
- VA Ann Arbor Healthcare System, Center for Clinical Management Research, Ann Arbor, MI, USA; Department of Internal Medicine, Division of General Medicine, University of Michigan, Ann Arbor, MI, USA.
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Coleman BC, Lisi AJ, Abel EA, Runels T, Goulet JL. Association between early nonpharmacological management and follow-up for low back pain in the veterans health administration. NORTH AMERICAN SPINE SOCIETY JOURNAL 2023; 14:100233. [PMID: 37440983 PMCID: PMC10333712 DOI: 10.1016/j.xnsj.2023.100233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/23/2023] [Accepted: 05/26/2023] [Indexed: 07/15/2023]
Abstract
Background Low back pain (LBP) is a common reason individuals seek healthcare. Nonpharmacologic management (NPM) is often recommended as a primary intervention, and earlier use of NPM for LBP shows positive clinical outcomes. Our purpose was to evaluate how timing of engagement in NPM for LBP affects downstream LBP visits during the first year. Methods This study was a secondary analysis of an observational cohort study of national electronic health record data. Patients entering the Musculoskeletal Diagnosis/Complementary and Integrative Health Cohort with LBP from October 1, 2016 to September 30, 2017 were included. Exclusive patient groups were defined by engagement in NPM within 30 days of entry ("very early NPM"), between 31 and 90 days ("early NPM"), or not within the first 90 days ("no NPM"). The outcome was time, in days, to the final LBP follow-up after 90 days and within the first year. Cox proportional hazards regression was used to model time to final follow up, controlling for additional demographic and clinical covariables. Results The study population included 44,175 patients, with 16.7% engaging in very early NPM and 13.1% in early NPM. Patients with very early NPM (5.2 visits, SD=4.5) or early NPM (5.7 visits, SD=4.6) had a higher mean number of LBP visits within the first year than those not receiving NPM in the first 90 days (3.2 visits, SD = 2.5). The very early NPM (HR=1.50, 95% CI: 1.46-1.54; median=48 days, IQR=97) and early NPM (HR=1.27, 95% CI: 1.23-1.30; median=88 days, IQR=92) had a significantly shorter time to final follow-up than the no NPM group (median=109 days, IQR=150). Conclusions Veterans Health Administration patients receiving NPM for LBP within the first 90 days after initially seeking care demonstrate a significantly faster time to final follow-up visit within the first year compared to those who do not.
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Affiliation(s)
- Brian C. Coleman
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, 950 Campbell Ave, West Haven, CT 06516, United States
- Yale School of Medicine, Yale University, 333 Cedar Street, New Haven, CT 06510, United States
| | - Anthony J. Lisi
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, 950 Campbell Ave, West Haven, CT 06516, United States
- Yale School of Medicine, Yale University, 333 Cedar Street, New Haven, CT 06510, United States
| | - Erica A. Abel
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, 950 Campbell Ave, West Haven, CT 06516, United States
- Yale School of Medicine, Yale University, 333 Cedar Street, New Haven, CT 06510, United States
| | - Tessa Runels
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, 950 Campbell Ave, West Haven, CT 06516, United States
| | - Joseph L. Goulet
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, 950 Campbell Ave, West Haven, CT 06516, United States
- Yale School of Medicine, Yale University, 333 Cedar Street, New Haven, CT 06510, United States
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Han L, Luther SL, Finch DK, Dobscha SK, Skanderson M, Bathulapalli H, Fodeh SJ, Hahm B, Bouayad L, Lee A, Goulet JL, Brandt CA, Kerns RD. Complementary and Integrative Health Approaches and Pain Care Quality in the Veterans Health Administration Primary Care Setting: A Quasi-Experimental Analysis. JOURNAL OF INTEGRATIVE AND COMPLEMENTARY MEDICINE 2023; 29:420-429. [PMID: 36971840 PMCID: PMC10280173 DOI: 10.1089/jicm.2022.0686] [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: 06/10/2023]
Abstract
Background: Complementary and integrative health (CIH) approaches have been recommended in national and international clinical guidelines for chronic pain management. We set out to determine whether exposure to CIH approaches is associated with pain care quality (PCQ) in the Veterans Health Administration (VHA) primary care setting. Methods: We followed a cohort of 62,721 Veterans with newly diagnosed musculoskeletal disorders between October 2016 and September 2017 over 1-year. PCQ scores were derived from primary care progress notes using natural language processing. CIH exposure was defined as documentation of acupuncture, chiropractic or massage therapies by providers. Propensity scores (PSs) were used to match one control for each Veteran with CIH exposure. Generalized estimating equations were used to examine associations between CIH exposure and PCQ scores, accounting for potential selection and confounding bias. Results: CIH was documented for 14,114 (22.5%) Veterans over 16,015 primary care clinic visits during the follow-up period. The CIH exposure group and the 1:1 PS-matched control group achieved superior balance on all measured baseline covariates, with standardized differences ranging from 0.000 to 0.045. CIH exposure was associated with an adjusted rate ratio (aRR) of 1.147 (95% confidence interval [CI]: 1.142, 1.151) on PCQ total score (mean: 8.36). Sensitivity analyses using an alternative PCQ scoring algorithm (aRR: 1.155; 95% CI: 1.150-1.160) and redefining CIH exposure by chiropractic alone (aRR: 1.118; 95% CI: 1.110-1.126) derived consistent results. Discussion: Our data suggest that incorporating CIH approaches may reflect higher overall quality of care for patients with musculoskeletal pain seen in primary care settings, supporting VHA initiatives and the Declaration of Astana to build comprehensive, sustainable primary care capacity for pain management. Future investigation is warranted to better understand whether and to what degree the observed association may reflect the therapeutic benefits patients actually received or other factors such as empowering provider-patient education and communication about these approaches.
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Affiliation(s)
- Ling Han
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- VA Connecticut Healthcare System, Pain Research, Informatics, Multimorbdities and Education (PRIME) Center, West Haven, CT, USA
| | - Stephen L. Luther
- James A. Haley Veterans Hospital, Tampa, FL, USA
- University of South Florida, College of Public Health, Tampa, FL, USA
| | | | - Steven K. Dobscha
- Oregon Health and Science University, Portland, OR, USA
- VA Portland Health Care System, Portland, OR, USA
| | - Melissa Skanderson
- VA Connecticut Healthcare System, Pain Research, Informatics, Multimorbdities and Education (PRIME) Center, West Haven, CT, USA
| | - Harini Bathulapalli
- VA Connecticut Healthcare System, Pain Research, Informatics, Multimorbdities and Education (PRIME) Center, West Haven, CT, USA
| | - Samah J. Fodeh
- VA Connecticut Healthcare System, Pain Research, Informatics, Multimorbdities and Education (PRIME) Center, West Haven, CT, USA
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Bridget Hahm
- James A. Haley Veterans Hospital, Tampa, FL, USA
| | - Lina Bouayad
- James A. Haley Veterans Hospital, Tampa, FL, USA
- Florida International University, Miami, FL, USA
| | - Allison Lee
- VA Connecticut Healthcare System, Pain Research, Informatics, Multimorbdities and Education (PRIME) Center, West Haven, CT, USA
| | - Joseph L. Goulet
- VA Connecticut Healthcare System, Pain Research, Informatics, Multimorbdities and Education (PRIME) Center, West Haven, CT, USA
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Cynthia A. Brandt
- VA Connecticut Healthcare System, Pain Research, Informatics, Multimorbdities and Education (PRIME) Center, West Haven, CT, USA
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Robert D. Kerns
- VA Connecticut Healthcare System, Pain Research, Informatics, Multimorbdities and Education (PRIME) Center, West Haven, CT, USA
- Departments of Psychiatry, Neurology and Psychology, Yale University, New Haven, CT, USA
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9
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C. Coleman B, Finch D, Wang R, L. Luther S, Heapy A, Brandt C, J. Lisi A. Extracting Pain Care Quality Indicators from U.S. Veterans Health Administration Chiropractic Care Using Natural Language Processing. Appl Clin Inform 2023; 14:600-608. [PMID: 37164327 PMCID: PMC10411229 DOI: 10.1055/a-2091-1162] [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: 01/05/2023] [Accepted: 04/27/2023] [Indexed: 05/12/2023] Open
Abstract
BACKGROUND Musculoskeletal pain is common in the Veterans Health Administration (VHA), and there is growing national use of chiropractic services within the VHA. Rapid expansion requires scalable and autonomous solutions, such as natural language processing (NLP), to monitor care quality. Previous work has defined indicators of pain care quality that represent essential elements of guideline-concordant, comprehensive pain assessment, treatment planning, and reassessment. OBJECTIVE Our purpose was to identify pain care quality indicators and assess patterns across different clinic visit types using NLP on VHA chiropractic clinic documentation. METHODS Notes from ambulatory or in-hospital chiropractic care visits from October 1, 2018 to September 30, 2019 for patients in the Women Veterans Cohort Study were included in the corpus, with visits identified as consultation visits and/or evaluation and management (E&M) visits. Descriptive statistics of pain care quality indicator classes were calculated and compared across visit types. RESULTS There were 11,752 patients who received any chiropractic care during FY2019, with 63,812 notes included in the corpus. Consultation notes had more than twice the total number of annotations per note (87.9) as follow-up visit notes (34.7). The mean number of total classes documented per note across the entire corpus was 9.4 (standard deviation [SD] = 1.5). More total indicator classes were documented during consultation visits with (mean = 14.8, SD = 0.9) or without E&M (mean = 13.9, SD = 1.2) compared to follow-up visits with (mean = 9.1, SD = 1.4) or without E&M (mean = 8.6, SD = 1.5). Co-occurrence of pain care quality indicators describing pain assessment was high. CONCLUSION VHA chiropractors frequently document pain care quality indicators, identifiable using NLP, with variability across different visit types.
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Affiliation(s)
- Brian C. Coleman
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut, United States
- Yale Center for Medical Informatics, Yale School of Medicine, Yale University, New Haven, Connecticut, United States
| | - Dezon Finch
- Research Service, James A. Haley Veterans Hospital, Tampa, Florida, United States
| | - Rixin Wang
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut, United States
- Yale Center for Medical Informatics, Yale School of Medicine, Yale University, New Haven, Connecticut, United States
| | - Stephen L. Luther
- Research Service, James A. Haley Veterans Hospital, Tampa, Florida, United States
- College of Public Health, University of South Florida, Tampa, Florida, United States
| | - Alicia Heapy
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut, United States
- Department of Psychiatry, Yale School of Medicine, Yale University, New Haven, Connecticut, United States
| | - Cynthia Brandt
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut, United States
- Yale Center for Medical Informatics, Yale School of Medicine, Yale University, New Haven, Connecticut, United States
| | - Anthony J. Lisi
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut, United States
- Yale Center for Medical Informatics, Yale School of Medicine, Yale University, New Haven, Connecticut, United States
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10
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Mattocks KM, LaChappelle KM, Krein SL, DeBar LL, Martino S, Edmond S, Ankawi B, MacLean RR, Higgins DM, Murphy JL, Cooper E, Heapy AA. Pre-implementation formative evaluation of cooperative pain education and self-management expanding treatment for real-world access: A pragmatic pain trial. Pain Pract 2023; 23:338-348. [PMID: 36527287 DOI: 10.1111/papr.13195] [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: 03/31/2022] [Revised: 09/01/2022] [Accepted: 11/21/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Cognitive behavioral therapy for chronic pain (CBT-CP) is an evidence-based treatment for improving functioning and pain intensity for people with chronic pain with extensive evidence of effectiveness. However, there has been relatively little investigation of the factors associated with successful implementation and uptake of CBT-CP, particularly clinician and system level factors. This formative evaluation examined barriers and facilitators to the successful implementation and uptake of CBT-CP from the perspective of CBT-CP clinicians and referring primary care clinicians. METHODS Qualitative interviews guided by the Consolidated Framework for Implementation Research were conducted at nine geographically diverse Veterans Affairs sites as part of a pragmatic clinical trial comparing synchronous, clinician-delivered CBT-CP and remotely delivered, technology-assisted CBT-CP. Analysis was informed by a grounded theory approach. RESULTS Twenty-six clinicians (CBT-CP clinicians = 17, primary care clinicians = 9) from nine VA medical centers participated in individual qualitative interviews conducted by telephone from April 2019 to August 2020. Four themes emerged in the qualitative interviews: (1) the complexity and variability of referral pathways across sites, (2) referring clinician's lack of knowledge about CBT-CP, (3) referring clinician's difficulty identifying suitable candidates for CBT-CP, and (4) preference for interventions that can be completed from home. CONCLUSIONS This formative evaluation identified clinician and system barriers to widespread implementation of CBT-CP and allowed for refinement of the subsequent implementation of two forms of CBT-CP in an ongoing pragmatic trial. Identification of relative difference in barriers and facilitators in the two forms of CBT-CP may emerge more clearly in a pragmatic trial that evaluates how treatments perform in real-world settings and may provide important information to guide future system-wide implementation efforts.
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Affiliation(s)
- Kristin M Mattocks
- VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts, USA
- University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Kathryn M LaChappelle
- VA Connecticut Healthcare System Pain Research, Informatics, Multimorbidities, and Education (PRIME) Health Services Research and Development Center of Innovation, West Haven, Connecticut, USA
| | - Sarah L Krein
- VA Ann Arbor Center for Clinical Management Research, Health Services Research and Development Center of Innovation, Ann Arbor, Michigan, USA
- University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Lynn L DeBar
- Kaiser Permanente Washington Health Research Institute, Washington, USA
| | - Steve Martino
- VA Connecticut Healthcare System Pain Research, Informatics, Multimorbidities, and Education (PRIME) Health Services Research and Development Center of Innovation, West Haven, Connecticut, USA
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Sara Edmond
- VA Connecticut Healthcare System Pain Research, Informatics, Multimorbidities, and Education (PRIME) Health Services Research and Development Center of Innovation, West Haven, Connecticut, USA
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Brett Ankawi
- VA Connecticut Healthcare System Pain Research, Informatics, Multimorbidities, and Education (PRIME) Health Services Research and Development Center of Innovation, West Haven, Connecticut, USA
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - R Ross MacLean
- VA Connecticut Healthcare System Pain Research, Informatics, Multimorbidities, and Education (PRIME) Health Services Research and Development Center of Innovation, West Haven, Connecticut, USA
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Diana M Higgins
- VA Boston Healthcare System, Boston, Massachusetts, USA
- Boston University School of Medicine, Boston, Massachusetts, USA
| | - Jennifer L Murphy
- US Department of Veterans Affairs Central Office, Washington, DC, USA
| | - Emily Cooper
- VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts, USA
- University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Alicia A Heapy
- VA Connecticut Healthcare System Pain Research, Informatics, Multimorbidities, and Education (PRIME) Health Services Research and Development Center of Innovation, West Haven, Connecticut, USA
- Yale University School of Medicine, New Haven, Connecticut, USA
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11
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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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12
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Clark JD, Bair MJ, Belitskaya-Lévy I, Fitzsimmons C, Zehm LM, Dougherty PE, Giannitrapani KF, Groessl EJ, Higgins DM, Murphy JL, Riddle DL, Huang GD, Shih MC. Sequential and Comparative Evaluation of Pain Treatment Effectiveness Response (SCEPTER), a pragmatic trial for conservative chronic low back pain treatment. Contemp Clin Trials 2023; 125:107041. [PMID: 36496154 DOI: 10.1016/j.cct.2022.107041] [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: 08/30/2022] [Revised: 11/18/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Chronic low back pain (cLBP) is a common and highly disabling problem world-wide. Although many treatment options exist, it is unclear how to best sequence the multitude of care options to provide the greatest benefit to patients. METHODS The Sequential and Comparative Evaluation of Pain Treatment Effectiveness Response (SCEPTER) trial uses a pragmatic, randomized, stepped design. Enrollment targets 2529 participants from 20 Veterans Affairs (VA) medical centers. Participants with chronic low back pain will first be randomized to one of three options: 1) an internet-based self-management program (Pain EASE); 2) a tailored physical therapy program (Enhanced PT); or 3) continued care with active monitoring (CCAM), a form of usual care. Participants not achieving a 30% or 2-point reduction on the study's primary outcome (Brief Pain Inventory Pain Interference (BPI-PI) subscale), 3 months after beginning treatment may undergo re-randomization in a second step to cognitive behavioral therapy for chronic pain, spinal manipulation therapy, or yoga. Secondary outcomes include pain intensity, back pain-related disability, depression, and others. Participants will be assessed every three months until 12 months after initiating their final trial therapy. Companion economic and implementation analyses are also planned. RESULTS The SCEPTER trial is currently recruiting and enrolling participants. CONCLUSIONS Trial results will inform treatment decisions for the stepped management of chronic low back pain - a common and disabling condition. Additional analyses will help tailor treatment selection to individual patient characteristics, promote efficient resource use, and identify implementation barriers of interventions. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT04142177.
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Affiliation(s)
- J David Clark
- Anesthesiology Service, VA Palo Alto Health Care System, Palo Alto, CA, USA; Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA, USA
| | - Matthew J Bair
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, IN, USA; Indiana University School of Medicine, Department of Medicine, Indianapolis, IN, USA; Regenstrief Institute, Inc., Indianapolis, IN, USA.
| | - Ilana Belitskaya-Lévy
- VA Cooperative Studies Program Coordinating Center, VA Palo Alto Health Care System, Mountain View, CA, USA
| | | | - Lisa M Zehm
- VA Cooperative Studies Program Coordinating Center, VA Palo Alto Health Care System, Mountain View, CA, USA
| | - Paul E Dougherty
- VA Finger Lakes Health Care System, Canandaigua, NY, USA; Northeast College of Health Sciences, Seneca Falls, NY, USA
| | - Karleen F Giannitrapani
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA; Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Erik J Groessl
- Research Service, VA San Diego Healthcare System, San Diego, CA, USA; Herbert Wertheim School of Public Health, University of California San Diego, La Jolla, CA, USA
| | - Diana M Higgins
- Durham VA Healthcare System Duram, NC, USA; Boston University School of Medicine, Boston, MA, USA
| | - Jennifer L Murphy
- Department of Veterans Affairs (VA), Specialty Care Program Office, Director of Pain Management, Washington, DC, USA
| | - Daniel L Riddle
- Departments of Physical Therapy, Orthopedic Surgery and Rheumatology, Virginia Commonwealth University, Richmond, VA, USA
| | - Grant D Huang
- Office of Research and Development, U.S. Department of Veterans Affairs, Washington, DC, USA
| | - Mei-Chiung Shih
- VA Cooperative Studies Program Coordinating Center, VA Palo Alto Health Care System, Mountain View, CA, USA
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13
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Rahpeyma A, Eshghpour M, Vaezi T, Abdolrahim S, Manafi A, Manafi N. Pharmacological and Non-Pharmacological Methods of Postoperative Pain Control Following Oral and Maxillofacial Surgery: A Systematic Review. World J Plast Surg 2023; 12:3-10. [PMID: 38130382 PMCID: PMC10732294 DOI: 10.52547/wjps.12.2.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 09/10/2023] [Indexed: 12/23/2023] Open
Abstract
Background We aimed to investigate the pharmacological and non-pharmacological interventions used for mitigating pain. Methods We integrated randomized controlled trials (RCTs) chosen from PubMed, Google scholar, and Scopus and aimed at assessing the effectiveness of one or multiple variants of Non-steroidal anti-inflammatory drugs (NSAIDs), as well as Narcotic analgesics, compared to corticosteroids, curcumin, hyaluronic acid, and antibiotics. In addition, trials utilizing NSAIDs, including Rofecoxib, which have been withdrawn from market circulation, were deemed ineligible for inclusion. Result A total of 9 RCTs were evaluated in this study, and the patients' postoperative pain was assessed using the visual analog scale (VAS) and the time measurement. Moreover, there were various approaches to alleviating pain and discomfort. Conclusion The administration of ibuprofen prior to surgery leads to a marked reduction in pain. Pharmacological interventions, such as the administration of dexamethasone and oxycodone, alongside non-pharmacological interventions, such as laser therapy, have been shown to effectively alleviate the discomfort resulting from surgical procedures on the jaw and face.
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Affiliation(s)
- Amin Rahpeyma
- Department of Oral & Maxillofacial Surgery, Mashhad University of Medical Science, Mashhad, Iran
| | - Majid Eshghpour
- Department of Oral & Maxillofacial Surgery, Mashhad University of Medical Science, Mashhad, Iran
| | - Tooraj Vaezi
- Department of Oral & Maxillofacial Surgery, Mashhad University of Medical Science, Mashhad, Iran
| | - Shams Abdolrahim
- Department of Oral & Maxillofacial Surgery, Student Research Committee, Faculty of Dentistry, Mashhad University of Medical Science, Mashhad, Iran
| | - Amir Manafi
- Department of Anesthesia, Detroit Medical Center, NorthStar Anesthesia, Detroit, MI
| | - Navid Manafi
- Department of Anesthesia, Detroit Medical Center, NorthStar Anesthesia, Detroit, MI
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14
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Holman A, Parikh N, Clauw DJ, Williams DA, Tapper EB. Contemporary management of pain in cirrhosis: Toward precision therapy for pain. Hepatology 2023; 77:290-304. [PMID: 35665522 PMCID: PMC9970025 DOI: 10.1002/hep.32598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 05/19/2022] [Accepted: 05/20/2022] [Indexed: 02/03/2023]
Abstract
Chronic pain is highly prevalent in patients with cirrhosis and is associated with poor health-related quality of life and poor functional status. However, there is limited guidance on appropriate pain management in this population, and pharmacologic treatment can be harmful, leading to adverse outcomes, such as gastrointestinal bleeding, renal injury, falls, and hepatic encephalopathy. Chronic pain can be categorized mechanistically into three pain types: nociceptive, neuropathic, and nociplastic, each responsive to different therapies. By discussing the identification, etiology, and treatment of these three mechanistic pain descriptors with a focus on specific challenges in patients with cirrhosis, we provide a framework for better tailoring treatments, including nonpharmacologic therapies, to patients' needs.
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Affiliation(s)
- Alexis Holman
- Division of Rheumatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Neehar Parikh
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Dan J. Clauw
- Chronic Pain and Fatigue Research Center, Anesthesiology Department, University of Michigan, Ann Arbor, Michigan, USA
| | - David A. Williams
- Chronic Pain and Fatigue Research Center, Anesthesiology Department, University of Michigan, Ann Arbor, Michigan, USA
| | - Elliot B. Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
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15
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Fritz JM, Del Fiol G, Gibson B, Wetter DW, Solis V, Bennett E, Thackeray A, Goode A, Lundberg K, Romero A, Ford I, Stevens L, Siaperas T, Morales J, Yack M, Greene T. BeatPain Utah: study protocol for a pragmatic randomised trial examining telehealth strategies to provide non-pharmacologic pain care for persons with chronic low back pain receiving care in federally qualified health centers. BMJ Open 2022; 12:e067732. [PMID: 36351735 PMCID: PMC9664275 DOI: 10.1136/bmjopen-2022-067732] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 10/21/2022] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Although evidence-based guidelines recommend non-pharmacologic treatments as first-line care for chronic low back pain (LBP), uptake has been limited, particularly in rural, low-income and ethnically diverse communities. The BeatPain study will evaluate the implementation and compare the effectiveness of two strategies to provide non-pharmacologic treatment for chronic LBP. The study will use telehealth to overcome access barriers for persons receiving care in federally qualified health centres (FQHCs) in the state of Utah. METHODS AND ANALYSIS BeatPain Utah is a pragmatic randomised clinical trial with a hybrid type I design investigating different strategies to provide non-pharmacologic care for adults with chronic LBP seen in Utah FQHCs. The intervention strategies include a brief pain consult (BPC) and telehealth physical therapy (PT) component provided using either an adaptive or sequenced delivery strategy across two 12-week treatment phases. Interventions are provided via telehealth by centrally located physical therapists. The sequenced delivery strategy provides the BPC, followed by telehealth PT in the first 12 weeks for all patients. The adaptive strategy uses a stepped care approach and provides the BPC in the first 12 weeks and telehealth PT to patients who are non-responders to the BPC component. We will recruit 500 English-speaking or Spanish-speaking participants who will be individually randomised with 1:1 allocation. The primary outcome is the Pain, Enjoyment and General Activity measure of pain impact with secondary outcomes including the additional pain assessment domains specified by the National Institutes (NIH) of Health Helping to End Addiction Long Initiative and implementation measures. Analyses of primary and secondary measures of effectiveness will be performed under longitudinal mixed effect models across assessments at baseline, and at 12, 26 and 52 weeks follow-ups. ETHICS AND DISSEMINATION Ethics approval for the study was obtained from the University of Utah Institutional Review Board. On completion, study data will be made available in compliance with NIH data sharing policies. TRIAL REGISTRATION NUMBER NCT04923334.
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Affiliation(s)
- Julie M Fritz
- Department of Physical Therapy & Athletic Training, The University of Utah, Salt Lake City, Utah, USA
| | - Guilherme Del Fiol
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
| | - Bryan Gibson
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
| | - David W Wetter
- Population Sciences, Huntsman Cancer Institute, Salt Lake City, Utah, USA
| | - Victor Solis
- Department of Physical Therapy & Athletic Training, The University of Utah, Salt Lake City, Utah, USA
| | - Emily Bennett
- Association for Utah Community Health, Salt Lake City, Utah, USA
| | - Anne Thackeray
- Department of Physical Therapy & Athletic Training, The University of Utah, Salt Lake City, Utah, USA
| | - Adam Goode
- Orthopedic Surgery and Population Health Sciences, Duke University, Durham, North Carolina, USA
| | - Kelly Lundberg
- Department of Psychiatry, University of Utah, Salt Lake City, Utah, USA
| | - Adrianna Romero
- Department of Physical Therapy & Athletic Training, The University of Utah, Salt Lake City, Utah, USA
| | - Isaac Ford
- Department of Physical Therapy & Athletic Training, The University of Utah, Salt Lake City, Utah, USA
| | - Leticia Stevens
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
| | - Tracey Siaperas
- Association for Utah Community Health, Salt Lake City, Utah, USA
| | - Jennyfer Morales
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah, USA
| | - Melissa Yack
- Center for Health Outcomes and Population Equity - Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Tom Greene
- Division of Epidemiology, University of Utah, Salt Lake City, Utah, USA
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16
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Non-pharmacological Treatment for Chronic Pain in US Veterans Treated Within the Veterans Health Administration: Implications for Expansion in US Healthcare Systems. J Gen Intern Med 2022; 37:3937-3946. [PMID: 35048300 PMCID: PMC8769678 DOI: 10.1007/s11606-021-07370-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 12/16/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Consensus guidelines recommend multimodal chronic pain treatment with increased use of non-pharmacological treatment modalities (NPM), including as first-line therapies. However, with many barriers to NPM uptake in US healthcare systems, NPM use may vary across medical care settings. Military veterans are disproportionately affected by chronic pain. Many veterans receive treatment through the Veterans Health Administration (VHA), an integrated healthcare system in which specific policies promote NPM use. OBJECTIVE To examine whether veterans with chronic pain who utilize VHA healthcare were more likely to use NPM than veterans who do not utilize VHA healthcare. DESIGN Cross-sectional nationally representative study. PARTICIPANTS US military veterans (N = 2,836). MAIN MEASURES In the 2019 National Health Interview Survey, veterans were assessed for VHA treatment, chronic pain (i.e., past 3-month daily or almost daily pain), symptoms of depression and anxiety, substance use, and NPM (i.e., physical therapy, chiropractic/spinal manipulation, massage, psychotherapy, educational class/workshop, peer support groups, or yoga/tai chi). KEY RESULTS Chronic pain (45.2% vs. 26.8%) and NPM use (49.8% vs. 39.4%) were more prevalent among VHA patients than non-VHA veterans. After adjusting for sociodemographic characteristics, psychiatric symptoms, physical health indicators, and use of cigarettes or prescription opioids, VHA patients were more likely than non-VHA veterans to use any NPM (adjusted odds ratio [aOR] = 1.52, 95% CI: 1.07-2.16) and multimodal NPM (aOR = 1.80, 95% CI: 1.12-2.87) than no NPM. Among veterans with chronic pain, VHA patients were more likely to use chiropractic care (aOR = 1.90, 95% CI = 1.12-3.22), educational class/workshop (aOR = 3.02, 95% CI = 1.35-6.73), or psychotherapy (aOR = 4.28, 95% CI = 1.69-10.87). CONCLUSIONS Among veterans with chronic pain, past-year VHA use was associated with greater likelihood of receiving NPM. These findings may suggest that the VHA is an important resource and possible facilitator of NPM. VHA policies may offer guidance for expanding use of NPM in other integrated US healthcare systems.
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17
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McGeary DD, Jaramillo C, Eapen B, Blount TH, Nabity PS, Moreno J, Pugh MJ, Houle TT, Potter JS, Young-McCaughan S, Peterson AL, Villarreal R, Brackins N, Sikorski Z, Johnson TR, Tapia R, Reed D, Caya CA, Bomer D, Simmonds M, McGeary CA. Mindfulness-Based Interdisciplinary Pain Management Program for Complex Polymorbid Pain in Veterans: A Randomized Clinical Trial. Arch Phys Med Rehabil 2022; 103:1899-1907. [DOI: 10.1016/j.apmr.2022.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 06/15/2022] [Accepted: 06/21/2022] [Indexed: 11/25/2022]
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18
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A Comprehensive Assessment of The Eight Vital Signs. THE EUROBIOTECH JOURNAL 2022. [DOI: 10.2478/ebtj-2022-0014] [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] Open
Abstract
Abstract
The term “vital sign” has been assigned to various phenomena with the presumptive intent to emphasize their importance in health care resulting in the emergence of eight vital signs with multiple designations and overlapping terms. This review developed a case definition for vital signs and identified and described the fifth through eighth vital signs. PubMed/Medline, Google and biographical databases were searched using the individual Medical Subject Headings (MeSH) terms, vital sign and fifth, vital sign and sixth, vital sign and seventh, and vital sign eighth. The search was limited to human clinical studies written in English literature from 1957 up until November 30, 2021. Excluded were articles containing the term vital sign if used alone without the qualifier fifth, sixth, seventh, or eighth or about temperature, blood pressure, pulse, and respiratory rate. One hundred ninety-six articles (122 for the fifth vital sign, 71 for the sixth vital sign, two for the seventh vital sign, and one for the eighth vital sign) constituted the final dataset. The vital signs consisted of 35 terms, classified into 17 categories compromising 186 unique papers for each primary authored article with redundant numbered vital signs for glucose, weight, body mass index, and medication compliance. Eleven terms have been named the fifth vital sign, 25 the sixth vital sign, three the seventh, and one as the eighth vital sign. There are four time-honored vital signs based on the case definition, and they represent an objective bedside measurement obtained noninvasively that is essential for life. Based on this case definition, pulse oximetry qualifies as the fifth while end-tidal CO2 and cardiac output as the sixth. Thus, these terms have been misappropriated 31 times. Although important to emphasize in patient care, the remainder are not vital signs and should not be construed in this manner.
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Luther SL, Finch DK, Bouayad L, McCart J, Han L, Dobscha SK, Skanderson M, Fodeh SJ, Hahm B, Lee A, Goulet JL, Brandt CA, Kerns RD. Measuring pain care quality in the Veterans Health Administration primary care setting. Pain 2022; 163:e715-e724. [PMID: 34724683 PMCID: PMC8920945 DOI: 10.1097/j.pain.0000000000002477] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/05/2021] [Accepted: 08/18/2021] [Indexed: 11/25/2022]
Abstract
ABSTRACT The lack of a reliable approach to assess quality of pain care hinders quality improvement initiatives. Rule-based natural language processing algorithms were used to extract pain care quality (PCQ) indicators from documents of Veterans Health Administration primary care providers for veterans diagnosed within the past year with musculoskeletal disorders with moderate-to-severe pain intensity across 2 time periods 2013 to 2014 (fiscal year [FY] 2013) and 2017 to 2018 (FY 2017). Patterns of documentation of PCQ indicators for 64,444 veterans and 124,408 unique visits (FY 2013) and 63,427 veterans and 146,507 visits (FY 2017) are described. The most commonly documented PCQ indicators in each cohort were presence of pain, etiology or source, and site of pain (greater than 90% of progress notes), while least commonly documented were sensation, what makes pain better or worse, and pain's impact on function (documented in fewer than 50%). A PCQ indicator score (maximum = 12) was calculated for each visit in FY 2013 (mean = 7.8, SD = 1.9) and FY 2017 (mean = 8.3, SD = 2.3) by adding one point for every indicator documented. Standardized Cronbach alpha for total PCQ scores was 0.74 in the most recent data (FY 2017). The mean PCQ indicator scores across patient characteristics and types of healthcare facilities were highly stable. Estimates of the frequency of documentation of PCQ indicators have face validity and encourage further evaluation of the reliability, validity, and utility of the measure. A reliable measure of PCQ fills an important scientific knowledge and practice gap.
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Affiliation(s)
- Stephen L. Luther
- Research and Development Service, James A. Haley Veterans Hospital, Tampa, FL, United States
- University of South Florida College of Public Health, Tampa, FL, United States
| | - Dezon K. Finch
- Research and Development Service, James A. Haley Veterans Hospital, Tampa, FL, United States
| | - Lina Bouayad
- Research and Development Service, James A. Haley Veterans Hospital, Tampa, FL, United States
- Florida International University, Miami, FL, United States
| | - James McCart
- Research and Development Service, James A. Haley Veterans Hospital, Tampa, FL, United States
- Morsani College of Medicine, University of South Florida, Tampa, FL, United States
| | - Ling Han
- Pain Research, Informatics, Multimorbidities and Education Center, VA Connecticut Healthcare System, West Haven, CT, United States
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States
| | - Steven K. Dobscha
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, United States
- Department of Psychiatry, Oregon Health & Science University, Portland, OR, United States
| | - Melissa Skanderson
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, United States
| | - Samah J. Fodeh
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, United States
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States
| | - Bridget Hahm
- Research and Development Service, James A. Haley Veterans Hospital, Tampa, FL, United States
| | - Allison Lee
- Pain Research, Informatics, Multimorbidities and Education Center, VA Connecticut Healthcare System, West Haven, CT, United States
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States
| | - Joseph L. Goulet
- Pain Research, Informatics, Multimorbidities and Education Center, VA Connecticut Healthcare System, West Haven, CT, United States
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, United States
| | - Cynthia A. Brandt
- Pain Research, Informatics, Multimorbidities and Education Center, VA Connecticut Healthcare System, West Haven, CT, United States
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, United States
| | - Robert D. Kerns
- Pain Research, Informatics, Multimorbidities and Education Center, VA Connecticut Healthcare System, West Haven, CT, United States
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States
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20
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Sud A, Buchman DZ, Furlan AD, Selby P, Spithoff SM, Upshur REG. Chronic Pain and Opioid Prescribing: Three Ways for Navigating Complexity at the Clinical‒Population Health Interface. Am J Public Health 2022; 112:S56-S65. [PMID: 35143271 PMCID: PMC8842204 DOI: 10.2105/ajph.2021.306500] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2021] [Indexed: 11/04/2022]
Abstract
Clinically focused interventions for people living with pain, such as health professional education, clinical decision support systems, prescription drug monitoring programs, and multidisciplinary care to support opioid tapering, have all been promoted as important solutions to the North American opioid crisis. Yet none have so far delivered substantive beneficial opioid-related population health outcomes. In fact, while total opioid prescribing has leveled off or reduced in many jurisdictions, population-level harms from opioids have continued to increase dramatically. We attribute this failure partly to a poor recognition of the epistemic and ethical complexities at the interface of clinical and population health. We draw on a framework of knowledge networks in wicked problems to identify 3 strategies to help navigate these complexities: (1) designing and evaluating clinically focused interventions as complex interventions, (2) reformulating evidence to make population health dynamics apparent, and (3) appealing to the inseparability of facts and values to support decision-making in uncertainty. We advocate that applying these strategies will better equip clinically focused interventions as complements to structural and public health interventions to achieve the desired beneficial population health effects. (Am J Public Health. 2022;112(S1):S56-S65. https://doi.org/10.2105/AJPH.2021.306500).
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Affiliation(s)
- Abhimanyu Sud
- Abhimanyu Sud is with the Department of Family and Community Medicine and Institute for Health Policy, Management, and Evaluation, University of Toronto, Canada. Daniel Z. Buchman is with Centre for Addiction and Mental Health and Dalla Lana School of Public Health, Toronto. Andrea D. Furlan is with the Institute for Work and Health and Department of Medicine, University of Toronto. Peter Selby is with the Centre for Addiction and Mental Health and Department of Family and Community Medicine, Department of Psychiatry, University of Toronto. Sheryl M. Spithoff is with Department of Family and Community Medicine, University of Toronto. Ross E. G. Upshur is with the Bridgepoint Collaboratory for Research and Innovation, Department of Family and Community Medicine, Dalla Lana School of Public Health, University of Toronto
| | - Daniel Z Buchman
- Abhimanyu Sud is with the Department of Family and Community Medicine and Institute for Health Policy, Management, and Evaluation, University of Toronto, Canada. Daniel Z. Buchman is with Centre for Addiction and Mental Health and Dalla Lana School of Public Health, Toronto. Andrea D. Furlan is with the Institute for Work and Health and Department of Medicine, University of Toronto. Peter Selby is with the Centre for Addiction and Mental Health and Department of Family and Community Medicine, Department of Psychiatry, University of Toronto. Sheryl M. Spithoff is with Department of Family and Community Medicine, University of Toronto. Ross E. G. Upshur is with the Bridgepoint Collaboratory for Research and Innovation, Department of Family and Community Medicine, Dalla Lana School of Public Health, University of Toronto
| | - Andrea D Furlan
- Abhimanyu Sud is with the Department of Family and Community Medicine and Institute for Health Policy, Management, and Evaluation, University of Toronto, Canada. Daniel Z. Buchman is with Centre for Addiction and Mental Health and Dalla Lana School of Public Health, Toronto. Andrea D. Furlan is with the Institute for Work and Health and Department of Medicine, University of Toronto. Peter Selby is with the Centre for Addiction and Mental Health and Department of Family and Community Medicine, Department of Psychiatry, University of Toronto. Sheryl M. Spithoff is with Department of Family and Community Medicine, University of Toronto. Ross E. G. Upshur is with the Bridgepoint Collaboratory for Research and Innovation, Department of Family and Community Medicine, Dalla Lana School of Public Health, University of Toronto
| | - Peter Selby
- Abhimanyu Sud is with the Department of Family and Community Medicine and Institute for Health Policy, Management, and Evaluation, University of Toronto, Canada. Daniel Z. Buchman is with Centre for Addiction and Mental Health and Dalla Lana School of Public Health, Toronto. Andrea D. Furlan is with the Institute for Work and Health and Department of Medicine, University of Toronto. Peter Selby is with the Centre for Addiction and Mental Health and Department of Family and Community Medicine, Department of Psychiatry, University of Toronto. Sheryl M. Spithoff is with Department of Family and Community Medicine, University of Toronto. Ross E. G. Upshur is with the Bridgepoint Collaboratory for Research and Innovation, Department of Family and Community Medicine, Dalla Lana School of Public Health, University of Toronto
| | - Sheryl M Spithoff
- Abhimanyu Sud is with the Department of Family and Community Medicine and Institute for Health Policy, Management, and Evaluation, University of Toronto, Canada. Daniel Z. Buchman is with Centre for Addiction and Mental Health and Dalla Lana School of Public Health, Toronto. Andrea D. Furlan is with the Institute for Work and Health and Department of Medicine, University of Toronto. Peter Selby is with the Centre for Addiction and Mental Health and Department of Family and Community Medicine, Department of Psychiatry, University of Toronto. Sheryl M. Spithoff is with Department of Family and Community Medicine, University of Toronto. Ross E. G. Upshur is with the Bridgepoint Collaboratory for Research and Innovation, Department of Family and Community Medicine, Dalla Lana School of Public Health, University of Toronto
| | - Ross E G Upshur
- Abhimanyu Sud is with the Department of Family and Community Medicine and Institute for Health Policy, Management, and Evaluation, University of Toronto, Canada. Daniel Z. Buchman is with Centre for Addiction and Mental Health and Dalla Lana School of Public Health, Toronto. Andrea D. Furlan is with the Institute for Work and Health and Department of Medicine, University of Toronto. Peter Selby is with the Centre for Addiction and Mental Health and Department of Family and Community Medicine, Department of Psychiatry, University of Toronto. Sheryl M. Spithoff is with Department of Family and Community Medicine, University of Toronto. Ross E. G. Upshur is with the Bridgepoint Collaboratory for Research and Innovation, Department of Family and Community Medicine, Dalla Lana School of Public Health, University of Toronto
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21
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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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22
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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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23
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Hayes CJ, Krebs EE, Brown J, Li C, Hudson T, Martin BC. Association Between Pain Intensity and Discontinuing Opioid Therapy or Transitioning to Intermittent Opioid Therapy After Initial Long-Term Opioid Therapy: A Retrospective Cohort Study. THE JOURNAL OF PAIN 2021; 22:1709-1721. [PMID: 34186177 PMCID: PMC10068896 DOI: 10.1016/j.jpain.2021.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 05/21/2021] [Accepted: 05/23/2021] [Indexed: 11/25/2022]
Abstract
The purpose of this study was to evaluate changes in pain intensity among Veterans transitioning from long-term opioid therapy (LTOT) to either intermittent therapy or discontinuation compared to continued LTOT. Pain intensity was assessed using the Numeric Rating Scale in 90-day increments starting in the 90-day period prior to potential opioid transitions and the two ensuing 90-day periods after transition. Primary analyses used a 1:1 greedy propensity matched sample. A total of 29,293 Veterans switching to intermittent opioids and 5,972 discontinuing opioids were matched to Veterans continuing LTOT. Covariates were well balanced after matching except minor differences in baseline mean pain scores. Pain scores were lower in the follow up periods for those switching to intermittent opioids and discontinuing opioids compared to those continuing LTOT (0-90 days: Intermittent: 3.79, 95%CI: 3.76, 3.82; LTOT: 4.09, 95%CI: 4.06, 4.12, P < .0001; Discontinuation: 3.06, 95%CI: 2.99, 3.13; LTOT: 3.86, 95%CI: 3.79, 3.94, P = <.0001; 91-180 days: Intermittent: 3.76, 95%CI: 3.73, 3.79; LTOT: 3.99, 95%CI: 3.96, 4.02, P < .0001; Discontinuation: 3.01, 95%CI: 2.94, 3.09; LTOT: 3.80, 95%CI: 3.73, 3.87, P = <.0001). Sensitivity analyses found similar results. Discontinuing opioid therapy or switching to intermittent opioid therapy was not associated with increased pain intensity. PERSPECTIVE: This article evaluates the association of switching to intermittent opioid therapy or discontinuing opioids with pain intensity after using opioids long-term. Pain intensity decreased after switching to intermittent therapy or discontinuing opioids, but remained relatively stable for those continuing long-term opioid therapy. Switching to intermittent opioids or discontinuing opioids was not associated with increased pain intensity.
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Affiliation(s)
- Corey J Hayes
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas; Center for Health Services Research, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Erin E Krebs
- Center for Care Delivery and Outcomes Research, Minneapolis VA Healthcare System, 1 Veterans Dr, Minneapolis, Minneapolis; College of Medicine, University of Minnesota, Minneapolis, Minneapolis
| | - Joshua Brown
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Chenghui Li
- Division of Pharmaceutical Evaluation and Policy, College of Pharmacy, University of Arkansas for Medical Sciences, Arkansas
| | - Teresa Hudson
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas; Center for Health Services Research, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Bradley C Martin
- Division of Pharmaceutical Evaluation and Policy, College of Pharmacy, University of Arkansas for Medical Sciences, Arkansas.
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24
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Bushey MA, Wu J, Outcalt SD, Krebs EE, Ang D, Kline M, Yu Z, Bair MJ. Opioid use as a predictor of pain outcomes in Iraq and Afghanistan Veterans with chronic pain: Analysis of a randomized controlled trial. PAIN MEDICINE 2021; 22:2964-2970. [PMID: 34411252 DOI: 10.1093/pm/pnab237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE Our objectives were to: 1) assess the relationship between self-reported opioid use and baseline demographics, clinical characteristics and pain outcomes; and 2) examine whether baseline opioid use moderated the intervention effect on outcomes at 9 months. DESIGN We conducted a secondary analysis of data from the Evaluation of Stepped Care for Chronic Pain (ESCAPE) trial, which found stepped-care to be effective for chronic pain in military veterans. SETTING A post-deployment clinic and 5 general medicine clinics at a Veteran Affairs Medical Center. SUBJECTS 241 veterans with chronic musculoskeletal pain; 220 with complete data at 9 months. METHODS Examination of baseline relationships and multivariable linear regression to examine baseline opioid use as a moderator of pain-related outcomes including Roland Morris Disability Questionnaire (RMDQ), Brief Pain Inventory (BPI) Interference scale, and Graded Chronic Pain Scale (GCPS) at 9 months. RESULTS Veterans reporting baseline opioid use (n = 80) had significantly worse RMDQ (16.0 ± 4.9 vs. 13.4 ± 4.2, P < 0.0001), GCPS (68.7 ± 12.0 vs. 65.0 ± 14.4, p = 0.049), BPI Interference (6.2 ± 2.2 vs. 5.0 ± 2.1, P < 0.0001), and depression (PHQ-9 12.5 ± 6.2 vs. 10.6 ± 5.7, p = 0.016) compared to veterans not reporting baseline opioid use. Using multivariable modeling we found that baseline opioid use moderated the intervention effect on pain-related disability (RMDQ) at 9 months (interaction Beta = -3.88, p = 0.0064), but not pain intensity or interference. CONCLUSIONS In a stepped-care trial for pain, patients reporting baseline opioid use had greater improvement in pain disability at 9 months compared to patients not reporting opioid use.
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Affiliation(s)
- Michael A Bushey
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jingwei Wu
- Department of Epidemiology and Biostatistics, Temple University College of Public Health, Philadelphia, Pennsylvania, USA
| | - Samantha D Outcalt
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, Indiana, USA
| | - Erin E Krebs
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
- Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Dennis Ang
- Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Matthew Kline
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, Indiana, USA
| | - Zhangsheng Yu
- Department of Bioinformatics and Biostatistics, Shanghai Jiao Tong University, Shanghai, China
| | - Matthew J Bair
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, Indiana, USA
- Indiana University School of Medicine; Department of Medicine, Indianapolis, Indiana, USA
- Regenstrief Institute, Inc., Indianapolis, Indiana, USA
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25
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Chen JA, DeFaccio RJ, Gelman H, Thomas ER, Indresano JA, Dawson TC, Glynn LH, Sandbrink F, Zeliadt SB. Telehealth and rural-urban differences in receipt of pain care in the Veterans Health Administration. PAIN MEDICINE 2021; 23:466-474. [PMID: 34145892 DOI: 10.1093/pm/pnab194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE Examine changes in specialty pain utilization in the Veterans Health Administration (VHA) after establishing a virtual interdisciplinary pain team (TelePain). DESIGN Retrospective cohort study. SETTING A single VHA healthcare system, 2015-2019. SUBJECTS 33,169 patients with chronic pain-related diagnoses. METHODS We measured specialty pain utilization (in-person and telehealth) among patients with moderate to severe chronic pain. We used generalized estimating equations to test the association of time (pre- or post-TelePain) and rurality on receipt of specialty pain care. RESULTS Among patients with moderate to severe chronic pain, the reach of specialty pain care increased from 11.1% to 16.2% in the pre- to post-TelePain periods (aOR: 1.37, 95% CI: 1.26-1.49). This was true of both urban patients (aOR: 1.62, 95% CI: 1.53-1.71) and rural patients (aOR: 1.16, 95% CI: 0.99-1.36), although the difference for rural patients was not statistically significant. Among rural patients who received specialty pain care, a high percentage of the visits were delivered by telehealth (nearly 12% in the post-TelePain period), much higher than among urban patients (3%). CONCLUSIONS We observed increased use of specialty pain services among all patients with chronic pain. Although rural patients did not achieve the same degree of access and utilization overall as urban patients, their use of pain telehealth increased substantially and may have substituted for in-person visits. Targeted implementation efforts may be needed to further increase the reach of services to patients living in areas with limited specialty pain care options.
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Affiliation(s)
- Jessica A Chen
- Veterans Affairs (VA) Puget Sound Health Care System., Seattle-Denver Center of Innovation (COIN) for Veteran-Centered Value-Driven Care, Health Services Research & Development (HSR&D).,VA Puget Sound Health Care System, VISN 20 Pain Medicine & Functional Restoration Center.,University of Washington, Department of Psychiatry & Behavioral Sciences
| | - Rian J DeFaccio
- Veterans Affairs (VA) Puget Sound Health Care System., Seattle-Denver Center of Innovation (COIN) for Veteran-Centered Value-Driven Care, Health Services Research & Development (HSR&D)
| | - Hannah Gelman
- Veterans Affairs (VA) Puget Sound Health Care System., Seattle-Denver Center of Innovation (COIN) for Veteran-Centered Value-Driven Care, Health Services Research & Development (HSR&D)
| | - Eva R Thomas
- Veterans Affairs (VA) Puget Sound Health Care System., Seattle-Denver Center of Innovation (COIN) for Veteran-Centered Value-Driven Care, Health Services Research & Development (HSR&D)
| | - Jessica A Indresano
- Veterans Affairs (VA) Puget Sound Health Care System., Seattle-Denver Center of Innovation (COIN) for Veteran-Centered Value-Driven Care, Health Services Research & Development (HSR&D)
| | - Timothy C Dawson
- VA Puget Sound Health Care System, VISN 20 Pain Medicine & Functional Restoration Center.,University of Washington, Department of Anesthesiology & Pain Medicine
| | - Lisa H Glynn
- VA Puget Sound Health Care System, VISN 20 Pain Medicine & Functional Restoration Center
| | - Friedhelm Sandbrink
- Veterans Health Administration, National Program for Pain Management and Opioid Safety, Specialty Care Services.,George Washington University, Department of Neurology
| | - Steven B Zeliadt
- Veterans Affairs (VA) Puget Sound Health Care System., Seattle-Denver Center of Innovation (COIN) for Veteran-Centered Value-Driven Care, Health Services Research & Development (HSR&D).,University of Washington, Department of Health Services
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Reyes Velez J, Thompson JM, Sweet J, Busse JW, VanTil L. Cluster analysis of Canadian Armed Forces veterans living with chronic pain: Life After Service Studies 2016. CANADIAN JOURNAL OF PAIN-REVUE CANADIENNE DE LA DOULEUR 2021; 5:81-95. [PMID: 34189392 PMCID: PMC8210876 DOI: 10.1080/24740527.2021.1898278] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objective: This study explored the heterogeneity of Canadian Armed Forces veterans living with chronic pain to inform service needs planning and research using cluster analysis. Design: We used a national cross-sectional Statistics Canada population survey. Participants: Participants included 2754 Canadian Armed Forces (CAF) Regular Force veterans released from service between 1998 and 2015 and surveyed in 2016. Methods: We used cluster analysis of veterans with chronic pain based on pain severity, mental health, and activity limitation characteristics. We compared clusters for sociodemographic, health, and service utilization characteristics. Results: Of 2754 veterans, 1126 (41%) reported chronic pain. Veterans in cluster I (47%) rarely had severe pain (2%) or severe mental health problems (8%), and none had severe activity limitations. Veterans in cluster II (26%) more often than veterans in cluster I but less often than veterans in cluster III endorsed severe pain (27%) and severe mental health problems (22%) and were most likely to report severe activity limitation (91%). Veterans in cluster III (27%) were most likely to report severe pain (36%) and severe mental health problems (96%), and a majority reported severe activity limitations (72%). There was evidence of considerable heterogeneity among individuals in terms of socioeconomic characteristics, pain characteristics, mental and physical health status, activity limitations, social integration, and service utilization indicators. Conclusions: About half of Canadian veterans living with chronic pain infrequently endorse severe pain or serious mental health issues without severe activity limitations. The other half had more complex characteristics. The heterogeneity of CAF veterans with chronic pain emphasizes the need for support systems that can address variability of needs.
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Affiliation(s)
| | - James M Thompson
- Department of Public Health Sciences, Queens University, Kingston, Ontario, Canada
| | - Jill Sweet
- VAC Research Directorate, Charlottetown, Prince Edward Island, Canada
| | - Jason W Busse
- Michael DeGroote Pain Centre, McMaster University, Hamilton, Ontario, Canada
| | - Linda VanTil
- VAC Research Directorate, Charlottetown, Prince Edward Island, Canada
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Santini A, Petruzzo A, Giannetta N, Ruggiero A, Di Muzio M, Latina R. Management of chronic musculoskeletal pain in veterans: a systematic review. ACTA BIO-MEDICA : ATENEI PARMENSIS 2021; 92:e2021011. [PMID: 33855991 PMCID: PMC8138808 DOI: 10.23750/abm.v92is2.11352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 03/04/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND AIM OF THE WORK Veterans are military with health problems due to military conditions. The improved body armor and operational conditions has reduced the number of deaths, but increased the number of veterans with severe injuries, affected by musculoskeletal pain and associated syndromes, such as post-traumatic stress disorder. Multimodal approaches are considered in USA the gold standard for the treatment of these problems, while in Europe and Italy the data are unknown. The aim of this review was to describe and summarize multimodal therapeutic approaches that apply to the veteran population for chronic musculoskeletal pain and relate syndromes management. METHODS A comprehensive systematic review of the literature on Cochrane Library, PubMed, CINAHL e PsycINFO databases was conducted, from 2001 to 2020. RESULTS 228 papers have been found, 134 were selected after the first screening. 24 quantitative studies were included in the review, all from USA. Different multimodal interventions with different kind of treatment types emerged. The analyzed studies' sample size was 11 million (mean age = 57.67 years; SD=±11.94). The multimodal approaches showed a significant improvement in all outcomes (pain reduction and control, opioid therapy reduction, psychosocial outcomes) compared to traditional therapy. CONCLUSIONS Multimodal therapeutic approaches seem to guarantee a good management chronic musculoskeletal pain and related mental disorders, and the reduction and control to opioid use. Military nurses emerged as professionals who have a central role in this approach. European and Italian authorities should consider veterans, in order to assess their expected increase in the future.
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Affiliation(s)
| | - Antonio Petruzzo
- School of Nursing Science and Midwifery, Sapienza University of Rome, A.O. S. Camillo-Forlanini Hospital, Rome, Italy.
| | - Noemi Giannetta
- Vita-Salute San Raffaele University, Tor Vergata, University of Rome, Italy.
| | - Antonio Ruggiero
- School of Nursing Science and Midwifery, Sapienza University of Rome, A.O. S. Camillo-Forlanini Hospital, Rome, Italy.
| | - Marco Di Muzio
- Department of Molecular Medicine, Sapienza University of Rome, Italy.
| | - Roberto Latina
- School of Nursing Science and Midwifery, Sapienza University of Rome, A.O. S. Camillo-Forlanini Hospital, Rome, Italy.
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Tsai J, Mehta K, Hunt-Johnson N, Pietrzak RH. Experiences and Knowledge of US Department of Veterans Affairs Clinical Services, Research, and Education: Results From a National Survey of Veterans. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2021; 27:173-185. [PMID: 31592984 DOI: 10.1097/phh.0000000000001053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study examined (1) sociodemographic, health, and psychosocial characteristics associated with using the Department of Veterans Affairs (VA) health care system as a primary health care provider; (2) veterans' experience and knowledge of VA clinical services, research, and education; and (3) veteran characteristics associated with VA experience and knowledge. DESIGN A nationally representative survey was conducted in 2018; eligibility criteria for participation were adults aged 18 years or older, currently living in the United States, and having served on active duty in the US military. SETTING The survey was conducted online using large national survey panels. PARTICIPANTS A sample of 1002 veterans across 49 states participated. MAIN OUTCOME MEASURES The survey assessed experience and knowledge of majority of VA clinical services, research, and education. RESULTS One-quarter of the total sample reported that the VA was their primary health care provider. Among veterans who had ever used VA health care, the majority (68%) reported overall high satisfaction with VA health care but also agreed with "privatizing parts of the VA" (70%). The majority (51%-73%) of veterans reported knowledge of major VA clinical services, with the exception of comprehensive management for chronic pain (24%) and treatment of opioid use disorders (31%). One-quarter to one-half also reported knowledge of several VA research and education centers. Less than 10% of veterans reported having ever used a VA mobile app. CONCLUSIONS The US veterans generally reported positive experiences and good knowledge of VA services and resources. Greater awareness of available VA services for chronic pain and opioid use disorders, as well as VA mobile apps, may help promote more comprehensive care in this population.
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Affiliation(s)
- Jack Tsai
- US Department of Veterans Affairs, National Center on Homelessness among Veterans, West Haven, Connecticut (Dr Tsai); US Department of Veterans Affairs, National Center on Homelessness among Veterans, Bedford, Massachusetts (Mr Mehta); US Department of Veterans Affairs, National Center on Homelessness among Veterans, Philadelphia, Pennsylvania (Hunt-Johnson); Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut (Drs Tsai and Pietrzak); and US Department of Veterans Affairs National Center for Posttraumatic Stress Disorder, VA Connecticut Healthcare System, West Haven, Connecticut (Dr Pietrzak)
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Adherence to Stepped Care for Management of Musculoskeletal Knee Pain Leads to Lower Health Care Utilization, Costs, and Recurrence. Am J Med 2021; 134:351-360.e1. [PMID: 32931762 DOI: 10.1016/j.amjmed.2020.08.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 08/04/2020] [Accepted: 08/22/2020] [Indexed: 12/29/2022]
Abstract
OBJECTIVES This study aimed to report compliance with stepped care management of patellofemoral pain and determine whether adherence to stepped care results in decreased recurrence and lower health care utilization. METHODS A total of 60,730 participants were included, using data from the Military Health System Data Repository, a large single-payer government health system. Outcomes included total knee-related care visits and costs, knee surgeries, opioid prescriptions, and 2-year recurrence. Stepped care was based on interventions delivered within the appropriate timing and in the appropriate order (low risk/cost before high risk/cost). RESULTS A total of 54,460 (89.7%) participants received adherent Step 1 care, 10,964 (18.1%) received step 2, and 4168 (6.9%) received step 3. A total of 32.0% and 50.8%, respectively, of all patients in Step 2 and Step 3 care were adherent. Of the 2385 participants (3.9% of cohort) that received both Step 2 and Step 3 care, 24.8% of participants received adherent care. For participants receiving both Step 2 and Step 3 care, adherence resulted in cost savings (mean difference [MD] $1708; 95% confidence interval [CI]: $1241, 2175), fewer knee-related visits (MD 3.4; 95% CI 2.2, 4.7), fewer episodes of knee pain (MD 0.7; 95% CI 0.5, 0.8), fewer knee surgeries (adjusted odds ratio 0.4; 95% CI 0.3, 0.5), and fewer opioid prescriptions (adjusted odds ratio 0.6; 95% CI 0.5, 0.8). CONCLUSION These findings demonstrate the value of following stepped care guidelines for pain management in patients with patellofemoral pain.
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Husebo BS, Kerns RD, Han L, Skanderson M, Gnjidic D, Allore HG. Pain, Complex Chronic Conditions and Potential Inappropriate Medication in People with Dementia. Lessons Learnt for Pain Treatment Plans Utilizing Data from the Veteran Health Administration. Brain Sci 2021; 11:86. [PMID: 33440668 PMCID: PMC7827274 DOI: 10.3390/brainsci11010086] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/05/2021] [Accepted: 01/07/2021] [Indexed: 12/21/2022] Open
Abstract
Alzheimer's disease and related dementias (ADRD), pain and chronic complex conditions (CCC) often co-occur leading to polypharmacy and with potential inappropriate medications (PIMs) use, are important risk factors for adverse drug reactions and hospitalizations in older adults. Many US veterans are at high risk for persistent pain due to age, injury or medical illness. Concerns about inadequate treatment of pain-accompanied by evidence about the analgesic efficacy of opioids-has led to an increase in the use of opioid medications to treat chronic pain in the Veterans Health Administration (VHA) and other healthcare systems. This study aims to investigate the relationship between receipt of pain medications and centrally (CNS) acting PIMs among veterans diagnosed with dementia, pain intensity, and CCC 90-days prior to hospitalization. The final analytic sample included 96,224 (81.7%) eligible older veterans from outpatient visits between October 2012-30 September 2013. We hypothesized that veterans with ADRD, and severe pain intensity may receive inappropriate pain management and CNS-acting PIMs. Seventy percent of the veterans, and especially people with ADRD, reported severe pain intensity. One in three veterans with ADRD and severe pain intensity have an increased likelihood for CNS-acting PIMs, and/or opioids. Regular assessment and re-assessment of pain among older persons with CCC, patient-centered tapering or discontinuation of opioids, alternatives to CNS-acting PIMs, and use of non-pharmacological approaches should be considered.
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Affiliation(s)
- Bettina S. Husebo
- Centre for Elderly and Nursing Home Medicine, Department of Global Public Health and Primary Care, University of Bergen, 5020 Bergen, Norway
- Municipality of Bergen, 5020 Bergen, Norway
| | - Robert D. Kerns
- Departments of Psychiatry, Neurology and Psychology, Yale University, New Haven, CT 06511, USA;
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT 06516, USA;
| | - Ling Han
- Section of Geriatrics, Department of Internal Medicine, School of Medicine, Yale University, New Haven, CT 06511, USA; (L.H.); (H.G.A.)
| | - Melissa Skanderson
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT 06516, USA;
| | - Danijela Gnjidic
- Charles Perkins Centre, Faculty of Medicine and Health, School of Pharmacy, University of Sydney, Sydney 2006 NSW, Australia;
| | - Heather G. Allore
- Section of Geriatrics, Department of Internal Medicine, School of Medicine, Yale University, New Haven, CT 06511, USA; (L.H.); (H.G.A.)
- Department of Biostatistics, School of Public Health, Yale University, New Haven, CT 06511, USA
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Fritz JM, Rhon DI, Teyhen DS, Kean J, Vanneman ME, Garland EL, Lee IE, Thorp RE, Greene TH. A Sequential Multiple-Assignment Randomized Trial (SMART) for Stepped Care Management of Low Back Pain in the Military Health System: A Trial Protocol. PAIN MEDICINE 2020; 21:S73-S82. [PMID: 33313724 DOI: 10.1093/pm/pnaa338] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND The Defense Health Agency has prioritized system-level pain management initiatives within the Military Health System (MHS), with low back pain as one of the key focus areas. A stepped care model focused on nonpharmacologic treatment to promote self-management is recommended. Implementation of stepped care is complicated by lack of information on the most effective nonpharmacologic strategies and how to sequence and tailor the various available options. The Sequential Multiple-Assignment Randomization Trial for Low Back Pain (SMART LBP) is a multisite pragmatic trial using a SMART design to assess the effectiveness of nonpharmacologic treatments for chronic low back pain. DESIGN This SMART trial has two treatment phases. Participants from three military treatment facilities are randomized to 6 weeks of phase I treatment, receiving either physical therapy (PT) or Army Medicine's holistic Move2Health (M2H) program in a package specific to low back pain. Nonresponders to treatment in phase I are again randomized to phase II treatment of combined M2H + PT or mindfulness-based treatment using the Mindfulness-Oriented Recovery Enhancement (MORE) program. The primary outcome is the Patient-Reported Outcomes Measurement Information System pain interference computer-adapted test score. SUMMARY This trial is part of an initiative funded by the National Institutes of Health, Veterans Affairs, and the Department of Defense to establish a national infrastructure for effective system-level management of chronic pain with a focus on nonpharmacologic treatments. The results of this study will provide important information on nonpharmacologic care for chronic LBP in the MHS embedded within a stepped care framework.
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Affiliation(s)
| | - Daniel I Rhon
- Brooke Army Medical Center, San Antonio, Texas.,Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Deydre S Teyhen
- Walter Reed Army Institute of Research, Silvers Spring, Maryland
| | - Jacob Kean
- University of Utah, Salt Lake City, Utah
| | | | | | - Ian E Lee
- Defense Health Management Systems, Falls Church, Virginia
| | - Richard E Thorp
- Directorate of Program Analysis and Evaluation, Office of the Army Surgeon General, Joint Base San Antonio Fort Sam Houston, San Antonio, Texas, USA
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Martino S, Lazar C, Sellinger J, Gilstad-Hayden K, Fenton B, Barnett PG, Brummett BR, Higgins DM, Holtzheimer P, Mattocks K, Ngo T, Reznik TE, Semiatin AM, Stapley T, Rosen MI. Screening, Brief Intervention, and Referral to Treatment for Pain Management for Veterans Seeking Service-Connection Payments for Musculoskeletal Disorders: SBIRT-PM Study Protocol. PAIN MEDICINE 2020; 21:S110-S117. [PMID: 33313731 PMCID: PMC7734657 DOI: 10.1093/pm/pnaa334] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background Veterans with significant chronic pain from musculoskeletal disorders are at risk of substance misuse. Veterans whose condition is the result of military service may be eligible for a disability pension. Department of Veterans Affairs compensation examinations, which determine the degree of disability and whether it was connected to military service, represent an opportunity to engage Veterans in pain management and substance use treatments. A multisite randomized clinical trial is testing the effectiveness and cost-effectiveness of Screening, Brief Intervention, and Referral to Treatment for Pain Management (SBIRT-PM) for Veterans seeking compensation for musculoskeletal disorders. This telephone-based intervention is delivered through a hub-and-spoke configuration. Design This study is a two-arm, parallel-group, 36-week, multisite randomized controlled single-blind trial. It will randomize 1,100 Veterans experiencing pain and seeking service-connection for musculoskeletal disorders to either SBIRT-PM or usual care across eight New England VA medical centers. The study balances pragmatic with explanatory methodological features. Primary outcomes are pain severity and number of substances misused. Nonpharmacological pain management and substance use services utilization are tracked in the trial. Summary Early trial enrollment targets were met across sites. SBIRT-PM could help Veterans, at the time of their compensation claims, use multimodal pain treatments and reduce existing substance misuse. Strategies to address COVID-19 pandemic impacts on the SBIRT-PM protocol have been developed to maintain its pragmatic and exploratory integrity.
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Affiliation(s)
- Steve Martino
- VA Connecticut Healthcare System, West Haven, Connecticut.,Yale University, New Haven, Connecticut
| | - Christina Lazar
- VA Connecticut Healthcare System, West Haven, Connecticut.,Yale University, New Haven, Connecticut
| | - John Sellinger
- VA Connecticut Healthcare System, West Haven, Connecticut.,Yale University, New Haven, Connecticut
| | | | - Brenda Fenton
- VA Connecticut Healthcare System, West Haven, Connecticut.,Yale University, New Haven, Connecticut
| | - Paul G Barnett
- Health Economics Resource Center, VA Palo Alto Health Care System, Palo Alto, California
| | - Brad R Brummett
- VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts.,University of Massachusetts, Amherst, Massachusetts
| | - Diana M Higgins
- VA Boston Healthcare System, Boston, Massachusetts.,Boston University School of Medicine, Boston, Massachusetts
| | - Paul Holtzheimer
- White River Junction VA Medical Center, White River Junction, Vermont.,Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Kristin Mattocks
- VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts.,University of Massachusetts Medical School, Worcester, Massachusetts
| | - Tu Ngo
- Bedford VA Medical Center, Bedford, Massachusetts
| | - Thomas E Reznik
- Providence VA Medical Center, Providence, Rhode Island.,Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | | | | | - Marc I Rosen
- VA Connecticut Healthcare System, West Haven, Connecticut.,Yale University, New Haven, Connecticut
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George SZ, Coffman CJ, Allen KD, Lentz TA, Choate A, Goode AP, Simon CB, Grubber JM, King H, Cook CE, Keefe FJ, Ballengee LA, Naylor J, Brothers JL, Stanwyck C, Alkon A, Hastings SN. Improving Veteran Access to Integrated Management of Back Pain (AIM-Back): Protocol for an Embedded Pragmatic Cluster-Randomized Trial. PAIN MEDICINE (MALDEN, MASS.) 2020; 21:S62-S72. [PMID: 33313728 PMCID: PMC7734660 DOI: 10.1093/pm/pnaa348] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Coordinated efforts between the National Institutes of Health, the Department of Defense, and the Department of Veterans Affairs have built the capacity for large-scale clinical research investigating the effectiveness of nonpharmacologic pain treatments. This is an encouraging development; however, what constitutes best practice for nonpharmacologic management of low back pain (LBP) is largely unknown. DESIGN The Improving Veteran Access to Integrated Management of Back Pain (AIM-Back) trial is an embedded pragmatic cluster-randomized trial that will examine the effectiveness of two different care pathways for LBP. Sixteen primary care clinics will be randomized 1:1 to receive training in delivery of 1) an integrated sequenced-care pathway or 2) a coordinated pain navigator pathway. Primary outcomes are pain interference and physical function (Patient-Reported Outcomes Measurement Information System Short Form [PROMIS-SF]) collected in the electronic health record at 3 months (n=1,680). A subset of veteran participants (n=848) have consented to complete additional surveys at baseline and at 3, 6, and 12 months for supplementary pain and other measures. SUMMARY AIM-Back care pathways will be tested for effectiveness, and treatment heterogeneity will be investigated to identify which veterans may respond best to a given pathway. Health care utilization patterns (including opioid use) will also be compared between care pathways. Therefore, the AIM-Back trial will provide important information that can inform the future delivery of nonpharmacologic treatment of LBP.
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Affiliation(s)
- Steven Z George
- Duke Clinical Research Institute and Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | - Cynthia J Coffman
- Department of Biostatistics and Bioinformatics, Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Duke University Medical Center, Durham, North Carolina
| | - Kelli D Allen
- University of North Carolina, Chapel Hill, Chapel Hill, North Carolina
| | - Trevor A Lentz
- Duke Clinical Research Institute and Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | - Ashley Choate
- Durham VA Health Care System, Health Services Research & Development, Durham, North Carolina
| | - Adam P Goode
- Department of Orthopaedic Surgery, Duke Clinical Research Institute, Durham, North Carolina
| | - Corey B Simon
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | - Janet M Grubber
- Durham VA Health Care System, Health Services Research & Development, Durham, North Carolina
| | - Heather King
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
- Department of Population Health Sciences, Division of General Internal Medicine, Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Health Services Research & Development, Duke University, Durham, North Carolina
| | - Chad E Cook
- Duke Clinical Research Institute and Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | - Francis J Keefe
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, North Carolina
| | - Lindsay A Ballengee
- Durham VA Health Care System, Health Services Research & Development, Duke University, Durham, North Carolina
| | - Jennifer Naylor
- Durham VA Health Care System, Mental Illness Research Education and Clinical Center, Duke University, Durham, North Carolina
| | | | - Catherine Stanwyck
- Durham VA Health Care System, Health Services Research & Development, Duke University, Durham, North Carolina
| | - Aviel Alkon
- Durham VA Health Care System, Health Services Research & Development, Duke University, Durham, North Carolina
| | - Susan N Hastings
- Durham Center of Innovation to Accelerate Discovery and Practice, Durham VA Health Care System, Geriatric Research, Education and Clinical Center at Durham VAHCS Health Services Research & Development, Durham, North Carolina
- Department of Population Health Sciences, Duke University, Durham, North Carolina
- Department of Medicine, Duke University, Durham, North Carolina, USA
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Frank JW, Bohnert ASB, Sandbrink F, McGuire M, Drexler K. Implementation and Policy Recommendations from the VHA State-of-the-Art Conference on Strategies to Improve Opioid Safety. J Gen Intern Med 2020; 35:983-987. [PMID: 33145691 PMCID: PMC7609348 DOI: 10.1007/s11606-020-06295-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 10/05/2020] [Indexed: 01/25/2023]
Abstract
Evidence-based treatment of opioid use disorder, the prevention of opioid overdose and other opioid-related harms, and safe and effective pain management are priorities for the Veterans Health Administration (VHA). The VHA Office of Health Services Research and Development hosted a State-of-the-Art Conference on "Effective Management of Pain and Addiction: Strategies to Improve Opioid Safety" on September 10-11, 2019. This conference convened a multidisciplinary group to discuss and achieve consensus on a research agenda and on implementation and policy recommendations to improve opioid safety for Veterans. Participants were organized into three workgroups: (1) managing opioid use disorder; (2) Long-term opioid therapy and opioid tapering; (3) managing co-occurring pain and substance use disorder. Here we summarize the implementation and policy recommendations of each workgroup and highlight important cross-cutting issues related to telehealth, care coordination, and stepped care model implementation.
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Affiliation(s)
- Joseph W Frank
- VA Eastern Colorado Health Care System, Aurora, CO, USA. .,Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Amy S B Bohnert
- University of Michigan Medical School, Ann Arbor, MI, USA.,Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Friedhelm Sandbrink
- Washington DC VA Medical Center, Washington, DC, USA.,Office of Specialty Care Services, Veterans Health Administration, Washington, DC, USA.,George Washington University, Washington, DC, USA
| | - Marsden McGuire
- Office of Mental Health and Suicide Prevention, Veterans Health Administration, Washington, DC, USA
| | - Karen Drexler
- Office of Mental Health and Suicide Prevention, Veterans Health Administration, Washington, DC, USA.,Atlanta VA Medical Center, Decatur, GA, USA.,Emory University School of Medicine, Atlanta, GA, USA
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App-Based Pain Management and Opioid Education Program for Patients in Clinic Waiting Rooms. Pain Manag Nurs 2020; 22:164-168. [PMID: 33223470 DOI: 10.1016/j.pmn.2020.10.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 10/18/2020] [Accepted: 10/18/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Best approaches to delivering patient education related to pain management and opioid safety are understudied. AIMS This study assessed the feasibility, acceptability, and preliminary patient-reported impact of an app-based patient pain education program. DESIGN Pilot study with data collection occurring on 43 weekdays between August 2019-February 2020. SETTING Waiting rooms at the pain clinic and a primary care medical home within two military treatment facilities. PARTICIPANTS Military health system beneficiaries seeking general care at the primary care medical home or pain-specific care at the pain clinic. METHODS The Joint Pain Education and Project curriculum includes patient-focused videos describing the biopsychosocial aspects of pain and pain management, medication take-back and safe disposal, and multidimensional pain assessments. The app-based videos were available on tablets in the waiting rooms for patients to view and complete surveys on after. RESULTS Overall, 152 patients viewed the videos and completed surveys. Most viewers were interested in receiving other tablet-based health education while in the waiting room (62%). Most viewers found videos to be moderately or very helpful (73%) and were satisfied or very satisfied with the information provided (85%). Participants at the primary care medical home were more likely to find videos helpful compared to participants at the pain clinic (OR = 2.11; 95% CI: 1.07, 4.20; p = .03). CONCLUSION Implementing app-based pain management education is feasible across clinic settings and is well received by patients. Clinics should consider providing pain education across care setting, rather than just pain specialty clinics, to help foster discussions between clinicians and patients regarding pain management and opioid safety.
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Coleman BC, Kean J, Brandt CA, Peduzzi P, Kerns RD. Adapting to disruption of research during the COVID-19 pandemic while testing nonpharmacological approaches to pain management. Transl Behav Med 2020; 10:827-834. [PMID: 32885815 PMCID: PMC7499692 DOI: 10.1093/tbm/ibaa074] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
The COVID-19 pandemic has slowed research progress, with particularly disruptive effects on investigations of addressing urgent public health challenges, such as chronic pain. The National Institutes of Health (NIH) Department of Defense (DoD) Department of Veterans Affairs (VA) Pain Management Collaboratory (PMC) supports 11 large-scale, multisite, embedded pragmatic clinical trials (PCTs) in military and veteran health systems. The PMC rapidly developed and enacted a plan to address key issues in response to the COVID-19 pandemic. The PMC tracked and collaborated in developing plans for addressing COVID-19 impacts across multiple domains and characterized the impact of COVID-19 on PCT operations, including delays in recruitment and revisions of study protocols. A harmonized participant questionnaire will facilitate later meta-analyses and cross-study comparisons of the impact of COVID-19 across all 11 PCTs. The pandemic has affected intervention delivery, outcomes, regulatory and ethics issues, participant recruitment, and study design. The PMC took concrete steps to ensure scientific rigor while encouraging flexibility in the PCTs, while paying close attention to minimizing the burden on research participants, investigators, and clinical care teams. Sudden changes in the delivery of pain management interventions will probably alter treatment effects measured via PMC PCTs. Through the use of harmonized instruments and surveys, we are capturing these changes and plan to monitor the impact on research practices, as well as on health outcomes. Analyses of patient-reported measures over time will inform potential relationships between chronic pain, mental health, and various socioeconomic stressors common among Americans during the COVID-19 pandemic.
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Affiliation(s)
- Brian C Coleman
- Pain Research, Informatics, Multimorbidities, and Education Center, VA Connecticut Healthcare System, West Haven, CT, USA.,Pain Management Collaboratory Coordinating Center, Yale School of Medicine, New Haven, CT, USA.,Yale Center for Medical Informatics, Yale School of Medicine, New Haven, CT, USA
| | - Jacob Kean
- Pain Management Collaboratory Coordinating Center, Yale School of Medicine, New Haven, CT, USA.,Informatics, Decision Enhancement, and Analytic Sciences (IDEAS 2.0) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA.,Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Cynthia A Brandt
- Pain Research, Informatics, Multimorbidities, and Education Center, VA Connecticut Healthcare System, West Haven, CT, USA.,Pain Management Collaboratory Coordinating Center, Yale School of Medicine, New Haven, CT, USA.,Yale Center for Medical Informatics, Yale School of Medicine, New Haven, CT, USA.,Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA.,Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - Peter Peduzzi
- Pain Management Collaboratory Coordinating Center, Yale School of Medicine, New Haven, CT, USA.,Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - Robert D Kerns
- Pain Management Collaboratory Coordinating Center, Yale School of Medicine, New Haven, CT, USA.,Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
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Thomas ER, Zeliadt SB, Coggeshall S, Gelman H, Resnick A, Giannitrapani K, Olson J, Kligler B, Taylor SL. Does Offering Battlefield Acupuncture Lead to Subsequent Use of Traditional Acupuncture? Med Care 2020; 58 Suppl 2 9S:S108-S115. [PMID: 32826780 PMCID: PMC7497608 DOI: 10.1097/mlr.0000000000001367] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Veterans Health Administration encourages auricular acupuncture (Battlefield Acupuncture/BFA) as a nonpharmacologic approach to pain management. Qualitative reports highlighted a "gateway hypothesis": providing BFA can lead to additional nonpharmacologic treatments. This analysis examines subsequent use of traditional acupuncture. RESEARCH DESIGN Cohort study of Veterans treated with BFA and a propensity score matched comparison group with a 3-month follow-up period to identify subsequent use of traditional acupuncture. Matching variables included pain, comorbidity, and demographics, with further adjustment in multivariate regression analysis. SUBJECTS We identified 41,234 patients who used BFA across 130 Veterans Health Administration medical facilities between October 1, 2016 and March 31, 2019. These patients were matched 2:1 on Veterans who used VA care but not BFA during the same period resulting in a population of 24,037 BFA users and a comparison cohort of 40,358 non-BFA users. Patients with prior use of traditional acupuncture were excluded. RESULTS Among Veterans receiving BFA, 9.5% subsequently used traditional acupuncture compared with 0.9% of non-BFA users (P<0.001). In adjusted analysis, accounting for patient characteristics and regional availability of traditional acupuncture, patients who used BFA had 10.9 times greater odds (95% confidence interval, 8.67-12.24) of subsequent traditional acupuncture use. CONCLUSIONS Providing BFA, which is easy to administer during a patient visit and does not require providers be formally certified, led to a substantial increase in use of traditional acupuncture. These findings suggest that the value of offering BFA may not only be its immediate potential for pain relief but also subsequent engagement in additional therapies.
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Affiliation(s)
- Eva R. Thomas
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System
| | - Steven B. Zeliadt
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System
- Department of Health Services, School of Public Health, University of Washington, Seattle, WA
| | - Scott Coggeshall
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System
| | - Hannah Gelman
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System
| | - Adam Resnick
- Center for the Study of Healthcare Innovation, Implementation and Policy, Greater Los Angeles VA Health Care System
- Department of Health Policy and Management, UCLA School of Public Health, Los Angeles
| | - Karleen Giannitrapani
- Center for Innovation to Implementation, Palo Alto VA Health Care System, Palo Alto, CA
| | - Juli Olson
- VA Central Iowa Health Care System, Des Moines, IA
| | - Benjamin Kligler
- Integrative Health Coordinating Center, Veterans Health Administration
- Office of Patient-Centered Care and Cultural Transformation, Veterans Health Administration, Washington, DC
| | - Stephanie L. Taylor
- Center for the Study of Healthcare Innovation, Implementation and Policy, Greater Los Angeles VA Health Care System
- Department of Health Policy and Management, UCLA School of Public Health, Los Angeles
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Ashrafioun L, Zerbo KRA, Bishop TM, Britton PC. Opioid use disorders, psychiatric comorbidities, and risk for suicide attempts among veterans seeking pain care. Psychol Med 2020; 50:2107-2112. [PMID: 31522694 DOI: 10.1017/s0033291719002307] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The purpose of this study was to assess the associations of comorbid opioid use disorders and psychiatric disorders with suicide attempts among veterans seeking pain care. METHODS The cohort (N = 226 444) was selected by identifying pain care initiation from 2012 to 2014 using national Veterans Health Administration (VHA) data. Data on opioid use disorders (OUD), psychiatric disorders, medical comorbidity, demographics at baseline, and suicide attempts in the year following the initiation of pain care were extracted from VHA databases. Relative excess risk due to interaction (RERI) was used to assess departure from additivity of effects. RESULTS Adjusted models indicated that both comorbid OUD and depression (RERI = 1.07) and comorbid OUD and AUD (RERI = 1.23) were significantly associated with additive risk of suicide attempt. In adjusted multiplicative interaction models, only comorbid OUD and bipolar disorder was significantly associated with suicide attempts; however, this association was protective (HR = 0.54). CONCLUSIONS The current findings highlight the importance of addressing opioid use disorders and alcohol use disorders and depression together to mitigate the risk of suicidal behavior.
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Affiliation(s)
- Lisham Ashrafioun
- Department of Veterans Affairs Center of Excellence for Suicide Prevention, VA Finger Lakes Healthcare System, 400 Fort Hill Avenue, Canandaigua, NY14424, USA
- Department of Psychiatry, University of Rochester School of Medicine & Dentistry, 300 Crittenden Boulevard, Rochester, NY14642, USA
| | - Kotwoallama R A Zerbo
- Department of Veterans Affairs Center of Excellence for Suicide Prevention, VA Finger Lakes Healthcare System, 400 Fort Hill Avenue, Canandaigua, NY14424, USA
| | - Todd M Bishop
- Department of Veterans Affairs Center of Excellence for Suicide Prevention, VA Finger Lakes Healthcare System, 400 Fort Hill Avenue, Canandaigua, NY14424, USA
- Department of Psychiatry, University of Rochester School of Medicine & Dentistry, 300 Crittenden Boulevard, Rochester, NY14642, USA
| | - Peter C Britton
- Department of Veterans Affairs Center of Excellence for Suicide Prevention, VA Finger Lakes Healthcare System, 400 Fort Hill Avenue, Canandaigua, NY14424, USA
- Department of Psychiatry, University of Rochester School of Medicine & Dentistry, 300 Crittenden Boulevard, Rochester, NY14642, USA
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Zeliadt SB, Thomas ER, Olson J, Coggeshall S, Giannitrapani K, Ackland PE, Reddy KP, Federman DG, Drake DF, Kligler B, Taylor SL. Patient Feedback on the Effectiveness of Auricular Acupuncture on Pain in Routine Clinical Care: The Experience of 11,406 Veterans. Med Care 2020; 58 Suppl 2 9S:S101-S107. [PMID: 32826779 PMCID: PMC7497594 DOI: 10.1097/mlr.0000000000001368] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Veterans Health Administration (VHA) launched a national initiative to train providers in a specific, protocolized auricular acupuncture treatment (also called Battlefield Acupuncture or BFA) as a nonpharmacological approach to pain management. This evaluation assessed the real-world effectiveness of BFA on immediate pain relief and identified subgroups of patients for whom BFA is most effective. RESEARCH DESIGN In a cross-sectional cohort study, electronic medical record data for 11,406 Veterans treated with BFA at 57 VHA medical centers between October 2016 and September 2018 was analyzed. The multivariate analysis incorporated data on pain history, change in pain level on an 11-point scale, complications, and demographic information. METHODS A total of 11,406 Veterans were treated with BFA at 57 VHA medical centers between October 2016 and September 2018 and had effectiveness data recorded in their electronic medical record. RESULTS More than 3 quarters experienced immediate decreases in pain following administration of BFA, with nearly 60% reported experiencing a minimal clinically important difference in pain intensity. The average decrease in pain intensity was -2.5 points (SD=2.2) at the initial BFA treatment, and -2.2 points (SD=2.0) at subsequent treatments. BFA was effective across a wide range of Veterans with many having preexisting chronic pain, or physical, or psychological comorbid conditions. Veterans with opioid use in the year before BFA experienced less improvement, with pain intensity scores improving more among Veterans who had not recently used opioids. CONCLUSION VHA's rapid expansion of training providers to offer BFA as a nonpharmacological approach to pain management has benefited many Veterans.
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Affiliation(s)
- Steven B. Zeliadt
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System
- Department of Health Services, School of Public Health, University of Washington, Seattle, WA
| | - Eva R. Thomas
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System
| | - Juli Olson
- VA Central Iowa Health Care System, Des Moines, IA
| | - Scott Coggeshall
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System
| | - Karleen Giannitrapani
- Center for Innovation to Implementation, Palo Alto VA Health Care System, Palo Alto, CA
| | - Princess E. Ackland
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System
- Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Kavitha P. Reddy
- John Cochran Veterans Hospital, VA St. Louis Health Care System
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO
| | - Daniel G. Federman
- VA Connecticut Health Care System
- Yale University School of Medicine, New Haven, CT
| | - David F. Drake
- Department of Physical Medicine and Rehabilitation, Hunter Holmes McGuire VA Medical Center, Richmond, VA
- Integrative Health Coordinating Center, Veterans Health Administration, Washington, DC
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA
| | - Benjamin Kligler
- Integrative Health Coordinating Center, Veterans Health Administration, Washington, DC
- Office of Patient-Centered Care and Cultural Transformation, Veterans Health Administration, Washington, DC
| | - Stephanie L. Taylor
- Center for the Study of Healthcare Innovation, Implementation and Policy, Greater Los Angeles VA Health Care System
- Department of Health Policy and Management, UCLA School of Public Health, Los Angeles, CA
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Wandner LD, Fenton BT, Goulet JL, Carroll CM, Heapy A, Higgins DM, Bair MJ, Sandbrink F, Kerns RD. Treatment of a Large Cohort of Veterans Experiencing Musculoskeletal Disorders with Spinal Cord Stimulation in the Veterans Health Administration: Veteran Characteristics and Outcomes. J Pain Res 2020; 13:1687-1697. [PMID: 32753944 PMCID: PMC7354010 DOI: 10.2147/jpr.s241567] [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: 12/09/2019] [Accepted: 05/07/2020] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE Spinal cord stimulator (SCS) implantation is used to treat chronic pain, including painful musculoskeletal disorders (MSDs). This study examined the characteristics and outcomes of veterans receiving SCSs in Veterans Health Administration (VHA) facilities. METHODS The sample was drawn from the MSD Cohort and limited to three MSDs with the highest number of implants (N=815,475). There were 1490 veterans with these conditions who received SCS implants from 2000 to 2012, of which 95% (n=1414) had pain intensity numeric rating scale (NRS) data both pre- and post-implant. RESULTS Veterans who were 35-44 years old, White, and married reported higher pain NRS ratings, had comorbid inclusion diagnoses, had no medical comorbidities, had a BMI 25-29.9, or had a depressive disorder diagnosis were more likely to receive an SCS. Veterans 55+ years old or with an alcohol or substance use disorder were less likely to receive an SCS. Over 90% of those receiving an SCS were prescribed opioids in the year prior to implant. Veterans who had a presurgical pain score ≥4 had a clinically meaningful decrease in their pain score in the year following their 90-day recovery period (Day 91-456) greater than expected by chance alone. Similarly, there was a significant decrease in the percent of veterans receiving opioid therapy (92.4% vs 86.6%, p<0.0001) and a significant overall decrease in opioid dose [morphine equivalent dose per day (MEDD) =26.48 vs MEDD=22.59, p<0.0003]. CONCLUSION Results offer evidence of benefit for some veterans with the examined conditions. Given known risks of opioid therapy, the reduction is an important potential benefit of SCS implants.
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Affiliation(s)
- Laura D Wandner
- National Institute of Neurological Disorders and Stroke (NINDS), National Institutes of Health (NIH), Bethesda, MD, USA
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Brenda T Fenton
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, USA
| | - Joseph L Goulet
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | | | - Alicia Heapy
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Diana M Higgins
- VA Boston Healthcare System, Boston, MA, USA
- Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA
| | - Matthew J Bair
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, IN, USA
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Regenstrief Institute, Indianapolis, IN, USA
| | - Friedhelm Sandbrink
- Department of Neurology, VA Medical Center, Washington, DC, USA
- Department of Neurology, Georgetown University, Washington, DC, USA
| | - Robert D Kerns
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
- Department of Psychology, Yale University, New Haven, CT, USA
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Bair MJ, Outcalt SD, Ang D, Wu J, Yu Z. Pain and Psychological Outcomes Among Iraq and Afghanistan Veterans with Chronic Pain and PTSD: ESCAPE Trial Longitudinal Results. PAIN MEDICINE 2020; 21:1369-1376. [DOI: 10.1093/pm/pnaa007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
Objective
To compare pain and psychological outcomes in veterans with chronic musculoskeletal pain and comorbid post-traumatic stress disorder (PTSD) or pain alone and to determine if veterans with comorbidity respond differently to a stepped-care intervention than those with pain alone.
Design
Secondary analysis of data from the Evaluation of Stepped Care for Chronic Pain (ESCAPE) trial.
Setting
Six Veterans Health Affairs clinics.
Subjects
Iraq and Afghanistan veterans (N = 222) with chronic musculoskeletal pain.
Methods
Longitudinal analysis of veterans with chronic musculoskeletal pain and PTSD or pain alone and available baseline and nine-month trial data. Participants randomized to either usual care or a stepped-care intervention were analyzed. The pain–PTSD comorbidity group screened positive for PTSD and had a PTSD Checklist–Civilian score ≥41 at baseline.
Results
T tests demonstrated statistically significant differences and worse outcomes on pain severity, pain cognitions, and psychological outcomes in veterans with comorbid pain and PTSD compared with those with pain alone. Analysis of covariance (ANCOVA) modeling change scores from baseline to nine months indicated no statistically significant differences, controlling for PTSD, on pain severity, pain centrality, or pain self-efficacy. Significant differences emerged for pain catastrophizing (t = 3.10, P < 0.01), depression (t = 3.39, P < 0.001), and anxiety (t = 3.80, P < 0.001). The interaction between PTSD and the stepped-care intervention was not significant.
Conclusions
Veterans with the pain–PTSD comorbidity demonstrated worse pain and psychological outcomes than those with chronic pain alone. These findings indicate a more intense chronic pain experience for veterans when PTSD co-occurs with pain. PTSD did not lead to a differential response to a stepped-care intervention.
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Affiliation(s)
- Matthew J Bair
- Center for Health Information and Communication, Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service, Indianapolis, Indiana
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
- Regenstrief Institute, Inc., Indianapolis, Indiana
| | - Samantha D Outcalt
- Center for Health Information and Communication, Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service, Indianapolis, Indiana
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, Indiana
| | - Dennis Ang
- Division of Rheumatology, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Jingwei Wu
- Department of Biostatistics, Temple University, Philadelphia, Pennsylvania
| | - Zhangsheng Yu
- Center of Statistics Research, Research Department, School of Statistics, Shanghai Jiaotong University, Shanghai, China
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Frank JW, Carey E, Nolan C, Kerns RD, Sandbrink F, Gallagher R, Ho PM. Increased Nonopioid Chronic Pain Treatment in the Veterans Health Administration, 2010-2016. PAIN MEDICINE 2020; 20:869-877. [PMID: 30137520 DOI: 10.1093/pm/pny149] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Joseph W Frank
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Denver, Colorado, USA.,Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Evan Carey
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Denver, Colorado, USA
| | - Charlotte Nolan
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Denver, Colorado, USA
| | - Robert D Kerns
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center of Innovation, VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Departments of Psychiatry, Neurology and Psychology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Friedhelm Sandbrink
- Department of Neurology, Washington DC VA Medical Center, Washington, DC, USA.,Department of Neurology, George Washington University, Washington, DC, USA
| | - Rollin Gallagher
- Center for Health Equity Research and Promotion (CHERP), Corporal Michael J. Crescenz VAMC, Philadelphia, Pennsylvania, USA.,Departments of Psychiatry and Anesthesiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - P Michael Ho
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Denver, Colorado, USA.,Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
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Fowler CA, Ballistrea LM, Mazzone KE, Martin AM, Kaplan H, Kip KE, Murphy JL, Winkler SL. A virtual reality intervention for fear of movement for Veterans with chronic pain: protocol for a feasibility study. Pilot Feasibility Stud 2019; 5:146. [PMID: 31890259 PMCID: PMC6907328 DOI: 10.1186/s40814-019-0501-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Accepted: 09/16/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A key concern for people with chronic pain is experiencing increased pain and/or re-injury. Consequently, individuals with chronic pain can develop a maladaptive fear of movement that leads to adverse functional consequences. A primary goal of chronic pain rehabilitation is re-engagement in feared movements through exposure. This is often challenging since safe movement can be uncomfortable. Virtual environments provide a promising opportunity to safely and gradually expose Veterans to movements that are avoided in the real world. The current study will utilize multiple virtual reality (VR) applications (APPs) of varying the intensity levels ranging from passive distraction from pain to active exposure to feared movement. The primary aims of this pilot are to examine VR as an adjunctive nonpharmacological intervention to assist with the adoption and implementation of skills to decrease fear of movement and increase overall functioning among Veterans with chronic pain. Second, to build a hierarchy of VR APPs to assist in gradual exposure to feared movements. METHODS This study will be conducted in the Chronic Pain Rehabilitation Program (CPRP) at the James A. Haley Veterans Hospital, a unique inpatient program within the VA system. Participants will include up to 20 Veterans who receive a VR intervention as part of their physical therapy. A rating form containing qualitative and quantitative experiences will be administered following each VR session to assess feasibility and to provide descriptive information for the proposed hierarchy. Effect sizes will be calculated from intake and discharge measures for the primary outcome fear of movement and secondary pain and functional outcomes. DISCUSSION This study will inform the feasibility of a randomized controlled trial examining the clinical utility of using VR to reduce fear of movement and increase function among Veterans with chronic pain. VR has the advantage of being easily implemented both within VA healthcare settings as well as in Veterans' own residences, where engagement in ongoing self-management approaches is often most challenging. Presumably, VR that is matched to patient needs, progresses in intensity, immerses Veterans in the applications, and is perceived positively by Veterans, will result in positive functional outcomes.
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Affiliation(s)
- Christopher A. Fowler
- Research and Development Service, James A. Haley Veterans Hospital and Clinics, 8900 Grand Oak Circle, Tampa, FL 33705 USA
| | - Lisa M. Ballistrea
- Research and Development Service, James A. Haley Veterans Hospital and Clinics, 8900 Grand Oak Circle, Tampa, FL 33705 USA
| | - Kerry E. Mazzone
- James A. Haley Veterans Hospital and Clinics, 13000 Bruce B. Downs Blvd, Tampa, FL 33612 USA
| | - Aaron M. Martin
- James A. Haley Veterans Hospital and Clinics, 13000 Bruce B. Downs Blvd, Tampa, FL 33612 USA
| | - Howard Kaplan
- Advanced Visualization Center, University of South Florida – Information Technology, 4202 E. Fowler Avenue, CMC147, Tampa, FL 33620 USA
| | - Kevin E. Kip
- Research and Development Service, James A. Haley Veterans Hospital and Clinics, 8900 Grand Oak Circle, Tampa, FL 33705 USA
- College of Public Health, University of South Florida, 13201 Bruce B. Downs Blvd, MDC56, Tampa, FL 33612 USA
| | - Jennifer L. Murphy
- Research and Development Service, James A. Haley Veterans Hospital and Clinics, 8900 Grand Oak Circle, Tampa, FL 33705 USA
- James A. Haley Veterans Hospital and Clinics, 13000 Bruce B. Downs Blvd, Tampa, FL 33612 USA
- Department of Neurology, University of South Florida, 12901 Bruce B. Downs Blvd, Tampa, FL 33612 USA
| | - Sandra L. Winkler
- Research and Development Service, James A. Haley Veterans Hospital and Clinics, 8900 Grand Oak Circle, Tampa, FL 33705 USA
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46
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Edmond SN, Moore BA, Dorflinger LM, Goulet JL, Becker WC, Heapy AA, Sellinger JJ, Lee AW, Levin FL, Ruser CB, Kerns RD. Project STEP: Implementing the Veterans Health Administration's Stepped Care Model of Pain Management. PAIN MEDICINE 2019; 19:S30-S37. [PMID: 30203015 DOI: 10.1093/pm/pny094] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Objective The "stepped care model of pain management" (SCM-PM) prioritizes the role of primary care providers in optimizing pharmacological management and timely and equitable access to patient-centered, evidence-based nonpharmacological approaches, when indicated. Over the past several years, the Veterans Health Administration (VHA) has supported implementation of SCM-PM, but few data exist regarding changes in pain care resulting from implementation. We examined trends in prescribing and referral practices of primary care providers with hypotheses of decreased opioid prescribing, increased nonopioid prescribing, and increased referrals to specialty care for nonpharmacological services. Design An initiative was designed to foster implementation and systematic evaluation of the SCM-PM over a five-year period at the VA Connecticut Healthcare System (VACHS) while fostering collaborative, partnered initiatives to promote organizational improvements in the delivery of pain care. Subjects Participants were veterans receiving care at VACHS with at least one pain intensity rating ≥4/10 over the course of the study period (7/2008-6/2013). Methods We used electronic health record data to examine changes in indicators of pain care including pharmacy and health care utilization data. Results We observed hypothesized changes in long-term opioid and nonopioid analgesic prescribing and increased utilization of nonpharmacological treatments such as physical therapy, occupational therapy, and clinical health psychology. Conclusions Through a multifaceted comprehensive implementation approach, primary care providers demonstrated increases in guideline-concordant pain care practices. Findings suggest that engagement of interdisciplinary teams and partnerships to promote organizational improvements is a useful strategy to increase the use of integrated, multimodal pain care for veterans, consistent with VHA's SCM-PM.
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Affiliation(s)
- Sara N Edmond
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut.,Department of Psychiatry
| | - Brent A Moore
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut.,Department of Psychiatry
| | - Lindsey M Dorflinger
- Health Psychology Service, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Joseph L Goulet
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut.,Department of Emergency Medicine
| | - William C Becker
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut.,Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Alicia A Heapy
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut.,Department of Psychiatry
| | - John J Sellinger
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut.,Department of Psychiatry
| | - Allison W Lee
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Forrest L Levin
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Christopher B Ruser
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Robert D Kerns
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut.,Department of Psychiatry.,Departments of Neurology and Psychology, Yale University, New Haven, Connecticut, USA
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Bonakdar R, Palanker D, Sweeney MM. Analysis of State Insurance Coverage for Nonpharmacologic Treatment of Low Back Pain as Recommended by the American College of Physicians Guidelines. Glob Adv Health Med 2019; 8:2164956119855629. [PMID: 31384512 PMCID: PMC6664625 DOI: 10.1177/2164956119855629] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 05/07/2019] [Accepted: 05/14/2019] [Indexed: 12/15/2022] Open
Abstract
Background In 2017, the American College of Physicians (ACP) released guidelines
encouraging nonpharmacologic treatment of chronic low back pain (LBP). These
guidelines recommended utilization of treatments including multidisciplinary
rehabilitation, acupuncture, mindfulness-based stress reduction (MBSR), tai
chi, yoga, progressive relaxation, biofeedback, cognitive behavioral therapy
(CBT), and spinal manipulation. Objective We aimed to determine status of insurance coverage status for multiple
nonpharmacological pain therapies based on the 2017 Essential Health
Benefits (EHB) benchmark plans across all states. Methods The 2017 EHB benchmark plans represent the minimum benefits required in all
new policies in the individual and small group health insurance markets and
were reviewed for coverage of treatments for LBP recommended by the ACP
guidelines. Additionally, plans were reviewed for limitations and
exclusionary criteria. Results In nearly all state-based coverage policies, chronic pain management and
multidisciplinary rehabilitation were not addressed. Coverage was most
extensive (supported by 46 states) for spinal manipulation. Acupuncture,
massage, and biofeedback were each covered by fewer than 10 states, while
MBSR, tai chi, and yoga were not covered by any states. Behavioral health
treatment (CBT and biofeedback) coverage was often covered solely for mental
health diagnoses, although excluded for treating LBP. Conclusion Other than spinal manipulation, evidence-based, nonpharmacological therapies
recommended by the 2017 ACP guidelines were routinely excluded from EHB
benchmark plans. Insurance coverage discourages multidisciplinary
rehabilitation for chronic pain management by providing ambiguous
guidelines, restricting ongoing treatments, and excluding behavioral or
complementary therapy despite a cohesive evidence base. Better EHB plan
coverage of nondrug therapies may be a strategy to mitigate the opioid
crisis. Recommendations that reflect current research-based findings are
provided to update chronic pain policy statements.
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Affiliation(s)
- Robert Bonakdar
- Scripps Center for Integrative Medicine, La Jolla, California
| | - Dania Palanker
- Center on Health Insurance Reforms, Health Policy Institute at Georgetown University, Washington, District of Columbia
| | - Megan M Sweeney
- Scripps Center for Integrative Medicine, La Jolla, California.,School of Medicine, University of California San Diego, La Jolla, California
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Ashrafioun L, Kane C, Bishop TM, Britton PC, Pigeon WR. The Association of Pain Intensity and Suicide Attempts Among Patients Initiating Pain Specialty Services. THE JOURNAL OF PAIN 2019; 20:852-859. [DOI: 10.1016/j.jpain.2019.01.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 01/02/2019] [Accepted: 01/08/2019] [Indexed: 01/27/2023]
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49
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Koffel E, McCurry SM, Smith MT, Vitiello MV. Improving pain and sleep in middle-aged and older adults: the promise of behavioral sleep interventions. Pain 2019; 160:529-534. [PMID: 30562269 PMCID: PMC6377323 DOI: 10.1097/j.pain.0000000000001423] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- Erin Koffel
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- University of Minnesota Medical School, F282/2A West Building, 2450 Riverside Avenue South, Minneapolis, MN 55454, USA
| | - Susan M. McCurry
- Psychosocial and Community Health, University of Washington, Seattle, WA 98195
| | - Michael T. Smith
- Johns Hopkins University, School of Medicine, Behavioral Medicine Research Laboratory and Clinic, Joseph Brady, Behavioral Biology Building, STE 100, 5510 Nathan Shock Drive, Baltimore, MD 21224
| | - Michael V. Vitiello
- Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, 98195
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50
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Han L, Goulet JL, Skanderson M, Bathulapalli H, Luther SL, Kerns RD, Brandt CA. Evaluation of Complementary and Integrative Health Approaches Among US Veterans with Musculoskeletal Pain Using Propensity Score Methods. PAIN MEDICINE (MALDEN, MASS.) 2019; 20:90-102. [PMID: 29584926 PMCID: PMC6329442 DOI: 10.1093/pm/pny027] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Objectives To examine the treatment effectiveness of complementary and integrative health approaches (CIH) on chronic pain using Propensity Score (PS) methods. Design, Settings, and Participants A retrospective cohort of 309,277 veterans with chronic musculoskeletal pain assessed over three years after initial diagnosis. Methods CIH exposure was defined as one or more clinical visits for massage, acupuncture, or chiropractic care. The treatment effect of CIH on self-rated pain intensity was examined using a longitudinal model. PS-matching and inverse probability of treatment weighting (IPTW) were used to account for potential selection and confounding biases. Results At baseline, veterans with (7,621) and without (301,656) CIH exposure differed significantly in 21 out of 35 covariates. During the follow-up period, on average CIH recipients had 0.83 (95% confidence interval [CI] = 0.77 to 0.89) points higher pain intensity ratings (range = 0-10) than nonrecipients. This apparent unfavorable effect size was reduced to 0.37 (95% CI = 0.28 to 0.45) after PS matching, 0.36 (95% CI = 0.29 to 0.44) with IPTW on the treated (IPTW-T) weighting, and diminished to null when integrating IPTW-T with PS matching (0.004, 95% CI = -0.09 to 0.10). An alternative IPTW model and conventional covariate adjustment appeared least powerful in terms of potential bias reduction. Sensitivity analyses restricting the follow-up period to one year after CIH initiation derived consistent results. Conclusions PS-based causal methods successfully eliminated baseline difference between exposure groups in all measured covariates, yet they did not detect a significant difference in the self-rated pain intensity outcome between veterans who received CIHs and those who did not during the follow-up period.
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Affiliation(s)
- Ling Han
- Departments of *Internal Medicine
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Joseph L Goulet
- Psychiatry
- Medicine
- Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Melissa Skanderson
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Harini Bathulapalli
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
| | | | - Robert D Kerns
- Psychiatry
- Medicine
- Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Cynthia A Brandt
- Psychiatry
- Medicine
- Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
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