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Munk N, Daggy JK, Slaven JE, Evans E, Foote T, Laws BV, Matthias MS, Bair MJ. Care ally-assisted massage for Veterans with chronic neck pain: TOMCATT results. Contemp Clin Trials 2024; 142:107561. [PMID: 38704120 DOI: 10.1016/j.cct.2024.107561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 04/23/2024] [Accepted: 05/01/2024] [Indexed: 05/06/2024]
Abstract
PURPOSE Chronic neck pain (CNP) is prevalent and challenging to treat. Despite evidence of massage's effectiveness for CNP, multiple accessibility barriers exist. The Trial Outcomes for Massage: Care Ally-Assisted vs. Therapist Treated (TOMCATT) study examined a care ally-assisted massage (CA-M) approach compared to a waitlist control prior to a study design modification (WL-C0). METHODS CA-M consisted of in-person training for veteran/care-ally dyads to learn a standardized 30-minue massage routine, instructional DVD, and printed treatment manual. Participants were to complete three care ally-assisted massage sessions weekly for 12-weeks. Outcomes collected at baseline, 1-, 3-, and 6-months included validated measures of neck pain severity and associated disability. Linear mixed-model approaches were used for analysis with 3-months as the primary outcome timepoint. RESULTS Participants (N = 203) were 56.7 ± 14 years old, 75% White, 15% female, and 75% married/partnered. Among 102 CA-M participants, 45% did not attend the in-person training and subsequently withdrew from the study and were more likely to be younger (p = .016) and employed (p = .004). Compared to WL-C0, CA-M participants had statistically significant reductions in pain-related disability at 3-months (-3.4, 95%CI = [-5.8, -1.0]; p = .006) and 6-months (-4.6, 95%CI = [-7.0, -2.1]; p < .001) and pain severity at 3-months (-1.3, 95%CI = [-1.9, -0.8]; p < .001) and 6-months (-1.0, 95%CI = [-1.6, -0.4]; p = .007), respectively. CONCLUSION In this analysis, CA-M led to greater reductions in CNP with disability and pain severity compared to WL-C0, despite treatment engagement and retention challenges. Future work is needed to determine how to better engage Veterans and their care-allies to attend CA-M training.
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Affiliation(s)
- N Munk
- Indiana University School of Health and Human Sciences, Department of Health Sciences, Indianapolis, Indiana, USA; Australian Research Centre in Complementary and Integrative Medicine (ARCCIM), Massage & Myotherapy Australia Fellow and Visiting Faculty of Health, University of Technology Sydney, Sydney, Australia.
| | - J K Daggy
- Indiana University School of Medicine, Department of Biostatistics and Health Data Science, Indianapolis, IN, United States
| | - J E Slaven
- Indiana University School of Medicine, Department of Biostatistics and Health Data Science, Indianapolis, IN, United States
| | - E Evans
- Richard L. Roudebush VA Medical Center, Center for Health Information and Communication, Indianapolis, Indiana, USA
| | - T Foote
- Richard L. Roudebush VA Medical Center, Center for Health Information and Communication, Indianapolis, Indiana, USA
| | - B V Laws
- Richard L. Roudebush VA Medical Center, Center for Health Information and Communication, Indianapolis, Indiana, USA
| | - M S Matthias
- Richard L. Roudebush VA Medical Center, Center for Health Information and Communication, Indianapolis, Indiana, USA; Indiana University School of Medicine and Regenstrief Institute, Indianapolis, Indiana, USA
| | - M J Bair
- Richard L. Roudebush VA Medical Center, Center for Health Information and Communication, Indianapolis, Indiana, USA; Indiana University School of Medicine and Regenstrief Institute, Indianapolis, Indiana, USA
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Mulcahy AC, Govier DJ, Than CT, Chawla N, Danan E, Hooker ER, McCready H, Hoggatt KJ, Yano EM, Hynes DM. Application of a comprehensive disability measure: Disability prevalence among US Veterans and non-veterans from the National Health Interview Survey Data from 2015 to 2018. Prev Med 2024; 185:108051. [PMID: 38906274 DOI: 10.1016/j.ypmed.2024.108051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 06/17/2024] [Accepted: 06/18/2024] [Indexed: 06/23/2024]
Abstract
BACKGROUND Current measures of condition-specific disabilities or those capturing only severe limitations may underestimate disability prevalence, including among Veterans. OBJECTIVES To develop a comprehensive measure to characterize and compare disabilities among US Veterans and non-Veterans. METHODS Using 2015-2018 pooled cross-sectional National Health Interview Survey data, we compared the frequency and survey-weighted prevalence of non-mutually exclusive sensory, social, and physical disabilities by Veteran status. We developed a measure for and examined the frequency and survey-weighted prevalence of eight mutually exclusive disability categories-sensory only; physical only; social only; sensory and physical; social and sensory; physical and social; and sensory, social, and physical. RESULTS Among 118,818 NHIS respondents, 11,943 were Veterans. Veterans had a greater prevalence than non-Veterans of non-mutually exclusive physical [52.01% vs. 34.68% (p < 0.001)], sensory [44.47% vs. 21.79% (p < 0.001)], and social [17.20% vs. 11.61% (p < 0.001)] disabilities (after survey-weighting). The most frequently reported mutually exclusive disability categories for both Veterans and non-Veterans were sensory and physical (19.20% and 8.02%, p < 0.001) and physical only (16.24% and 15.69%, p = 0.216) (after survey-weighting). The least frequently reported mutually exclusive disability categories for both Veterans and non-Veterans were social only (0.31% and 0.44%, p = 0.136) and sensory and social (0.32% and 0.20%, respectively, 0.026) (after survey-weighting). CONCLUSIONS Our disability metric demonstrates that Veterans have a higher disability prevalence than non-Veterans, and a higher prevalence than previously reported. Public policy and future research should consider this broader definition of disability to more fully account for the variable needs of people with disabilities.
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Affiliation(s)
- Abigail C Mulcahy
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, OR, United States of America; Oregon Health and Sciences University/Portland State University School of Public Health, United States of America
| | - Diana J Govier
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, OR, United States of America; Oregon Health and Sciences University/Portland State University School of Public Health, United States of America
| | - Claire T Than
- National Precision Oncology Program, VHA Specialty Care Services, United States of America
| | - Neetu Chawla
- VA Health Systems Research (HSR) Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California, United States of America
| | - Elisheva Danan
- VA Center for Care Delivery and Outcomes Research, Minneapolis, Minnesota, United States of America; Division of General Internal Medicine, Minneapolis VA Healthcare System, Minneapolis, Minnesota, United States of America; Department of Medicine, University of Minnesota, Minneapolis, MN, United States of America
| | - Elizabeth R Hooker
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, OR, United States of America; Oregon Health and Sciences University/Portland State University School of Public Health, United States of America
| | - Holly McCready
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, OR, United States of America
| | - Katherine J Hoggatt
- San Francisco VA Health Care System, San Francisco, California, United States of America; Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Elizabeth M Yano
- VA Health Systems Research (HSR) Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California, United States of America; Department of Health Policy & Management, UCLA Fielding School of Public Health, Los Angeles, California, United States of America; Department of Medicine, UCLA Geffen School of Medicine, Los Angeles, California, United States of America
| | - Denise M Hynes
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, OR, United States of America; Health Management and Policy, College of Health & Center for Quantitative Life Sciences, Oregon State University, Corvallis, OR, United States of America; School of Nursing, Oregon Health & Science University, Portland, OR, United States of America.
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Rupp TL, Amoako M, Johnson K, Rojas W, Highland KB. Massage Therapy Utilization in the Military Health System. Mil Med 2024:usae299. [PMID: 38861401 DOI: 10.1093/milmed/usae299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 05/06/2024] [Accepted: 05/23/2024] [Indexed: 06/13/2024] Open
Abstract
INTRODUCTION Massage therapy is an evidence-based approach for pain management. Information regarding its utilization in the Military Health System (MHS) is lacking. The goal of this study is to evaluate massage therapy utilization patterns across the MHS to include who receives (patient characteristics and diagnoses) and provides (e.g., massage therapists) massage therapy and where (e.g., clinic type). MATERIALS AND METHODS Medical record data of adult TRICARE Prime enrollees receiving outpatient massage therapy (Current Procedural Terminology codes: 97124 and 97140) from June 1, 2021, to May 31, 2023, were extracted from the MHS Data Repository. After identifying the index massage therapy visit, records for 6 months pre- and post-index were included. Descriptive statistics described massage therapy utilization patterns overall. Bivariate analysis compared patients who received massage therapy from massage therapists versus nonmassage therapist clinicians. RESULTS Of patients who received massage therapy (n = 179,215), the median number of visits was 2 (interquartile range 1 to 4), the median age was 32 years (interquartile range 25 to 40), they were mostly assigned male (72%), White (53%), Senior Enlisted (51%), with a musculoskeletal diagnosis (90%), and recent non-steroidal anti-inflammatory drug (NSAID) prescription (58%). Massage therapy was primarily delivered by physical therapists (49%) in physical therapy clinics (74%). Massage therapists provided 0.2% of massage therapy. Patients who received massage therapy from massage therapists versus nonmassage therapists significantly varied across several patient and care characteristics. CONCLUSIONS While massage therapy codes are documented frequently, massage therapists do not commonly provide massage therapy relative to nonmassage therapist providers. Access to massage therapists may be stymied by both lack of massage therapists and need for tertiary pain management referrals to access massage therapist-delivered care. Future research will leverage a health equity framework to (1) evaluate accessibility to massage therapy provided by massage therapists and (2) evaluate real-world evidence of massage therapy effectiveness.
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Affiliation(s)
- Tracy L Rupp
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Rockville, MD 20817, USA
| | - Maxwell Amoako
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Rockville, MD 20817, USA
- Enterprise Intelligence and Data Solutions (EIDS) program office, Program Executive Office, Defense Healthcare Management Systems (PEO DHMS), Arlington, VA 22209, USA
| | - Kevin Johnson
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Rockville, MD 20817, USA
| | - Winifred Rojas
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Rockville, MD 20817, USA
| | - Krista B Highland
- Department of Anesthesiology, School of Medicine, Uniformed Services University, Bethesda, MD 20814, USA
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Yarns BC, Jackson NJ, Alas A, Melrose RJ, Lumley MA, Sultzer DL. Emotional Awareness and Expression Therapy vs Cognitive Behavioral Therapy for Chronic Pain in Older Veterans: A Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2415842. [PMID: 38869899 DOI: 10.1001/jamanetworkopen.2024.15842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/14/2024] Open
Abstract
Importance Chronic pain is common and disabling in older adults, and psychological interventions are indicated. However, the gold standard approach, cognitive-behavioral therapy (CBT), produces only modest benefits, and more powerful options are needed. Objectives To evaluate whether emotional awareness and expression therapy (EAET) is superior to CBT for treatment of chronic pain among predominantly male older veterans and whether higher baseline depression, anxiety, or posttraumatic stress disorder (PTSD) symptoms-key targets of EAET-moderate treatment response. Design, Setting, and Participants This 2-arm randomized clinical trial was conducted from May 16, 2019, to September 14, 2023, in the US Department of Veterans Affairs Greater Los Angeles Healthcare System. The trial included a racially and ethnically diverse group of veterans aged 60 to 95 years with at least 3 months of musculoskeletal pain. Interventions Emotional awareness and expression therapy or CBT, conducted concurrently, each presented as one 90-minute individual session followed by eight 90-minute group sessions. Main Outcomes and Measures The primary outcome was Brief Pain Inventory pain severity (range, 0 to 10) from baseline to posttreatment (week 10, primary end point) and 6-month follow-up. Secondary outcomes included Patient Reported Outcomes Institute Measurement System Anxiety, Depression, Fatigue, General Life Satisfaction (NIH Toolbox), Pain Interference, and Sleep Disturbance Short Forms, Patient Global Impression of Change (PGIC), and Satisfaction with Therapy and Therapist Scale-Revised. A subset of participants completed the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition). All analyses were for the intention-to-treat population and included all randomized participants. Results Among 126 randomized participants (66 in the EAET group and 60 in the CBT group; mean [SD] age, 71.9 [5.9] years; 116 [92%] male), 111 (88%) completed posttreatment, and 104 (82%) completed the 6-month follow-up. The EAET was superior to CBT for the primary outcome of reduction in pain severity at posttreatment (estimate, -1.59 [95% CI, -2.35 to -0.83]; P < .001) and follow-up (estimate, -1.01 [95% CI, -1.78 to -0.24]; P = .01). A greater percentage of participants in EAET vs CBT had clinically significant (at least 30%) pain reduction (63% vs 17%; odds ratio, 21.54 [95% CI, 4.66-99.56]; P < .001) at posttreatment. In addition, EAET was superior to CBT on 50% pain reduction (35% vs 7%; odds ratio, 11.77 [95% CI, 2.38-58.25]; P = .002), anxiety (estimate, -2.49 [95% CI, -4.30 to -0.68]; P = .006), depression (estimate, -3.06 [95% CI, -5.88 to -0.25]; P = .03), general life satisfaction (estimate, 1.23 [95% CI, 0.36-2.10]; P = .005), PTSD symptoms (estimate, -4.39 [95% CI, -8.44 to -0.34]; P = .03), PGIC score (estimate, 1.46 [95% CI, 0.77-2.15]; P < .001), and global treatment satisfaction (estimate, 0.28 [95% CI, 0.12-0.45]; P < .001) at posttreatment. Higher baseline depression (estimate, -1.55 [95% CI, -0.37 to 2.73]; P < .001), anxiety (estimate, -1.53 [95% CI, -2.19 to -0.88]; P < .001), and PTSD symptoms (estimate, -1.69 [95% CI, -2.96 to -0.42]; P = .009) moderated greater reduction in pain severity after EAET but not CBT. Conclusions and Relevance The results of this randomized clinical trial suggest that EAET may be a preferred intervention for medically and psychiatrically complex patients with pain. The societal burden of chronic pain could be improved by further incorporating the principles of EAET into mainstream clinical pain medicine. Trial Registration ClinicalTrials.gov Identifier: NCT03918642.
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Affiliation(s)
- Brandon C Yarns
- Department of Mental Health, VA Greater Los Angeles Healthcare System, California
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at University of California, Los Angeles
| | - Nicholas J Jackson
- Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles
| | - Alexander Alas
- Department of Mental Health, VA Greater Los Angeles Healthcare System, California
| | - Rebecca J Melrose
- Department of Mental Health, VA Greater Los Angeles Healthcare System, California
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at University of California, Los Angeles
| | - Mark A Lumley
- Department of Psychology, Wayne State University, Detroit, Michigan
| | - David L Sultzer
- Department of Mental Health, VA Greater Los Angeles Healthcare System, California
- Department of Psychiatry and Human Behavior, University of California, Irvine School of Medicine, Irvine
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Lakshman R, Tomlinson E, Bucknall T. A Systematic Review of Chronic Pain Management Interventions Among Veterans of Recent Wars and Armed Conflicts. Pain Manag Nurs 2024; 25:285-293. [PMID: 38604820 DOI: 10.1016/j.pmn.2024.03.008] [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: 09/15/2023] [Revised: 02/20/2024] [Accepted: 03/12/2024] [Indexed: 04/13/2024]
Abstract
OBJECTIVES To identify chronic pain management strategies aimed to reduce pain intensity and enhance functional outcomes in veterans of wars and armed conflict. DESIGN Systematic review without meta-analysis. DATA SOURCES Key words "chronic pain," "veterans," and "injuries" were used to search for articles in the MEDLINE, CINAHL, APA PsycInfo, and Embase databases. Articles published in English between 2000 and 2023 were included. REVIEW/ANALYSIS METHODS A systematic literature search was conducted in June 2020, updated in April 2023, and managed using Covidence review software. Inclusion criteria focused on combat-injured veterans with chronic pain, excluding nonveterans and civilians treated for acute or chronic pain. Data from included studies were extracted, summarized, and critically appraised using the 2018 Mixed Methods Appraisal Tool. This review is registered with PROSPERO (CRD42020207435). RESULTS Fourteen studies met the inclusion criteria, with 10 of them supporting nonpharmacological approaches for managing chronic pain among veterans of armed conflicts and wars. Interventions included psychological/behavioral therapies, peer support, biofeedback training via telephone-based therapy, manual therapy, yoga, cognitive processing therapy, cognitive-behavioral therapy, and social and community integration to reduce pain intensity and enhance functional outcomes. CONCLUSION Nonpharmacological treatments for chronic pain have increased in recent years, a shift from earlier reliance on pharmacological treatments. More evidence from randomized controlled trials on the benefits of combined pain interventions could improve pain management of veterans with complex care needs.
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Affiliation(s)
- Rital Lakshman
- School of Nursing and Midwifery, Deakin University, Geelong, Victoria, Australia.
| | - Emily Tomlinson
- School of Nursing and Midwifery, Deakin University, Geelong, Victoria, Australia; Centre for Quality and Patient Safety Research in the Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia. https://twitter.com/emjane88
| | - Tracey Bucknall
- School of Nursing and Midwifery, Deakin University, Geelong, Victoria, Australia; Centre for Quality and Patient Safety Research in the Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia; Centre for Quality and Patient Safety Research - Alfred Health Partnership, Melbourne, Victoria, Australia. https://twitter.com/nursedecisions
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Axson SA, Becker WC, Merlin JS, Lorenz KA, Midboe AM, C Black A. Long-term opioid therapy trajectories in veteran patients with and without substance use disorder. Addict Behav 2024; 153:107997. [PMID: 38442438 PMCID: PMC11080947 DOI: 10.1016/j.addbeh.2024.107997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 01/16/2024] [Accepted: 02/21/2024] [Indexed: 03/07/2024]
Affiliation(s)
- Sydney A Axson
- Health Services Research & Development, VA Connecticut Healthcare System, West Haven, CT, USA; The National Clinician Scholars Program, Yale School of Medicine, 333 Cedar St, New Haven, CT, USA; Ross and Carol Nese College of Nursing, The Pennsylvania State University, 201 Nursing Sciences Building, University Park, PA 16802, USA.
| | - William C Becker
- Department of Internal Medicine, Yale School of Medicine, 333 Cedar St, New Haven, CT, USA; Pain Research, Informatics, Multimorbidities and Education Center of Innovation, VA Connecticut Healthcare System, West Haven, CT, USA.
| | - Jessica S Merlin
- CHAllenges in Managing and Preventing Pain (CHAMPP) Clinical Research Center, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Karl A Lorenz
- Stanford University School of Medicine, Stanford, CA, USA.
| | - Amanda M Midboe
- Stanford University School of Medicine, Stanford, CA, USA; Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, CA, USA.
| | - Anne C Black
- Department of Internal Medicine, Yale School of Medicine, 333 Cedar St, New Haven, CT, USA; Pain Research, Informatics, Multimorbidities and Education Center of Innovation, VA Connecticut Healthcare System, West Haven, CT, USA.
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Friedman JK, Taylor BC, Campbell EH, Allen K, Bangerter A, Branson M, Bronfort G, Calvert C, Cross LJS, Driscoll MA, Evans R, Ferguson JE, Haley A, Hennessy S, Meis LA, Burgess DJ. Gender differences in PTSD severity and pain outcomes: Baseline results from the LAMP trial. PLoS One 2024; 19:e0293437. [PMID: 38753651 PMCID: PMC11098421 DOI: 10.1371/journal.pone.0293437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 05/01/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND Post-traumatic stress disorder (PTSD) and chronic pain are highly prevalent comorbid conditions. Veterans dually burdened by PTSD and chronic pain experience more severe outcomes compared to either disorder alone. Few studies have enrolled enough women Veterans to test gender differences in pain outcomes [catastrophizing, intensity, interference] by the severity of PTSD symptoms. AIM Examine gender differences in the association between PTSD symptoms and pain outcomes among Veterans enrolled in a chronic pain clinical trial. METHODS Participants were 421 men and 386 women Veterans with chronic pain who provided complete data on PTSD symptoms and pain outcomes. We used hierarchical linear regression models to examine gender differences in pain outcomes by PTSD symptoms. RESULTS Adjusted multivariable models indicated that PTSD symptoms were associated with higher levels of pain catastrophizing (0.57, 95% CI [0.51, 0.63]), pain intensity (0.30, 95% CI [0.24, 0.37]), and pain interference (0.46, 95% CI [0.39, 0.52]). No evidence suggesting gender differences in this association were found in either the crude or adjusted models (all interaction p-values<0.05). CONCLUSION These findings may reflect the underlying mutual maintenance of these conditions whereby the sensation of pain could trigger PTSD symptoms, particularly if the trauma and pain are associated with the same event. Clinical implications and opportunities testing relevant treatments that may benefit both chronic pain and PTSD are discussed.
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Affiliation(s)
- Jessica K. Friedman
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Health Care System (VAGLACS), Los Angeles, California, United States of America
| | - Brent C. Taylor
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Healthcare System (MVAHCS), Minneapolis, Minnesota, United States of America
- University of Minnesota Medical School, Minneapolis, Minnesota, United States of America
| | - Emily Hagel Campbell
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Healthcare System (MVAHCS), Minneapolis, Minnesota, United States of America
| | - Kelli Allen
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VAHCS, Durham, North Carolina, United States of America
- Thurston Arthritis Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Ann Bangerter
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Healthcare System (MVAHCS), Minneapolis, Minnesota, United States of America
| | - Mariah Branson
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Healthcare System (MVAHCS), Minneapolis, Minnesota, United States of America
| | - Gert Bronfort
- Integrative Health & Wellbeing Research Program, Earl E. Bakken Center for Spirituality & Healing, School of Nursing, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Collin Calvert
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Healthcare System (MVAHCS), Minneapolis, Minnesota, United States of America
- University of Minnesota Medical School, Minneapolis, Minnesota, United States of America
| | - Lee J. S. Cross
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Healthcare System (MVAHCS), Minneapolis, Minnesota, United States of America
| | - Mary A. Driscoll
- VA Connecticut Healthcare System, West Haven, Connecticut, United States of America
- Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Ronni Evans
- Integrative Health & Wellbeing Research Program, Earl E. Bakken Center for Spirituality & Healing, School of Nursing, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - John E. Ferguson
- University of Minnesota Medical School, Minneapolis, Minnesota, United States of America
| | - Alex Haley
- Integrative Health & Wellbeing Research Program, Earl E. Bakken Center for Spirituality & Healing, School of Nursing, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Sierra Hennessy
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Healthcare System (MVAHCS), Minneapolis, Minnesota, United States of America
| | - Laura A. Meis
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Healthcare System (MVAHCS), Minneapolis, Minnesota, United States of America
- University of Minnesota Medical School, Minneapolis, Minnesota, United States of America
- Women’s Health Sciences Division, National Center for PTSD, Boston, Massachusetts, United States of America
| | - Diana J. Burgess
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Healthcare System (MVAHCS), Minneapolis, Minnesota, United States of America
- University of Minnesota Medical School, Minneapolis, Minnesota, United States of America
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8
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O’Hanlon CE, Zeliadt SB, DeFaccio R, Gaj L, Bokhour BG, Taylor SL. Patient-reported pain and physical health for acupuncture and chiropractic care delivered by Veterans Affairs versus community providers. PLoS One 2024; 19:e0303651. [PMID: 38748671 PMCID: PMC11095679 DOI: 10.1371/journal.pone.0303651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 04/26/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND Acupuncture and chiropractic care are evidence-based pain management alternatives to opioids. The Veterans Health Administration (VA) provides this care in some VA facilities, but also refers patients to community providers. We aimed to determine if patient-reported outcomes differ for acupuncture and chiropractic care from VA versus community providers. MATERIALS AND METHODS We conducted an observational study using survey outcome data and electronic medical record utilization data for acupuncture and chiropractic care provided in 18 VA facilities or in community facilities reimbursed by VA. Study participants were users of VA primary care, mental health, pain clinic, complementary and integrative therapies, coaching or education services in 2018-2019. Patients received 1) 4+ acupuncture visits (N = 201) or 4+ chiropractic care visits (N = 178) from a VA or community provider from 60 days prior to baseline to six-months survey and 2) no acupuncture or chiropractic visits from 1 year to 60 days prior to baseline. Outcomes measured included patient-reported pain (PEG) and physical health (PROMIS) at baseline and six-month surveys. Multivariate analyses examined outcomes at six months, adjusting for baseline outcomes and demographics. RESULTS In unadjusted analyses, pain and physical health improved for patients receiving community-based acupuncture, while VA-based acupuncture patients experienced no change. Unadjusted analyses also showed improvements in physical health, but not pain, for patients receiving VA-based chiropractic care, with no changes for community-based chiropractic care patients. Using multivariate models, VA-based acupuncture was no different from community-based acupuncture for pain (-0.258, p = 0.172) or physical health (0.539, p = 0.399). Similarly, there were no differences between VA- and community-based chiropractic care in pain (-0.273, p = 0.154) or physical health (0.793, p = 0.191). CONCLUSIONS Acupuncture and chiropractic care were associated with modest improvements at six months, with no meaningful differences between VA and community providers. The choice to receive care from VA or community providers could be based on factors other than quality, like cost or convenience.
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Affiliation(s)
- Claire E. O’Hanlon
- Veterans Affairs Greater Los Angeles Healthcare System, Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), Los Angeles, California, United States of America
- RAND Corporation, Santa Monica, California, United States of America
| | - Steven B. Zeliadt
- Veterans Affairs Puget Sound Health Care System, VA Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington, United States of America
- Department of Health Systems and Population Health, Hans Rosling Center for Population Health, University of Washington School of Public Health, Seattle, Washington, United States of America
| | - Rian DeFaccio
- Veterans Affairs Puget Sound Health Care System, VA Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington, United States of America
| | - Lauren Gaj
- VA Bedford Healthcare System, Center for Healthcare Organization and Implementation Research (CHOIR), Bedford, Massachusetts, United States of America
| | - Barbara G. Bokhour
- VA Bedford Healthcare System, Center for Healthcare Organization and Implementation Research (CHOIR), Bedford, Massachusetts, United States of America
- Division of Preventive and Behavioral Medicine, Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, Massachusetts, United States of America
| | - Stephanie L. Taylor
- Veterans Affairs Greater Los Angeles Healthcare System, Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), Los Angeles, California, United States of America
- Department of Health Policy and Management, Fielding School of Public Health, Los Angeles, California, United States of America
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
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Taylor KA, Kapos FP, Sharpe JA, Kosinski AS, Rhon DI, Goode AP. Seventeen-Year National Pain Prevalence Trends Among U.S. Military Veterans. THE JOURNAL OF PAIN 2024; 25:104420. [PMID: 37952861 PMCID: PMC11184511 DOI: 10.1016/j.jpain.2023.11.003] [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] [Received: 04/13/2023] [Revised: 10/30/2023] [Accepted: 11/05/2023] [Indexed: 11/14/2023]
Abstract
U.S. military veterans experience higher pain prevalence than nonveterans. However, it is unclear how the disparities in pain prevalence have changed over time because previous trend studies are limited to veterans using the Veterans Health Administration. This repeated cross-sectional study aimed to characterize pain prevalence trends in the overall population of U.S. veterans compared to nonveterans, using nationally representative data. We analyzed 17 years of data from the National Health Interview Survey (2002-2018), with a mean annual unweighted sample of 29,802 U.S. adults (total unweighted n = 506,639) and mean annual weighted population of 229.7 million noninstitutionalized adults. The weighted proportion of veterans ranged from 11.48% in 2002 (highest) to 8.41% in 2017 (lowest). We found that veterans experience a similar or higher prevalence of pain than nonveterans across the study period, except for severe headaches or migraine and facial pain. Pain prevalence among veterans increased over time, with a higher rate of increase compared to nonveterans for all pain variables. From 2002 to 2018, there was an absolute increase (95% confidence interval) in pain prevalence among veterans (severe headache or migraine: 2.0% [1.6-2.4%]; facial pain: 1.9% [1.4-2.4%]; neck pain: 4.7% [4.1-5.2%]; joint pain: 11.4% [10.8-11.9%]; low back pain: 10.3% [9.5-11.1%]; any pain: 10.0% [9.6-10.4%]; and multiple pains: 9.9% [9.2-10.6%]). The continued pain prevalence increase among veterans may have implications for health care utilization, highlighting the need for improved pain prevention and care programs for this population with a disproportionate pain burden. PERSPECTIVE: This article uses routinely-collected cross-sectional data that are nationally representative of U.S. adults to present changes in pain prevalence among military veterans compared to nonveterans. The findings underscore the need for improved prevention and pain care programs for veterans, who experienced a widening disproportionate pain burden from 2002 to 2018.
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Affiliation(s)
- Kenneth Adam Taylor
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina; Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Flavia Penteado Kapos
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina; Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina; Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington
| | - Jason Arthur Sharpe
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs (VA) Healthcare System, Durham, North Carolina
| | - Andrzej Stanislaw Kosinski
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina; Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Daniel I Rhon
- Department of Rehabilitation Medicine, School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Adam Payne Goode
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina; Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina; Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
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10
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Moore LC, Woodruff NA, Seal KH, Feinberg T, Purcell N. Natural Product Use Among Veterans with Chronic Pain: A Qualitative Study of Attitudes and Communication with Healthcare Providers. J Gen Intern Med 2024:10.1007/s11606-024-08746-2. [PMID: 38689119 DOI: 10.1007/s11606-024-08746-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 03/27/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Despite mixed evidence regarding the safety and efficacy of natural products, many are marketed for pain and related symptoms. Use of these products is prevalent among veterans, who have disproportionately high rates of chronic pain. To date, however, there is limited research on veterans' beliefs and attitudes about natural products and their communication with healthcare providers about their natural product use. OBJECTIVE To explore how veterans experiencing chronic pain make decisions about natural product use, to investigate veterans' beliefs about the safety and efficacy of these products, and to examine veterans' experiences discussing natural products with their providers. DESIGN Qualitative sub-study conducted as a supplement to a pragmatic randomized controlled trial for chronic pain management. PARTICIPANTS Twenty veterans experiencing chronic pain who reported using natural products for pain management or related health concerns. APPROACH Qualitative interviews with veterans were conducted over the phone and audio-recorded. Interviews were guided by an original semi-structured interview guide and qualitative data were analyzed using a template-based rapid analysis technique. KEY RESULTS Veterans with chronic pain may perceive natural products as safer than pharmaceutical products and may prefer to use natural products. Talking with providers about natural products is important to veterans, who would like information regarding the safety and potential for interaction of natural products with pharmaceutical products. However, veterans were frequently disappointed with these conversations. Veterans felt their providers demonstrated biases against natural products, which negatively impacted patient-provider relationships. CONCLUSIONS Veterans wish to have more productive conversations with providers about natural products. They value providers' open-mindedness towards natural products and transparency about limitations in their knowledge. Suggestions for how providers and healthcare systems might better support veterans interested in natural products are discussed.
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Affiliation(s)
- Liliana Celesia Moore
- Integrative Health Service, San Francisco VA Health Care System, San Francisco, CA, USA.
- Northern California Institute for Research and Education, San Francisco, CA, USA.
- San Francisco VA Health Care System, 4150 Clement St. (11A1, T-31), San Francisco, CA, USA.
| | - Nicole A Woodruff
- Integrative Health Service, San Francisco VA Health Care System, San Francisco, CA, USA
- Northern California Institute for Research and Education, San Francisco, CA, USA
| | - Karen H Seal
- Integrative Health Service, San Francisco VA Health Care System, San Francisco, CA, USA
- University of California, San Francisco, San Francisco, CA, USA
| | - Termeh Feinberg
- Department of Biostatistics, Yale University School of Public Health, New Haven, CT, USA
- VA Connecticut PRIME Center, West Haven, CT, USA
- Kelly Government Solutions, Rockville, CT, USA
| | - Natalie Purcell
- Integrative Health Service, San Francisco VA Health Care System, San Francisco, CA, USA
- University of California, San Francisco, San Francisco, CA, USA
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Sutton KF, Cabell GH, Ashley LW, Lentz TA, Lewis BD, Olson SA, Mather RC. Does psychological distress predict risk of orthopaedic surgery and postoperative opioid prescribing in patients with hip pain? A retrospective study. BMC Musculoskelet Disord 2024; 25:304. [PMID: 38643071 PMCID: PMC11031887 DOI: 10.1186/s12891-024-07418-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 04/05/2024] [Indexed: 04/22/2024] Open
Abstract
BACKGROUND Clinicians and public health professionals have allocated resources to curb opioid over-prescription and address psychological needs among patients with musculoskeletal pain. However, associations between psychological distress, risk of surgery, and opioid prescribing among those with hip pathologies remain unclear. METHODS Using a retrospective cohort study design, we identified patients that were evaluated for hip pain from January 13, 2020 to October 27, 2021. Patients' surgical histories and postoperative opioid prescriptions were extracted via chart review. Risk of hip surgery within one year of evaluation was analyzed using multivariable logistic regression. Multivariable linear regression was employed to predict average morphine milligram equivalents (MME) per day of opioid prescriptions within the first 30 days after surgery. Candidate predictors included age, gender, race, ethnicity, employment, insurance type, hip function and quality of life on the International Hip Outcome Tool (iHOT-12), and psychological distress phenotype using the OSPRO Yellow Flag (OSPRO-YF) Assessment Tool. RESULTS Of the 672 patients, n = 350 (52.1%) underwent orthopaedic surgery for hip pain. In multivariable analysis, younger patients, those with TRICARE/other government insurance, and those with a high psychological distress phenotype had higher odds of surgery. After adding iHOT-12 scores, younger patients and lower iHOT-12 scores were associated with higher odds of surgery, while Black/African American patients had lower odds of surgery. In multivariable analysis of average MME, patients with periacetabular osteotomy (PAO) received opioid prescriptions with significantly higher average MME than those with other procedures, and surgery type was the only significant predictor. Post-hoc analysis excluding PAO found higher average MME for patients undergoing hip arthroscopy (compared to arthroplasty or other non-PAO procedures) and significantly lower average MME for patients with public insurance (Medicare/Medicaid) compared to those with private insurance. Among those only undergoing arthroscopy, older age and having public insurance were associated with opioid prescriptions with lower average MME. Neither iHOT-12 scores nor OSPRO-YF phenotype assignment were significant predictors of postoperative mean MME. CONCLUSIONS Psychological distress characteristics are modifiable targets for rehabilitation programs, but their use as prognostic factors for risk of orthopaedic surgery and opioid prescribing in patients with hip pain appears limited when considered alongside other commonly collected clinical information such as age, insurance, type of surgery pursued, and iHOT-12 scores.
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Affiliation(s)
- Kent F Sutton
- Duke University School of Medicine, Duke University Medical Center, Durham, NC, USA.
| | - Grant H Cabell
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Lucas W Ashley
- Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Trevor A Lentz
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Brian D Lewis
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Steven A Olson
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Richard C Mather
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
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12
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Fritz JM, Ford I, George SZ, Vinci de Vanegas L, Cope T, Burke CA, Goode AP. Telehealth delivery of physical therapist-led interventions for persons with chronic low back pain in underserved communities: lessons from pragmatic clinical trials. FRONTIERS IN PAIN RESEARCH 2024; 5:1324096. [PMID: 38706872 PMCID: PMC11066221 DOI: 10.3389/fpain.2024.1324096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 04/08/2024] [Indexed: 05/07/2024] Open
Abstract
In this perspective, we present our experience developing and conducting two pragmatic clinical trials investigating physical therapist-led telehealth strategies for persons with chronic low back pain. Both trials, the BeatPain Utah and AIM-Back trials, are part of pragmatic clinical trial collaboratories and are being conducted with persons from communities that experience pain management disparities. Practice guidelines recommend nonpharmacologic care, and advise against opioid therapy, for the primary care management of persons with chronic low back pain. Gaps between these recommendations and actual practice patterns are pervasive, particularly for persons from racial or ethnic minoritized communities, those with fewer economic resources, and those living in rural areas including Veterans. Access barriers to evidence-based nonpharmacologic care, which is often provided by physical therapists, have contributed to these evidence-practice gaps. Telehealth delivery has created new opportunities to overcome access barriers for nonpharmacologic pain care. As a relatively new delivery mode however, telehealth delivery of physical therapy comes with additional challenges related to technology, intervention adaptations and cultural competence. The purpose of this article is to describe the challenges encountered when implementing telehealth physical therapy programs for persons with chronic low back pain in historically underserved communities. We also discuss strategies developed to overcome barriers in an effort to improve access to telehealth physical therapy and reduce pain management disparities. Inclusion of diverse and under-represented communities in pragmatic clinical trials is a critical consideration for improving disparities, but the unique circumstances present in these communities must be considered when developing implementation strategies.
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Affiliation(s)
- Julie M. Fritz
- Department of Physical Therapy & Athletic Training, University of Utah, Salt Lake City, UT, United States
| | - Isaac Ford
- Department of Physical Therapy & Athletic Training, University of Utah, Salt Lake City, UT, United States
| | - Steven Z. George
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC, United States
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, United States
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States
| | - Laura Vinci de Vanegas
- Department of Physical Therapy & Athletic Training, University of Utah, Salt Lake City, UT, United States
| | - Tyler Cope
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, United States
| | - Colleen A. Burke
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC, United States
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States
| | - Adam P. Goode
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC, United States
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, United States
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States
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13
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Kang H, Clary K, Zhao Z, Quintero Silva L, Bobitt J. Characteristics of Cannabis and Opioid Users Among Older U.S. Veterans and Their Health Outcomes: A Longitudinal Perspective. J Psychoactive Drugs 2024; 56:157-167. [PMID: 36919533 DOI: 10.1080/02791072.2023.2186286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 01/30/2023] [Indexed: 03/16/2023]
Abstract
Medical cannabis use among U.S. Veterans has continued to rise. However, data on cannabis use by older Veterans is generally less available. This study aims to understand the characteristics of older Veterans who enrolled in the Medical Cannabis Patient Program in Illinois and analyze their health outcomes and co-use of cannabis and opioids using longitudinal survey data. Overall, participants reported positive outcomes for pain, sleep, and emotional problems because of cannabis use in two survey periods. Approximately, 62% and 85% respondents reported no change in memory and falls, respectively, with only 3% and 1% reporting a negative outcome for the conditions in both surveys. About 20.4% of those who indicated cannabis use only in the initial survey started to co-use opioids in the follow-up survey, while 44.1% of those who indicated the use of both substances in the initial survey reported no longer using opioids in the follow-up survey. However, these changes were not statistically significant (α = 0.05 ) . The logistic regression showed that both clinical and contextual factors affected co-use. In conclusion, older U.S. Veterans may be using cannabis to alleviate their pain and other chronic conditions. More research is needed to understand the effect of cannabis use on reducing or substituting opioids.
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Affiliation(s)
- Hyojung Kang
- College of Applied Health Sciences, University of Illinois at Urbana-Champaign, Champaign, IL, USA
| | - Kelly Clary
- School of Social Work, Texas State University, San Marcos, TX, USA
| | - Ziang Zhao
- Department of Statistics, University of Illinois at Urbana-Champaign, Champaign, IL, USA
| | - Laura Quintero Silva
- College of Applied Health Sciences, University of Illinois at Urbana-Champaign, Champaign, IL, USA
| | - Julie Bobitt
- College of Medicine, University of Illinois at Chicago, Chicago, IL, USA
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14
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Van Houtven CH, Smith VA, Miller KEM, Berkowitz TSZ, Shepherd-Banigan M, Hein T, Penney LS, Allen KD, Kabat M, Jobin T, Hastings SN. Comprehensive Caregiver Supports and Ascertainment and Treatment of Veteran Pain. Med Care Res Rev 2024; 81:107-121. [PMID: 38062735 DOI: 10.1177/10775587231210026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
Disabled Veterans commonly experience pain. The Program of Comprehensive Assistance for Family Caregivers (PCAFC) provides training, a stipend, and services to family caregivers of eligible Veterans to support their caregiving role. We compared ascertainment of veteran pain and pain treatment through health care encounters and medications (pain indicators) of participants (treated group) and non-participants (comparison group) using inverse probability treatment weights. Modeled results show that the proportion of Veterans with a pain indicator in the first year post-application was higher than that pre-application for both groups. However, the proportion of Veterans with a pain indicator was substantially higher in the treatment group: 76.1% versus 63.9% in the comparison group (p < .001). Over time, the proportion of Veterans with any pain indicator fell and group differences lessened. However, differences persisted through 8 years post-application (p < .001). PCAFC caregivers appear to help Veterans engage in pain treatment at higher rates than caregivers not in PCAFC.
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Affiliation(s)
- Courtney H Van Houtven
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System
- Department of Population Health Sciences, Duke University School of Medicine
- Duke Margolis Center for Health Policy, Duke University
| | - Valerie A Smith
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System
- Department of Population Health Sciences, Duke University School of Medicine
- Department of General Internal Medicine, Duke University
| | - Katherine E M Miller
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System
- Department of Medical Ethics and Health Policy, University of Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania
| | - Theodore S Z Berkowitz
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System
| | - Megan Shepherd-Banigan
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System
- Department of Population Health Sciences, Duke University School of Medicine
| | - Tyler Hein
- Office of Mental Health and Suicide Prevention, Department of Veterans Affairs
| | - Lauren S Penney
- The Elizabeth Dole Center of Excellence for Veteran and Caregiver Research, South Texas Veterans Health Care System
- Department of Medicine, Division of Hospital Medicine, University of Texas Health San Antonio
| | - Kelli D Allen
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System
- Department of Medicine, University of North Carolina at Chapel Hill
| | - Margaret Kabat
- Office of the Secretary US Department of Veterans Affairs
| | - Timothy Jobin
- Caregiver Support Program, Veterans Health Administration, US Department of Veterans Affairs
| | - S Nicole Hastings
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System
- Department of Population Health Sciences, Duke University School of Medicine
- Department of Medicine, Division of Geriatrics, Duke University School of Medicine
- Center for the Study of Aging and Human Development, Duke University School of Medicine
- Geriatrics Research, Education and Clinical Center, Durham VA Health Care System
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15
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Gasperi M, Schuster NM, Franklin B, Nievergelt CM, Stein MB, Afari N. Migraine Prevalence, Environmental Risk, and Comorbidities in Men and Women Veterans. JAMA Netw Open 2024; 7:e242299. [PMID: 38483390 PMCID: PMC10940970 DOI: 10.1001/jamanetworkopen.2024.2299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 01/20/2024] [Indexed: 03/17/2024] Open
Abstract
Importance Migraine is a prevalent and debilitating condition that substantially impacts quality of life. Investigating migraine prevalence, associated comorbidities, and potential military service exposures in veterans, focusing on gender differences, is crucial for targeted interventions and management strategies. Objective To determine the prevalence of migraine, associated health comorbidities, and potential military service and environmental exposures among men and women US veterans using a large-scale epidemiological sample from the Million Veteran Program (MVP). Design, Setting, and Participants This cross-sectional study analyzed self-report survey data from the MVP, a large epidemiological sample of US veterans that was started in 2011 and has ongoing enrollment. Eligible participants were selected from the MVP database in 2023. The study included 491 604 veterans to examine migraine prevalence, health comorbidities, demographic characteristics, military service history, and environmental exposures. Data were analyzed from December 2022 to July 2023. Exposures Military service and environmental factors, such as chemical or biological warfare exposure, were considered. Main Outcomes and Measures The primary outcome was migraine prevalence among men and women veterans, assessed through self-reported diagnoses. Secondary outcomes included the association between migraine and health comorbidities, demographic characteristics, military service history, and environmental exposures. Results Of the 491 604 veterans included in this study, 450 625 (91.8%) were men and 40 979 (8.2%) were women. The lifetime prevalence of migraine was significantly higher in women (12 324 of 40 979 [30.1%]) than in men (36 816 of 450 625 [8.2%]). Migraine prevalence varied by race and ethnicity, with the highest prevalence in Hispanic or Latinx women (1213 of 3495 [34.7%]). Veterans with migraine reported worse general health, higher levels of pain, increased pain interference with work, a higher likelihood of psychiatric and neurological health conditions, and greater lifetime opioid use. Specific aspects of military service, including service post-September 2001 and deployment in Operation Enduring Freedom and Operation Iraqi Freedom, and environmental factors, including Agent Orange, chemical and biological welfare, and antinerve agent pills history, were significantly associated with migraine prevalence. Conclusions and Relevance In this cross-sectional study of migraine, the results highlighted gender differences in migraine prevalence and associated health comorbidities among US veterans. The findings emphasized the need for interdisciplinary approaches to migraine management, increased awareness and education efforts, and population-based screening strategies, particularly for women and Hispanic veterans who are at greater risk. Our findings encourage further research into tailored interventions for specific subpopulations and the impact of military service and environmental exposures on migraine and related health conditions.
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Affiliation(s)
- Marianna Gasperi
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle
- Veteran Affairs (VA) Puget Sound Health Care System, Seattle, Washington
- VA Northwest Mental Illness Research, Education and Clinical Center VA Puget Sound Health Care System, Seattle, Washington
| | | | - Brooke Franklin
- Department of Psychology, University of Utah, Salt Lake City
| | - Caroline M. Nievergelt
- Department of Psychiatry, University of California, San Diego, La Jolla
- VA San Diego Health Care System, San Diego, California
- VA Center of Excellence for Stress and Mental Health, VA San Diego Health Care System, San Diego, California
| | - Murray B. Stein
- Department of Psychiatry, University of California, San Diego, La Jolla
- VA San Diego Health Care System, San Diego, California
- Herbert Wertheim School of Public Health, University of California, San Diego, La Jolla
| | - Niloofar Afari
- Department of Psychiatry, University of California, San Diego, La Jolla
- VA San Diego Health Care System, San Diego, California
- VA Center of Excellence for Stress and Mental Health, VA San Diego Health Care System, San Diego, California
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16
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Moskal D, Loughran TA, Funderburk JS, Scharer JL, Buckheit KA, Beehler GP. Pain and Hazardous Alcohol Use in Veterans in Primary Care: The Role of Affective Pain Interference and Alcohol Pain-Coping Perceptions. THE JOURNAL OF PAIN 2024; 25:682-689. [PMID: 37783381 DOI: 10.1016/j.jpain.2023.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 09/17/2023] [Accepted: 09/26/2023] [Indexed: 10/04/2023]
Abstract
Chronic pain and unhealthy alcohol use commonly co-occur and are associated with negative health outcomes. Veterans may be particularly vulnerable to these conditions, yet limited research has examined factors involved in their co-occurrence. This cross-sectional study aimed to examine the role of affective pain interference and alcohol pain-coping perceptions in the relationship between pain and hazardous alcohol use. As informed by the catastrophizing, anxiety, negative urgency, and expectancy model, we hypothesized that the relationship between pain and hazardous alcohol consumption is mediated by affective pain interference and stronger among those with greater perceptions that alcohol helps cope with pain. Participants were 254 VA primary care patients (87.8% male, Mage = 64.03, 76.4% White) with a history of chronic musculoskeletal pain, past-year alcohol use, and past-week pain. Veterans completed a mailed survey including measures of pain, affective pain interference, alcohol pain-coping perceptions, and hazardous alcohol use. Hypotheses were tested with regression models and PROCESS macros. As hypothesized, affective pain interference mediated the pain-hazardous alcohol use association. Contrary to hypotheses, results showed no moderating effect of alcohol pain-coping perceptions. Findings partially support relationships among theorized constructs and suggest that for Veterans with co-occurring pain and alcohol use it may be important to target pain-related affective interference and perceptions that alcohol helps cope with pain. PERSPECTIVE: This article presents a test of factors involved in the pain and alcohol relationship, as informed by the CANUE model. Findings suggest that for Veterans with co-occurring pain and past-year alcohol use, it may be important to target pain-related affective interference and perceptions that alcohol helps cope with pain.
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Affiliation(s)
- Dezarie Moskal
- VA Center for Integrated Healthcare, VA Western New York Healthcare System, Buffalo, New York; Department of Community Health and Health Behavior, School of Public Health and Health Professions, University at Buffalo, Buffalo, New York
| | - Travis A Loughran
- VA Center for Integrated Healthcare, VA Western New York Healthcare System, Buffalo, New York
| | - Jennifer S Funderburk
- VA Center for Integrated Healthcare, Syracuse VA Medical Center, Syracuse, New York; Department of Psychology, Syracuse University, Syracuse, New York; Department of Psychiatry, University of Rochester, Rochester, New York
| | - Jacob L Scharer
- VA Center for Integrated Healthcare, Syracuse VA Medical Center, Syracuse, New York
| | - Katherine A Buckheit
- VA Center for Integrated Healthcare, Syracuse VA Medical Center, Syracuse, New York
| | - Gregory P Beehler
- VA Center for Integrated Healthcare, VA Western New York Healthcare System, Buffalo, New York; Department of Community Health and Health Behavior, School of Public Health and Health Professions, University at Buffalo, Buffalo, New York
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17
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Pogue J, Lau L, Boyer J. Data-Based Opioid Risk Review in Patients with Chronic Pain: A Retrospective Chart Review. J Pain Palliat Care Pharmacother 2024; 38:74-83. [PMID: 38019479 DOI: 10.1080/15360288.2023.2288109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 11/19/2023] [Indexed: 11/30/2023]
Abstract
A retrospective, cohort, single center, chart review was conducted to compare rates of opioid-associated serious adverse events (SAEs) in a patient cohort 6 months before and 6 months after data-based opioid risk review. The primary objective was the composite reduction in opioid-related SAEs including suicide-related events and opioid overdoses. The impact of the reviews was assessed via multivariate logistic regression and a McNemar's test to analyze difference in rates of opioid-associated SAEs. This study demonstrates that data-based opioid risk review can reduce opioid-related SAEs, opioid overdoses, and suicide-related events in the 6 months post-review. The primary outcome was not statistically significant with a p-value of 0.080. In the population that underwent opioid tapers, the hazard ratios (HR) for suicide-related events and opioid-related SAEs were 6.64 (1.09-40.53, p = 0.05) and 10.43 (0.48-226.80, p = 0.02) respectively when compared to non-tapered patients. The HR for suicide-related events and opioid-related SAEs when opioid therapy was discontinued were 9.95 (2.16-45.94, p = 0.009) and 15.64 (1.09-225.19, p = 0.001) respectively when compared to continuation of opioids. This study showed that data-based opioid risk review may reduce incidence of opioid-related SAEs in patients with chronic pain. Additionally, opioid tapers and discontinuations are significant risk factors for suicide-related events and opioid-related SAEs.
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Affiliation(s)
- Joshua Pogue
- Southern Arizona VA Healthcare System, Tucson, Arizona, USA
| | - Lily Lau
- Southern Arizona VA Healthcare System, Tucson, Arizona, USA
| | - Jeffrey Boyer
- Southern Arizona VA Healthcare System, Tucson, Arizona, USA
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18
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Wolf EJ, Higgins DM, Zhao X, Hawn SE, Sanborn V, Todd CA, Fein-Schaffer D, Houranieh A, Miller MW. MMPI-2-RF Profiles of Treatment-Seeking Veterans in a VA Pain Clinic and Associations with Markers of Physical Performance. J Clin Psychol Med Settings 2024; 31:58-76. [PMID: 37418093 PMCID: PMC10771538 DOI: 10.1007/s10880-023-09967-z] [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] [Accepted: 06/15/2023] [Indexed: 07/08/2023]
Abstract
Chronic pain is a debilitating condition for many military Veterans and is associated with posttraumatic stress disorder (PTSD). This study examined the Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) in 144 Veterans (88.2% male, mean age = 57.95 years) recruited from a VA outpatient pain clinic and associations with self-reported pain severity, pain-related interference in daily activities, prescription opioid use, and objective metrics of physical performance on tasks impacted by pain (walking, stair climbing, grip strength, indexed by a single latent variable). Among the cohort with valid responses on the MMPI-2-RF (n = 117) and probable PTSD, mean Somatic Complaints (RC1) and Ideas of Persecution (RC6) scores were clinically elevated. All MMPI-2-RF scales were more strongly correlated with self-reported pain interference than severity. Regressions revealed associations between self-rated pain interference (but not pain or PTSD severity) and physical performance scores (β = .36, p = .001). MMPI-2-RF overreporting Validity and Higher-Order scales contributed incremental variance in predicting physical performance, including Infrequent Psychopathology Responses (β = .33, p = .002). PTSD severity was associated with prescription opioid use when accounting for the effects of over-reported somatic and cognitive symptoms (odds ratio 1.05, p ≤ .025). Results highlight the role of symptom overreporting and perceptions of functional impairment to observable behaviors among individuals with chronic pain.
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Affiliation(s)
- Erika J Wolf
- National Center for PTSD at VA Boston Healthcare System, Boston, USA.
- Department of Psychiatry, Boston University Chobanian and Avedisian School of Medicine, Boston, USA.
| | - Diana M Higgins
- Department of Psychiatry, Boston University Chobanian and Avedisian School of Medicine, Boston, USA
- VA Boston Healthcare System, 150 South Huntington Ave (116B-2), Boston, MA, 02130, USA
| | - Xiang Zhao
- National Center for PTSD at VA Boston Healthcare System, Boston, USA
- Department of Psychiatry, Boston University Chobanian and Avedisian School of Medicine, Boston, USA
| | - Sage E Hawn
- National Center for PTSD at VA Boston Healthcare System, Boston, USA
- Department of Psychiatry, Boston University Chobanian and Avedisian School of Medicine, Boston, USA
- Department of Psychology, Old Dominion University, Norfolk, USA
| | - Victoria Sanborn
- Department of Psychiatry, Boston University Chobanian and Avedisian School of Medicine, Boston, USA
- VA Boston Healthcare System, 150 South Huntington Ave (116B-2), Boston, MA, 02130, USA
- Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, USA
| | - Catherine A Todd
- VA Boston Healthcare System, 150 South Huntington Ave (116B-2), Boston, MA, 02130, USA
| | | | - Antoun Houranieh
- VA Boston Healthcare System, 150 South Huntington Ave (116B-2), Boston, MA, 02130, USA
| | - Mark W Miller
- National Center for PTSD at VA Boston Healthcare System, Boston, USA
- Department of Psychiatry, Boston University Chobanian and Avedisian School of Medicine, Boston, USA
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19
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Flike K, St Pierre C, Howard A, Tsai J. Changes in Pain Among Housed and Unhoused U.S. Veterans After Receiving Battlefield Acupuncture at One Medical Center. JOURNAL OF INTEGRATIVE AND COMPLEMENTARY MEDICINE 2024; 30:306-309. [PMID: 37878270 DOI: 10.1089/jicm.2023.0131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Abstract
This study reports on 54 homeless and 53 stably housed veterans who received battlefield acupuncture (BFA) between September 2018 and October 2022. Linear mixed-effects regressions were used to examine change in overall pain score and how pain impacted four areas: (1) activity, (2) sleep, (3) mood, and (4) stress over the course of 8 weeks from the baseline visit at one BFA clinic. Results indicated significant reductions in the impact of pain on activity, sleep, and stress among both homeless and housed veterans. Although overall pain levels were not significantly impacted, further research on the impact of BFA on homeless populations is warranted.
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Affiliation(s)
- Kimberlee Flike
- Center for Health Care Organization and Implementation Research, VA Bedford Health Care System, Bedford, MA, USA
| | - Cathy St Pierre
- Center for Health Care Organization and Implementation Research, VA Bedford Health Care System, Bedford, MA, USA
| | - Alexandra Howard
- Center for Health Care Organization and Implementation Research, VA Bedford Health Care System, Bedford, MA, USA
| | - Jack Tsai
- National Center on Homelessness Among Veterans, U.S. Department of Veterans Affairs Central Office, Washington, DC, USA
- School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, USA
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20
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Jairam V. Increased pain in veterans with cancer-time to re-evaluate opioid prescribing practices? JNCI Cancer Spectr 2024; 8:pkae024. [PMID: 38605595 PMCID: PMC11009462 DOI: 10.1093/jncics/pkae024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 03/24/2024] [Indexed: 04/13/2024] Open
Affiliation(s)
- Vikram Jairam
- Department of Radiation Oncology, Sutter Medical Group, Sacramento, CA, USA
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21
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Burgess DJ, Hagel Campbell EM, Branson M, Calvert C, Evans R, Allen KD, Bangerter A, Cross LJ, Driscoll MA, Hennessy S, Ferguson JE, Friedman JK, Matthias MS, Meis LA, Polusny MA, Taylor SL, Taylor BC. Exploring Gender Differences in Veterans in a Secondary Analysis of a Randomized Controlled Trial of Mindfulness for Chronic Pain. WOMEN'S HEALTH REPORTS (NEW ROCHELLE, N.Y.) 2024; 5:82-92. [PMID: 38404673 PMCID: PMC10890953 DOI: 10.1089/whr.2023.0086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 01/10/2024] [Indexed: 02/27/2024]
Abstract
Background Although studies have documented higher rates of chronic pain among women Veterans compared to men Veterans, there remains a lack of comprehensive information about potential contributors to these disparities. Materials and Methods This study examined gender differences in chronic pain and its contributors among 419 men and 392 women Veterans, enrolled in a mindfulness trial for chronic pain. We conducted descriptive analyses summarizing distributions of baseline measures, obtained by survey and through the electronic health record. Comparisons between genders were conducted using chi-square tests for categorical variables and t-tests for continuous measures. Results Compared to men, women Veterans were more likely to have chronic overlapping pain conditions and had higher levels of pain interference and intensity. Women had higher prevalence of psychiatric and sleep disorder diagnoses, greater levels of depression, anxiety, post-traumatic stress disorder, fatigue, sleep disturbance, stress and pain catastrophizing, and lower levels of pain self-efficacy and participation in social roles and activities. However, women were less likely to smoke or have a substance abuse disorder and used more nonpharmacological pain treatment modalities. Conclusion Among Veterans seeking treatment for chronic pain, women differed from men in their type of pain, had greater pain intensity and interference, and had greater prevalence and higher levels of many known biopsychosocial contributors to pain. Results point to the need for pain treatment that addresses the comprehensive needs of women Veterans. Clinical Trial Registration Number: NCT04526158. Patient enrollment began on December 4, 2020.
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Affiliation(s)
- Diana J. Burgess
- VA HSR&D 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
| | - Emily M. Hagel Campbell
- VA HSR&D Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
| | - Mariah Branson
- VA HSR&D Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
| | - Collin Calvert
- VA HSR&D 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
| | - Roni Evans
- Integrative Health and Wellbeing Research Program, Center for Spirituality and Healing, School of Nursing, University of Minnesota, Minneapolis, Minnesota, USA
| | - Kelli D. Allen
- VA HSR&D Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- Thurston Arthritis Research Center, University of North Carolina at Chapel Hill, North Carolina, USA
| | - Ann Bangerter
- VA HSR&D Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
| | - Lee J.S. Cross
- VA HSR&D Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
| | - Mary A. Driscoll
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Health Care System, West Haven, Connecticut, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
| | - Sierra Hennessy
- VA HSR&D Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
| | - John E. Ferguson
- Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Jessica K. Friedman
- VA HSR&D Center for the Study of Health Care Innovation, Implementation and Policy, Greater Los Angeles VA Health Care System, Los Angeles, California, USA
| | - Marianne S. Matthias
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, Indiana, USA
- Regenstrief Institute, Indianapolis, Indiana, USA
- Department of Medicine, School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Laura A. Meis
- VA HSR&D 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
| | - Melissa A. Polusny
- VA HSR&D 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
| | - Stephanie L. Taylor
- VA HSR&D Center for the Study of Health Care Innovation, Implementation and Policy, Greater Los Angeles VA Health Care System, Los Angeles, California, USA
- Department of Health Policy and Management, UCLA School of Public Health, Los Angeles, California, USA
- Department of Medicine, UCLA School of Medicine, Los Angeles, California, USA
| | - Brent C. Taylor
- VA HSR&D 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
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22
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Lentz TA, Coffman CJ, Cope T, Stearns Z, Simon CB, Choate A, Gladney M, France C, Hastings SN, George SZ. If You Build It, Will They Come? Patient and Provider Use of a Novel Hybrid Telehealth Care Pathway for Low Back Pain. Phys Ther 2024; 104:pzad127. [PMID: 37756618 PMCID: PMC10851867 DOI: 10.1093/ptj/pzad127] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 05/10/2023] [Accepted: 07/09/2023] [Indexed: 09/29/2023]
Abstract
OBJECTIVE The purpose of this study was to describe the referrals and use of a hybrid care model for low back pain that includes on-site care by physical therapists, physical activity training, and psychologically informed practice (PiP) delivered by telehealth in the Improving Veteran Access to Integrated Management of Low Back Pain (AIM-Back) trial. METHODS Data were collected from November 2020 through February 2023 from 5 Veteran Health Administration clinics participating in AIM-Back, a multisite, cluster-randomized embedded pragmatic trial. The authors extracted data from the Veteran Health Administration Corporate Data Warehouse to describe referral and enrollment metrics, telehealth use (eg, distribution of physical activity and PiP calls), and treatments used by physical therapists and telehealth providers. RESULTS Seven hundred one veterans were referred to the AIM-Back trial with 422 enrolling in the program (consult-to-enrollment rate = 60.2%). After travel restrictions were lifted, site visits resulted in a significant increase in referrals and a number of new referring providers. At initial evaluation by on-site physical therapists, 92.2% of veterans received pain modulation (eg, transcutaneous electrical nerve stimulation, manual therapy). Over 81% of enrollees completed at least 1 telehealth physical activity call, with a mean of 2.8 (SD = 2.0) calls out of 6. Of the 167 veterans who screened as medium to high risk of persistent disability, 74.9% completed at least 1 PiP call, with a mean of 2.5 (SD = 2.0) calls out of 6. Of those who completed at least 1 PiP call (n = 125), 100% received communication strategies, 97.6% received pain coping skills training, 89.6% received activity-based treatments, and 99.2% received education in a home program. CONCLUSION In implementing a hybrid care pathway for low back pain, the authors observed consistency in the delivery of core components (ie, pain modulation, use of physical activity training, and risk stratification to PiP), notable variability in telehealth calls, high use of PiP components, and increased referrals with tailored provider engagement. IMPACT These findings describe variability occurring within a hybrid care pathway and can inform future implementation efforts.
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Affiliation(s)
- Trevor A Lentz
- Duke Clinical Research Institute, Durham, North Carolina, USA
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina, USA
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA
| | - Cynthia J Coffman
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina, USA
| | - Tyler Cope
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Zachary Stearns
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Corey B Simon
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Ashley Choate
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
| | - Micaela Gladney
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
| | - Courtni France
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
| | - S Nicole Hastings
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Medicine, Division of Geriatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Steven Z George
- Duke Clinical Research Institute, Durham, North Carolina, USA
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
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23
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Courtney RE, Schadegg MJ, Bolton R, Smith S, Harden SM. Using a Whole Health Approach to Build Biopsychosocial-Spiritual Personal Health Plans for Veterans with Chronic Pain. Pain Manag Nurs 2024; 25:69-74. [PMID: 37839983 DOI: 10.1016/j.pmn.2023.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 09/08/2023] [Accepted: 09/18/2023] [Indexed: 10/17/2023]
Abstract
Chronic pain affects over 50 million Americans per year and costs society billions of dollars annually. It is widely accepted that the biomedical model is outdated and research on the biopsychosocial model of chronic pain has increased in recent years, concurrent with investigations into self-management of chronic pain. The Veterans Health Administration (VHA) has incorporated both of these approaches into their Whole Health System. This work describes the VHA Whole Health System, reviews the literature on alignment between the Whole Health System's Circle of Health and chronic pain, and explains how the VHA Whole Health model may be used as a method for organizing self-management strategies within a personal health plan in the context of chronic pain. Given the infusion of nurses throughout the healthcare system, nurses are in a unique position to champion this biopsychosocial-spiritual approach to care.
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Affiliation(s)
- Rena E Courtney
- PREVAIL Center for Chronic Pain, Salem, VA Health Care System, Salem, Virginia; Virginia Tech Carilion School of Medicine, Salem, Virginia.
| | - Mary J Schadegg
- NYU Grossman School of Medicine/NYU Langone Health, New York, New York
| | - Rendelle Bolton
- Center for Healthcare Organization and Implementation Research, Bedford VA Health Care System, Bedford, Massachusetts
| | - Stephanie Smith
- PREVAIL Center for Chronic Pain, Salem, VA Health Care System, Salem, Virginia
| | - Samantha M Harden
- Virginia Tech Carilion School of Medicine, Salem, Virginia; Virginia Tech, Blacksburg, Virginia
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24
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Matthias MS, Daggy JK, Perkins AJ, Adams J, Bair MJ, Burgess DJ, Eliacin J, Flores P, Myers LJ, Menen T, Procento P, Rand KL, Salyers MP, Shanahan ML, Hirsh AT. Communication and activation in pain to enhance relationships and treat pain with equity (COOPERATE): a randomized clinical trial. Pain 2024; 165:365-375. [PMID: 37733487 DOI: 10.1097/j.pain.0000000000003021] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 05/23/2023] [Indexed: 09/23/2023]
Abstract
ABSTRACT Racialized disparities in chronic pain care are well-documented and persist despite national priorities focused on health equity. Similar disparities have been observed in patient activation (ie, having the knowledge, confidence, and skills to manage one's health). As such, interventions targeting patient activation represent a novel approach to addressing and reducing disparities in pain care. Communication and Activation in Pain to Enhance Relationships and Treat Pain with Equity is a randomized controlled trial of a 6-session telephone-delivered intervention to increase patient activation for Black patients with chronic pain. Two hundred fifty Black patients from a Midwestern Veterans Affairs medical center were randomized to the intervention or attention control. The primary outcome was patient activation; secondary outcomes included communication self-efficacy, pain, and psychological functioning. Outcomes were assessed at baseline and at 3 (primary endpoint), 6, and 9 months (sustained effects). Analyses used an intent-to-treat approach. Compared with baseline, patient activation increased 4.6 points at 3 months (versus +0.13 in control group, 95% CI: 0.48, 7.34; P = 0.03). These improvements in the intervention group were sustained, with +7 from baseline at 6 months and +5.77 at 9 months, and remained statistically significant from the control group. Communication self-efficacy increased significantly relative to the control group from baseline to 3 months. Pain intensity and interference improved at 3 months, but differences were not significant after adjusting for multiple comparisons. Most other secondary outcomes improved, but group differences were not statistically significant after controlling for multiple comparisons. Results suggest that increasing patient activation is a potentially fruitful path toward improving pain management and achieving health equity.
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Affiliation(s)
- Marianne S Matthias
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, IN, United States
- Regenstrief Institute, Indianapolis, IN, United States
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Joanne K Daggy
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Anthony J Perkins
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Jasma Adams
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, IN, United States
| | - Matthew J Bair
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, IN, United States
- Regenstrief Institute, Indianapolis, IN, United States
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Diana J Burgess
- Department of Medicine, University of Minnesota, Minneapolis, MN, United States
- Center for Care Delivery and Outcomes Research, Veterans Affairs Medical Center, Minneapolis, MN, United States
| | - Johanne Eliacin
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, IN, United States
- Regenstrief Institute, Indianapolis, IN, United States
- National Center for PTSD, VA Boston Healthcare System, Boston, MA, United States
| | - Perla Flores
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, IN, United States
| | - Laura J Myers
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, IN, United States
- Regenstrief Institute, Indianapolis, IN, United States
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Tetla Menen
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, IN, United States
| | - Philip Procento
- Department of Psychology, Indiana University-Purdue University, Indianapolis, IN, United States
| | - Kevin L Rand
- Department of Psychology, Indiana University-Purdue University, Indianapolis, IN, United States
| | - Michelle P Salyers
- Department of Psychology, Indiana University-Purdue University, Indianapolis, IN, United States
| | - Mackenzie L Shanahan
- VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, United States
| | - Adam T Hirsh
- Department of Psychology, Indiana University-Purdue University, Indianapolis, IN, United States
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25
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Tesfa A, Petrosyan H, Fahmy M, Sexton T, Arvanian V. Spinal magnetic stimulation to treat chronic back pain: a feasibility study in veterans. Pain Manag 2024; 14:75-85. [PMID: 38314568 DOI: 10.2217/pmt-2023-0004] [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] [Indexed: 02/06/2024] Open
Abstract
Aim: Chronic low back pain represents a significant societal problem leading to increased healthcare costs and quality of life. This study was designed to evaluate the feasibility and effectiveness of non-invasive spinal electromagnetic simulation (SEMS) to treat nonspecific chronic low back pain (CLBP). Methods: A single-site prospective study was conducted to evaluate SEMS in reducing pain and improving disability. A total of 17 patients received SEMS two to three sessions a week. The Numeric Rating Scale and the Modified Oswestry Disability Questionnaire were used to assess pain and disability. Results: Participants receiving SEMS exhibited statistically significant reductions in pain and disability. Conclusion: Current results suggest that non-invasive SEMS can be an effective treatment in reducing pain and improving disability associated with CLBP.
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Affiliation(s)
- Asrat Tesfa
- Research & Development Service, Department of Veterans Affairs Medical Center, Northport, 11768, NY, USA
| | - Hayk Petrosyan
- Department of Physical Medicine & Rehabilitation, Hackensack Meridian, JFK Johnson Rehabilitation Institute, Edison, 08820, NJ, USA
| | - Magda Fahmy
- Physical Medicine & Rehabilitation Service, Department of Veterans Affairs Medical Center, Northport, 11768, NY, USA
| | - Thomas Sexton
- College of Business, Stony Brook University, Stony Brook, 11790, NY, USA
| | - Victor Arvanian
- Research & Development Service, Department of Veterans Affairs Medical Center, Northport, 11768, NY, USA
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26
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Anastas TM, Turner AP, Ho EJ, Day MA, Ehde DM, Jensen MP, Williams RM. Evaluating the benefits of a second pain treatment following a clinical trial. Rehabil Psychol 2024; 69:74-83. [PMID: 37338442 PMCID: PMC10728346 DOI: 10.1037/rep0000510] [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] [Indexed: 06/21/2023]
Abstract
OBJECTIVE To examine the value of including an open label phase after a clinical trial of pain treatments by examining participant characteristics and potential benefits. METHOD Secondary data analysis. Veterans with chronic pain who completed a randomized controlled trial (RCT) comparing hypnosis, mindfulness meditation, and pain education were invited to participate in an open label phase. Average and worst pain intensities, pain interference, and depression were assessed pre- and postopen label phase; global impressions of change and treatment satisfaction were assessed at postopen label phase only. RESULTS Of those who were offered the open label phase, 40% (n = 68) enrolled. Enrollees were likely to be older, to have attended more sessions in the RCT, to be satisfied with their first treatment, and to perceive improvement in their ability to manage pain after the RCT. In the open label phase, depression and worst pain decreased across all three treatment conditions. No other improvements were observed. However, most Veterans perceived improvements in pain intensity, ability to manage pain, and pain interference, and were satisfied with the second intervention. CONCLUSIONS There appears to be some value to adding an open label phase to the end of a trial of pain treatments. A substantial portion of study participants elected to participate and reported it to be beneficial. Exploring data from an open label phase can illuminate important aspects of patient experience, barriers to and facilitators of care, as well as treatment preferences. (PsycInfo Database Record (c) 2024 APA, all rights reserved).
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Affiliation(s)
- Tracy M Anastas
- Rehabilitation Care Service, VA Puget Sound Health Care System
| | - Aaron P Turner
- Rehabilitation Care Service, VA Puget Sound Health Care System
| | - Erica J Ho
- Rehabilitation Care Service, VA Puget Sound Health Care System
| | - Melissa A Day
- Department of Rehabilitation Medicine, University of Washington School of Medicine
| | - Dawn M Ehde
- Department of Rehabilitation Medicine, University of Washington School of Medicine
| | - Mark P Jensen
- Department of Rehabilitation Medicine, University of Washington School of Medicine
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27
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Erickson AJ, Ravyts SG, Dzierzewski JM, Carlson GC, Kelly MR, Song Y, McGowan SK, Mitchell MN, Washington DL, Yano EM, Alessi CA, Martin JL. Pain in your day? Get sleep treatment anyway! The role of pain in insomnia treatment efficacy in women veterans. J Sleep Res 2024:e14147. [PMID: 38246598 PMCID: PMC11260272 DOI: 10.1111/jsr.14147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 12/26/2023] [Accepted: 12/29/2023] [Indexed: 01/23/2024]
Abstract
Insomnia and pain disorders are among the most common conditions affecting United States adults and veterans, and their comorbidity can cause detrimental effects to quality of life among other factors. Cognitive behavioural therapy for insomnia and related behavioural therapies are recommended treatments for insomnia, but chronic pain may hinder treatment benefit. Prior research has not addressed how pain impacts the effects of behavioural insomnia treatment in United States women veterans. Using data from a comparative effectiveness clinical trial of two insomnia behavioural treatments (both including sleep restriction, stimulus control, and sleep hygiene education), we examined the impact of pain severity and pain interference on sleep improvements from baseline to post-treatment and 3-month follow-up. We found no significant moderation effects of pain severity or interference in the relationship between treatment phase and sleep outcomes. Findings highlight opportunities for using behavioural sleep interventions in patients, particularly women veterans, with comorbid pain and insomnia, and highlight areas for future research.
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Affiliation(s)
- Alexander J. Erickson
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Scott G. Ravyts
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Gwendolyn C. Carlson
- Department of Mental Health, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles (UCLA) Geffen School of Medicine, Los Angeles, California, USA
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Monica R. Kelly
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, California, USA
| | - Yeonsu Song
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, California, USA
- School of Nursing, University of California Los Angeles (UCLA), Los Angeles, California, USA
| | - Sarah Kate McGowan
- Department of Mental Health, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles (UCLA) Geffen School of Medicine, Los Angeles, California, USA
| | - Michael N. Mitchell
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Donna L. Washington
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, California, USA
| | - Elizabeth M. Yano
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, California, USA
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California, USA
| | - Cathy A. Alessi
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, California, USA
| | - Jennifer L. Martin
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, California, USA
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Yarns BC, Molaie AM, Lumley MA, Zhu TA, Jazi AN, Ganz DA, Melrose RJ. Video telehealth emotional awareness and expression therapy for older U.S. military veterans with chronic pain: A pilot study. Clin Gerontol 2024; 47:136-148. [PMID: 36541672 DOI: 10.1080/07317115.2022.2159909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Emotional Awareness and Expression Therapy (EAET) targets trauma and emotional conflict to reduce or eliminate chronic pain, but video telehealth administration is untested. This uncontrolled pilot assessed acceptability, feasibility, and preliminary efficacy of group-based video telehealth EAET (vEAET) for older veterans with chronic musculoskeletal pain. METHODS Twenty veterans were screened, and 16 initiated vEAET, delivered as one 60-minute individual session and eight 90-minute group sessions. Veterans completed posttreatment satisfaction ratings and pain severity (primary outcome), pain interference, anxiety, depression, functioning, social connectedness, shame, and anger questionnaires at baseline, posttreatment, and 2-month follow-up. RESULTS Satisfaction was high, and veterans attended 7.4 (SD = 0.6) of 8 group sessions; none discontinued treatment. Veterans attained significant, large reductions in pain severity from baseline to posttreatment (p < .001, Hedges' g = -1.54) and follow-up (p < .001, g = -1.20); 14 of 16 achieved clinically significant (≥ 30%) pain reduction, and 3 achieved 90-100% pain reduction. Secondary outcomes demonstrated significant, medium-to-large improvements. CONCLUSIONS In this small sample, vEAET produced better attendance, similar benefits, and fewer dropouts than in-person EAET in prior studies. Larger, controlled trials are needed. CLINICAL IMPLICATIONS Group vEAET appears feasible and highly effective for older veterans with chronic pain.
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Affiliation(s)
- Brandon C Yarns
- Department of Psychiatry/Mental Health, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at University of California, Los Angeles (UCLA), Los Angeles, California, USA
| | - Ali M Molaie
- Department of Psychiatry/Mental Health, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Mark A Lumley
- Department of Psychology, Wayne State University, Detroit, Michigan, USA
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Tongtong A Zhu
- Department of Psychiatry/Mental Health, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at University of California, Los Angeles (UCLA), Los Angeles, California, USA
| | - Ali Najafian Jazi
- Department of Psychiatry/Mental Health, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at University of California, Los Angeles (UCLA), Los Angeles, California, USA
| | - David A Ganz
- Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Psychology, Wayne State University, Detroit, Michigan, USA
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Rebecca J Melrose
- Department of Psychiatry/Mental Health, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at University of California, Los Angeles (UCLA), Los Angeles, California, USA
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Saba SK, Davis JP, Prindle JJ, Howe E, Tran DD, Bunyi J, Hummer JF, Castro CA, Pedersen ER. Bidirectional Associations Between Pain and Perceived Stress Among Veterans: Depressive Disorder as a Predisposing Factor. Psychosom Med 2024; 86:44-51. [PMID: 37774110 PMCID: PMC10841244 DOI: 10.1097/psy.0000000000001253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/01/2023]
Abstract
OBJECTIVE Military veterans who were injured in combat very often report pain along with co-occurring perceived stress and preexisting depressive disorder. The systems model of pain is a theoretical model suggesting that pain and perceived stress are bidirectionally associated at the within-person level, and associations are heightened among those with depressive disorder. However, the systems model of pain has not been adequately tested. Testing the systems model of pain could illuminate salient treatment targets for combat-injured veterans with pain and co-occurring psychological problems. METHODS The present study empirically tests the systems model of pain among a sample of combat-injured veterans ( N = 902) surveyed five times during an 18-month period. We used a multigroup, autoregressive latent trajectory with structured residual statistical model to test the within-person associations between pain and perceived stress and determine whether associations differ between veterans with and without a positive screen for depressive disorder. RESULTS In line with the systems model of pain, pain and perceived stress were bidirectionally associated only among combat-injured veterans with depressive disorder. Among such veterans, perceived stress was positively associated with subsequent pain ( b = 0.12; 95% confidence interval = 0.06-0.17), and pain was positively associated with subsequent perceived stress ( b = 0.44; 95% CI = 0.11-0.77). CONCLUSIONS Our work highlights the interplay between pain and its psychological correlates among a particularly at-risk population. Clinicians addressing pain and perceived stress among combat-injured veterans should be prepared to identify and address depressive disorder.
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Affiliation(s)
- Shaddy K. Saba
- University of Southern California, Suzanne Dworak-Peck School of Social Work, 669 W. 34 St, Los Angeles, CA 90089
| | - Jordan P. Davis
- University of Southern California, Suzanne Dworak-Peck School of Social Work, 669 W. 34 St, Los Angeles, CA 90089
| | - John J. Prindle
- University of Southern California, Suzanne Dworak-Peck School of Social Work, 669 W. 34 St, Los Angeles, CA 90089
| | - Esther Howe
- University of California, Berkeley, Department of Psychology, 2121 Berkeley Way, Berkeley, CA 94720
| | - Denise D. Tran
- University of Southern California, Keck School of Medicine, Department of Psychiatry and Behavioral Sciences, 2250 Alcazar Street, Suite 2200, Los Angeles, CA 90033
| | - John Bunyi
- University of Southern California, Suzanne Dworak-Peck School of Social Work, 669 W. 34 St, Los Angeles, CA 90089
| | | | - Carl Andrew Castro
- University of Southern California, Suzanne Dworak-Peck School of Social Work, 669 W. 34 St, Los Angeles, CA 90089
| | - Eric R. Pedersen
- University of Southern California, Keck School of Medicine, Department of Psychiatry and Behavioral Sciences, 2250 Alcazar Street, Suite 2200, Los Angeles, CA 90033
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Wilson M, Skeiky L, Muck RA, Miller MA, Hansen DA, Williams RM, Jensen MP, Van Dongen HPA. Sleep and Pain in Veterans with Chronic Pain: Effects of Psychological Pain Treatment and Temporal Associations. Nat Sci Sleep 2023; 15:1061-1077. [PMID: 38144708 PMCID: PMC10748706 DOI: 10.2147/nss.s418532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 11/26/2023] [Indexed: 12/26/2023] Open
Abstract
Introduction Chronic pain is highly prevalent in US military Veterans. Non-opioid and non-pharmacologic treatments are recommended when clinically appropriate, but research on the mechanisms underlying benefits of these treatments is lacking. Here, we examined the role of sleep in the effects of three non-pharmacologic pain treatments in Veterans. Specifically, we investigated whether treatment effects on sleep predicted treatment effects on pain occurring later, or vice versa. Methods Veterans enrolled in a randomized controlled trial were invited to participate in this supplementary sleep study. A total of 174 Veterans were randomized to one of three 8-session, in-person, group-based pain treatments: hypnosis, mindfulness meditation, or education control. Measurements included self-reported sleep disturbance, pain intensity, and pain catastrophizing; sleep duration was assessed with actigraphy. Sleep and pain measurements were obtained at baseline, posttreatment, and 3-month posttreatment follow-up. Results At baseline, average pain intensity was moderate (mean ± SD: 5.7 ± 1.7 on the 0-10 Numeric Rating Scale), pain catastrophizing was just below the clinically relevant threshold (mean ± SD: 28.6 ± 12.2 on the Pain Catastrophizing Scale), and subjective sleep disturbance exceeded the US population average (mean ± SD: 58.5 ± 8.1 on the Patient Reported Outcomes Measurement Information System Sleep Disturbance - Short Form). By contrast, objective sleep duration was consistent with the recommended daily sleep amount of 7-8 h for adults (mean ± SD: 8.3 ± 1.4 h). Across treatment conditions, pain intensity, pain catastrophizing, and subjective sleep disturbance were significantly less at posttreatment and 3-month follow-up than at baseline (p < 0.001). Actigraphic sleep duration did not differ significantly as a function of time. There was a high degree of covariation among the measures of pain intensity, pain catastrophizing, and sleep disturbance (p < 0.05). However, self-reported sleep disturbance was not significantly correlated with actigraphic sleep duration (|r| <= 0.13, p > 0.05). Sleep and pain variables observed at prior assessments predicted these same variables at subsequent assessments. There was no significant evidence that changes in pain preceded changes in sleep or that changes in sleep preceded changes in pain (all p > 0.05). Discussion For this study's Veterans, treatment-related changes in sleep and pain appeared to occur in parallel. The concomitant changes in sleep and pain suggest that therapies improving pain in Veterans may yield attendant benefits for the treatment of sleep, and possibly vice versa.
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Affiliation(s)
- Marian Wilson
- College of Nursing, Washington State University, Spokane, WA, USA
- Sleep and Performance Research Center, Washington State University, Spokane, WA, USA
| | - Lillian Skeiky
- Sleep and Performance Research Center, Washington State University, Spokane, WA, USA
- Department of Translational Medicine and Physiology, Washington State University, Spokane, WA, USA
| | - Rachael A Muck
- Sleep and Performance Research Center, Washington State University, Spokane, WA, USA
- Department of Translational Medicine and Physiology, Washington State University, Spokane, WA, USA
| | - Megan A Miller
- Rehabilitation Care Service, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Devon A Hansen
- Sleep and Performance Research Center, Washington State University, Spokane, WA, USA
- Department of Translational Medicine and Physiology, Washington State University, Spokane, WA, USA
| | - Rhonda M Williams
- Rehabilitation Care Service, VA Puget Sound Health Care System, Seattle, WA, USA
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Mark P Jensen
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Hans P A Van Dongen
- Sleep and Performance Research Center, Washington State University, Spokane, WA, USA
- Department of Translational Medicine and Physiology, Washington State University, Spokane, WA, USA
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Qureshi AR, Patel M, Neumark S, Wang L, Couban RJ, Sadeghirad B, Bengizi A, Busse JW. Prevalence of chronic non-cancer pain among military veterans: a systematic review and meta-analysis of observational studies. BMJ Mil Health 2023:e002554. [PMID: 38124087 DOI: 10.1136/military-2023-002554] [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: 08/17/2023] [Accepted: 11/20/2023] [Indexed: 12/23/2023]
Abstract
INTRODUCTION Chronic non-cancer pain is common among military veterans; however, the prevalence is uncertain. This information gap complicates policy decisions and resource planning to ensure veterans have access to healthcare services that align with their needs. METHODS Following Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols, we searched MEDLINE, EMBASE, PsycINFO, CINAHL and Web of Science from inception to 9 February 2023 for observational studies reporting the prevalence of chronic non-cancer pain among military veterans. We performed random-effects meta-analysis to pool pain prevalence data across studies and used the Grading of Recommendations, Assessment, Development and Evaluation approach to evaluate the certainty of evidence. RESULTS Forty-two studies that included 14 305 129 veterans were eligible for review, of which 28 studies (n=5 011 634) contributed to our meta-analysis. Most studies (90%; 38 of 42) enrolled US veterans, the median of the mean age among study participants was 55 years (IQR 45-62) and 85% were male. The pooled prevalence of chronic non-cancer pain was 45%; however, we found evidence of a credible subgroup effect based on representativeness of the study population. Moderate certainty evidence found the prevalence of chronic pain among studies enrolling military veterans from the general population was 30% (95% CI 23% to 37%) compared with 51% (95% CI 38% to 64%) among military veterans sampled from populations with high rates of conditions associated with chronic pain (p=0.005). CONCLUSION We found moderate certainty evidence that 3 in every 10 military veterans from the general population live with chronic non-cancer pain. These findings underscore the importance of ensuring access to evidence-based care for chronic pain for veterans, and the need for prevention and early management to reduce transition from acute to chronic pain. Further research, employing a standardised assessment of chronic pain, is needed to disaggregate meaningful subgroups; for example, the proportion of veterans living with moderate to severe pain compared with mild pain.
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Affiliation(s)
- Abdul Rehman Qureshi
- College of Medicine and Health Sciences, Khalifa University, Abu Dhabi, UAE
- Department of Health Research Methods, Evidence and Impact, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - M Patel
- Department of Health Research Methods, Evidence and Impact, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - S Neumark
- Translational Research Program, Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - L Wang
- Department of Health Research Methods, Evidence and Impact, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
- Department of Anesthesia, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - R J Couban
- McMaster University Michael G DeGroote National Pain Centre, Hamilton, Ontario, Canada
| | - B Sadeghirad
- Department of Health Research Methods, Evidence and Impact, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
- Department of Anesthesia, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - A Bengizi
- Department of Health Research Methods, Evidence and Impact, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - J W Busse
- Department of Health Research Methods, Evidence and Impact, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
- Department of Anesthesia, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
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Carr MM, Wolkowicz NR, Cave S, Martino S, Masheb R, Midboe AM. Weight change in a national cohort of U.S. Military Veterans engaged in medication treatment for opioid use disorder. J Psychiatr Res 2023; 168:204-212. [PMID: 37918033 DOI: 10.1016/j.jpsychires.2023.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 09/27/2023] [Accepted: 10/07/2023] [Indexed: 11/04/2023]
Abstract
Medication treatments for opioid use disorder (MOUD) save lives and improve outcomes for countless individuals. However, data suggest the potential for significant weight gain during methadone treatment and little is known about weight change during buprenorphine treatment. Using Veteran Health Administration administrative data from fiscal year 2017 to fiscal year 2019, two cohorts were created: 1) Veterans diagnosed with opioid use disorder (OUD) taking methadone (N = 1425); and 2) Veterans diagnosed with OUD taking buprenorphine (N = 3756). Linear mixed models were used to analyze weight change during the first MOUD treatment episode in the observation period. Random slopes and intercepts were included in the model to estimate variation in BMI across individuals and time. The data revealed a slight upward trend in BMI over the course of treatment. Specifically, a daily increase of 0.004 for Veterans in methadone treatment and 0.002 for Veterans in buprenorphine treatment was observed. This translates to a gain of about 10 pounds over the course of 1 year of methadone treatment and 5 pounds for 1 year of buprenorphine treatment for a Veteran of average height and weight. The amount of weight gain in methadone treatment is significantly less than other published findings, but nonetheless indicates that assessment and discussions between patients and providers related to weight may be warranted.
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Affiliation(s)
- Meagan M Carr
- U.S. Department of Veterans Affairs, VA Connecticut Healthcare System, 950 Campbell Ave., West Haven, CT, 06516, USA; Department of Psychiatry, Yale School of Medicine, 333 Cedar Street, New Haven, CT, 06511, USA.
| | - Noah R Wolkowicz
- U.S. Department of Veterans Affairs, VA Connecticut Healthcare System, 950 Campbell Ave., West Haven, CT, 06516, USA; Department of Psychiatry, Yale School of Medicine, 333 Cedar Street, New Haven, CT, 06511, USA
| | - Shayna Cave
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, 795 Willow Rd, Menlo Park, CA, 94025, USA
| | - Steve Martino
- U.S. Department of Veterans Affairs, VA Connecticut Healthcare System, 950 Campbell Ave., West Haven, CT, 06516, USA; Department of Psychiatry, Yale School of Medicine, 333 Cedar Street, New Haven, CT, 06511, USA
| | - Robin Masheb
- U.S. Department of Veterans Affairs, VA Connecticut Healthcare System, 950 Campbell Ave., West Haven, CT, 06516, USA; Department of Psychiatry, Yale School of Medicine, 333 Cedar Street, New Haven, CT, 06511, USA
| | - Amanda M Midboe
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, 795 Willow Rd, Menlo Park, CA, 94025, USA; Division of Health Policy and Management, University of California Davis-School of Medicine, Davis, CA, USA
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Yoganandan N, Baisden J, Varghese V, Vedantam A, Stemper B, Banerjee A, Jebaseelan D. Preliminary Data of Neck Muscle Morphology With Head-Supported Mass in Male and Female Volunteers. Mil Med 2023; 188:385-392. [PMID: 37948211 DOI: 10.1093/milmed/usad165] [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: 12/12/2022] [Revised: 03/29/2023] [Accepted: 05/02/2023] [Indexed: 11/12/2023] Open
Abstract
INTRODUCTION This study quantified parameters related to muscle morphology using a group of upright seated female and male volunteers with a head-supported mass. MATERIALS AND METHODS Upright magnetic resonance images (MRIs) were obtained from 23 healthy volunteers after approval from the U.S. DoD. They were asymptomatic for neck pain, with no history of injury. The volunteers were scanned using an upright MRI scanner with a head-supported mass (army combat helmet). T1 and T2 sagittal and axial images were obtained. Measurements were performed by an engineer and a neurosurgeon. The cross-sectional areas of the sternocleidomastoid and multifidus muscles were measured at the inferior endplate in the sub-axial column, and the centroid angle and centroid radius were quantified. Differences in the morphology by gender and spinal level were analyzed using a repeated measures analysis of variance model, adjusted for multiple corrections. RESULTS For females and males, the cross-sectional area of the sternocleidomastoid muscle ranged from 2.3 to 3.6 cm2 and from 3.4 to 5.4 cm2, the centroid radius ranged from 4.1 to 5.1 cm and from 4.7 to 5.7 cm, and the centroid angle ranged from 75° to 131° and from 4.8° to 131.2°, respectively. For the multifidus muscle, the area ranged from 1.7 to 3.9 cm2 and from 2.4 to 4.2 cm2, the radius ranged from 3.1 to 3.4 cm and from 3.3 to 3.8 cm, the angle ranged from 15° to 24.4° and 16.2° to 24.4°, respectively. Results from all levels for both muscles and male and female spines are given. CONCLUSIONS The cross-sectional area, angulation, and centroid radii data for flexor and extensor muscles of the cervical spine serve as a dataset that may be used to better define morphologies in computational models and obtain segmental motions and loads under external mechanical forces. These data can be used in computational models for injury prevention, mitigation, and readiness.
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Affiliation(s)
- Narayan Yoganandan
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Jamie Baisden
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Vicky Varghese
- Department of Orthopedics, NorthShore University Health System, Skokie Hospital, Skokie, IL 60076, USA
| | - Aditya Vedantam
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Brian Stemper
- Department of Biomedical Engineering, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Anjishnu Banerjee
- Department of Biostatistics, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Davidson Jebaseelan
- School of Mechanical Engineering, Vellore Institute of Technology, Chennai 600036, India
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Hernandez-Tejada MA, Cherry KE, Rauch SAM, Acierno R, Fries GR, Muzzy W, Teng EJ, Wangelin B, Ahn H. Management of Chronic Pain and PTSD in Veterans With tDCS+Prolonged Exposure: A Pilot Study. Mil Med 2023; 188:3316-3321. [PMID: 35808998 DOI: 10.1093/milmed/usac200] [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: 04/04/2022] [Revised: 06/13/2022] [Accepted: 06/20/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Chronic pain and posttraumatic stress disorder (PTSD) are prevalent comorbid conditions, particularly in Veterans; however, there are few integrated treatments for chronic pain and PTSD. Instead, interventions are typically implemented separately and may involve addictive opioids. Although there are highly effective, non-pharmacological treatments for PTSD, they are plagued by high dropout, which may be exacerbated by comorbid pain, as these PTSD treatments typically require increased activity. Importantly, a noninvasive pain treatment, tDCS (transcranial direct current stimulation) shows indications of effectiveness and may be integrated with psychological treatments, even when delivered via telehealth. This study examines the feasibility and initial efficacy of integrating home telehealth tDCS with prolonged exposure (PE), an evidence-based PTSD treatment. MATERIALS AND METHODS Thirty-nine Veterans were contacted, 31 consented to evaluation, 21 were enrolled, and 16 completed treatment and provided pre- and post-treatment data at one of two Veterans Affairs Medical Centers. Transcranial direct current stimulation sessions corresponded with PE exposure assignments, as there is theoretical reason to believe that tDCS may potentiate extinction learning featured in PE. RESULTS Patients evinced significant improvement in both pain interference and PTSD symptoms and a trend toward improvement in depression symptoms. However, a significant change in pain intensity was not observed, likely because of the small sample size. DISCUSSION The findings provide initial support for the feasibility of an entirely home-based, integrated treatment for comorbid PTSD and pain.
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Affiliation(s)
- Melba A Hernandez-Tejada
- Department of Psychiatry and Behavioral Sciences, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX 77054, USA
| | - Kathryn E Cherry
- Department of Psychiatry and Behavioral Sciences, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX 77054, USA
- Department of Psychological Sciences, University of Missouri, St. Louis, St. Louis, MO 63121, USA
| | - Sheila A M Rauch
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA 30329, USA
- Atlanta VA Healthcare System, Atlanta, GA 30329, USA
| | - Ron Acierno
- Department of Psychiatry and Behavioral Sciences, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX 77054, USA
- Ralph H. Johnson VA Medical Center, Charleston, SC 29401, USA
| | - Gabriel R Fries
- Department of Psychiatry and Behavioral Sciences, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX 77054, USA
| | - Wendy Muzzy
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Ellen J Teng
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX 77030, USA
- Michael E. DeBakey VA Medical Center, Houston, TX 77030, USA
| | - Bethany Wangelin
- Ralph H. Johnson VA Medical Center, Charleston, SC 29401, USA
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Hyochol Ahn
- Florida State University College of Nursing, Tallahassee, FL 32306-4310, USA
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Rothmiller SJ, Lund BC, Burgess DJ, Lee S, Hadlandsmyth K. Race Differences in Veteran's Affairs Emergency Department Utilization. Mil Med 2023; 188:3599-3605. [PMID: 35713331 DOI: 10.1093/milmed/usac152] [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: 03/03/2022] [Revised: 04/07/2022] [Accepted: 05/17/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION African Americans (AAs) experience disparities in chronic pain care. This study aimed to identify the rates of emergency department (ED) utilization for visits associated with chronic pain diagnoses among AAs compared to Whites and to determine variables that accounted for any differences. METHODS This retrospective observational study used national Veterans Affairs (Veteran's Health Administration) administrative data to identify Veterans with chronic pain diagnoses in 2018. Race/ethnicity was self-reported and assessed to examine if differences exist in ED utilization. Differences between AAs and Whites were examined using negative binomial regression models, controlling for ethnicity. Multivariable models (including demographics, pain characteristics, psychiatric comorbidities, medical comorbidities, pain-related health care utilization, and medication utilization) were examined to determine factors that contributed to these disparities. RESULTS Among the 2,261,030 patients, 22% (n = 492,138) were AA. The incidence rate ratio of ED utilization for AAs, relative to Whites, was 1.58 (95% CI: 1.56-1.59). The only independent variable that produced a clinically meaningful reduction in the race effect on ED use was rurality, which was associated with reduced ED use. Post hoc model including all variables reduced the race effect to 1.37 (95% CI: 1.36-1.38). CONCLUSION AA Veterans had a 58% greater risk of ED utilization for visits associated with chronic pain diagnoses relative to White Veterans, which remained meaningfully elevated after adjustment for observable confounders (37%). This observation may reflect disparities in outpatient chronic pain care for AAs. Future research could focus on enhancing therapeutic alliance in primary care to improve chronic pain treatment for AAs.
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Affiliation(s)
- Shamira J Rothmiller
- Center for Access & Delivery Research and Evaluation, Iowa City VA Health Care System (152), Iowa City, IA 52246, USA
- Veterans Rural Health Resource Center, Iowa City VA Health Care System, Iowa City, IA 52246, USA
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA
| | - Brian C Lund
- Center for Access & Delivery Research and Evaluation, Iowa City VA Health Care System (152), Iowa City, IA 52246, USA
- Veterans Rural Health Resource Center, Iowa City VA Health Care System, Iowa City, IA 52246, USA
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA 52242, USA
| | - Diana J Burgess
- Center for Care Delivery and Outcomes Research, Veterans Affairs Medical Center, Minneapolis, MN 55417, USA
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
| | - Sangil Lee
- Department of Emergency Medicine, University of Iowa Carver School of Medicine, Iowa City, IA 52242, USA
| | - Katherine Hadlandsmyth
- Center for Access & Delivery Research and Evaluation, Iowa City VA Health Care System (152), Iowa City, IA 52246, USA
- Veterans Rural Health Resource Center, Iowa City VA Health Care System, Iowa City, IA 52246, USA
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA
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Saba SK, Davis JP, Bricker JB, Christie NC, Pedersen ER. Pain Trajectories among U.S. Veterans During COVID-19. THE JOURNAL OF PAIN 2023; 24:2093-2102. [PMID: 37414327 PMCID: PMC10615718 DOI: 10.1016/j.jpain.2023.06.018] [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] [Received: 06/20/2022] [Revised: 06/06/2023] [Accepted: 06/28/2023] [Indexed: 07/08/2023]
Abstract
Physical pain is highly prevalent among military veterans. As stress can impact pain, COVID-19-related stressors may have heightened pain among veterans. A prospective analysis of pain could advance understanding of how veterans fared during COVID-19 and lend knowledge of risk factors important beyond the pandemic. The present study employs growth mixture modeling with a sample of U.S. veterans high in pain (N = 1,230) followed from just before COVID-19 (February 2020) to 12 months later (February 2021; 81.7% retention). We explored heterogeneous pain trajectories as well as baseline and COVID-19-related predictors of pain. Results revealed 4 pain trajectory classes: 1) Chronic Pain (17.3% of the sample); 2) Decreasing Pain (57.2% of the sample); 3) Stable Mild Pain (19.8% of the sample); and 4) Increasing Pain (5.7% of the sample). Those with childhood trauma exposure were especially likely to report chronic pain. Female and racial/ethnic minority veterans were also relatively likely to fare poorly in pain. Loneliness was associated with subsequent pain among several classes. Most veterans in our sample fared better than expected in terms of pain. However, as those with childhood trauma and certain disadvantaged groups were less likely to fare well, we add to the important literature on disparities in pain. Clinicians should identify whether loneliness and other factors impacted pain during COVID-19 among their patients to inform ongoing, person-centered pain management approaches. PERSPECTIVE: This article presents pain trajectories and correlates of pain among a high-pain sample of U.S. veterans surveyed prior to and during COVID-19. Pain clinicians should screen for childhood trauma and remain vigilant in addressing health disparities.
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Affiliation(s)
- Shaddy K. Saba
- University of Southern California, Suzanne Dworak-Peck School of Social Work, 669 W. 34 St, Los Angeles, CA 90089
| | - Jordan P. Davis
- University of Southern California, Suzanne Dworak-Peck School of Social Work, USC Center for Artificial Intelligence in Society; USC Center for Mindfulness Science; USC Institute for Addiction Science, 669 W. 34 St, Los Angeles, CA 90089
| | - Jonathan B. Bricker
- Fred Hutchinson Cancer Research Center, Division of Public Health Sciences; University of Washington, Department of Psychology, 1100 Fairview Avenue North, Seattle, WA 98109
| | - Nina C. Christie
- University of Southern California, Department of Psychology, 3620 McClintock Avenue, Los Angeles, CA 90089
| | - Eric R. Pedersen
- University of Southern California, Keck School of Medicine, Department of Psychiatry and Behavioral Sciences, 2250 Alcazar Street, Suite 2200, Los Angeles, CA 90033
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Hasin DS, Wall MM, Alschuler DM, 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 legalisation, and cannabis use disorder among patients in the US Veterans Health Administration system, 2005 to 2019: a repeated, cross-sectional study. Lancet Psychiatry 2023; 10:877-886. [PMID: 37837985 PMCID: PMC10627060 DOI: 10.1016/s2215-0366(23)00268-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 07/24/2023] [Accepted: 07/28/2023] [Indexed: 10/16/2023]
Abstract
BACKGROUND Cannabis use disorder is associated with considerable comorbidity and impairment in functioning, and prevalence is increasing among adults with chronic pain. We aimed to assess the effect of introduction of medical cannabis laws (MCL) and recreational cannabis laws (RCL) on the increase in cannabis use disorder among patients in the US Veterans Health Administration (VHA). METHODS Data from patients with one or more primary care, emergency, or mental health visit to the VHA in 2005-19 were analysed using 15 repeated cross-sectional VHA electronic health record datasets (ie, one dataset per year). Patients in hospice or palliative care were excluded. Patients were stratified as having chronic pain or not using an American Pain Society taxonomy of painful medical conditions. We used staggered-adoption difference-in-difference analyses to estimate the role of MCL and RCL enactment in the increases in prevalence of diagnosed cannabis use disorder and associations with presence of chronic pain, accounting for the year that state laws were enacted. We did this by fitting a linear binomial regression model stratified by pain, with time-varying cannabis law status, fixed effects for state, categorical year, time-varying state-level sociodemographic covariates, and patient covariates (age group [18-34 years, 35-64 years, and 65-75 years], sex, and race and ethnicity). FINDINGS Between 2005 and 2019, 3 234 382-4 579 994 patients were included per year. Among patients without pain in 2005, 5·1% were female, mean age was 58·3 (SD 12·6) years, and 75·7%, 15·6%, and 3·6% were White, Black, and Hispanic or Latino, respectively. In 2019, 9·3% were female, mean age was 56·7 (SD 15·2) years, and 68·1%, 18·2%, and 6·5% were White, Black, and Hispanic or Latino, respectively. Among patients with pain in 2005, 7·1% were female, mean age was 57·2 (SD 11·4) years, and 74·0%, 17·8%, and 3·9% were White, Black, and Hispanic or Latino, respectively. In 2019, 12·4% were female, mean age was 57·2 (SD 13·8) years, and 65·3%, 21·9%, and 7·0% were White, Black, and Hispanic or Latino, respectively. Among patients with chronic pain, enacting MCL led to a 0·135% (95% CI 0·118-0·153) absolute increase in cannabis use disorder prevalence, with 8·4% of the total increase in MCL-enacting states attributable to MCL. Enacting RCL led to a 0·188% (0·160-0·217) absolute increase in cannabis use disorder prevalence, with 11·5% of the total increase in RCL-enacting states attributable to RCL. In patients without chronic pain, enacting MCL and RCL led to smaller absolute increases in cannabis use disorder prevalence (MCL: 0·037% [0·027-0·048], 5·7% attributable to MCL; RCL: 0·042% [0·023-0·060], 6·0% attributable to RCL). Overall, associations of MCL and RCL with cannabis use disorder were greater in patients with chronic pain than in patients without chronic pain. INTERPRETATION Increasing cannabis use disorder prevalence among patients with chronic pain following state legalisation is a public health concern, especially among older age groups. Given cannabis commercialisation and widespread public beliefs about its efficacy, clinical monitoring of cannabis use and discussion of the risk of cannabis use disorder among patients with chronic pain is warranted. FUNDING NIDA grant R01DA048860, New York State Psychiatric Institute, and the VA Centers of Excellence in Substance Addiction Treatment and Education.
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Affiliation(s)
- Deborah S Hasin
- Columbia University Irving Medical Center, New York, NY, USA; Columbia University Mailman School of Public Health, New York, NY, USA; New York State Psychiatric Institute, New York, NY, USA.
| | - Melanie M Wall
- Columbia University Irving Medical Center, New York, NY, USA; New York State Psychiatric Institute, New York, NY, 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, Seattle, WA, USA; Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Mark Olfson
- Columbia University Irving Medical Center, New York, NY, USA
| | - Katherine M Keyes
- Columbia University Mailman School of Public Health, New York, NY, 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, Seattle, WA, USA; University of Washington, Seattle, WA, USA
| | - Salomeh Keyhani
- San Francisco VA Health System, San Francisco, CA, USA; University of California at San Francisco, San Francisco, CA, USA
| | - Silvia S Martins
- Columbia University Mailman School of Public Health, New York, NY, USA
| | - David S Fink
- New York State Psychiatric Institute, New York, NY, USA
| | - Ofir Livne
- New York State Psychiatric Institute, New York, NY, USA
| | - Yoanna McDowell
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Scott Sherman
- New York University, New York, NY, USA; VA Manhattan Harbor Healthcare, New York, NY, 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, Seattle, WA, USA; Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care System, Seattle, WA, USA; University of Washington School of Medicine, Seattle, WA, USA
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Friedman JK, Taylor BC, Hagel Campbell E, Allen K, Bangerter A, Branson M, Bronfort G, Calvert C, Cross L, Driscoll M, Evans R, Ferguson JE, Haley A, Hennessy S, Meis LA, Burgess DJ. Gender differences in PTSD severity and pain outcomes: baseline results from the LAMP trial. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.10.13.23296998. [PMID: 37873176 PMCID: PMC10593051 DOI: 10.1101/2023.10.13.23296998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
Background Post-traumatic stress disorder (PTSD) and chronic pain are highly prevalent comorbid conditions. Veterans dually burdened by PTSD and chronic pain experience more severe outcomes compared to either disorder alone. Few studies have enrolled enough women Veterans to test gender differences in pain outcomes [catastrophizing, intensity, interference] by the severity of PTSD. Aim Examine gender differences in the association between PTSD symptoms and pain outcomes among Veterans enrolled in a chronic pain clinical trial. Methods Participants were 421 men and 386 women Veterans with chronic pain who provided complete data on PTSD symptoms and pain outcomes. We used hierarchical linear regression models to examine gender differences in pain outcomes by PTSD symptoms. Results Adjusted multivariable models indicated that PTSD symptoms were associated with higher levels of pain catastrophizing (0.57, 95% CI [0.51, 0.63]), pain intensity (0.30, 95% CI [0.24, 0.37]), and pain interference (0.46, 95% CI [0.39, 0.52]). No evidence suggesting differences in this association were found in either the crude or adjusted models (all interaction p-values<0.05). Conclusion These findings may reflect the underlying mutual maintenance of these conditions whereby the sensation of pain could trigger PTSD symptoms, particularly if the trauma and pain are associated with the same event. Clinical implications and opportunities testing relevant treatments that may benefit both chronic pain and PTSD are discussed.
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Affiliation(s)
- J K Friedman
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Healthcare System (MVAHCS), Minneapolis, MN
- University of Minnesota Medical School, Minneapolis, MN
| | - B C Taylor
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Healthcare System (MVAHCS), Minneapolis, MN
- University of Minnesota Medical School, Minneapolis, MN
| | - E Hagel Campbell
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Healthcare System (MVAHCS), Minneapolis, MN
| | - K Allen
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VAHCS, Durham, NC
- Thurston Arthritis Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - A Bangerter
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Healthcare System (MVAHCS), Minneapolis, MN
| | - M Branson
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Healthcare System (MVAHCS), Minneapolis, MN
| | - G Bronfort
- Integrative Health & Wellbeing Research Program, Bakken Center for Spirituality & Healing, University of Minnesota, Minneapolis, MN
- University of Minnesota School of Nursing, Minneapolis, MN
| | - C Calvert
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Healthcare System (MVAHCS), Minneapolis, MN
- University of Minnesota Medical School, Minneapolis, MN
| | - Ljs Cross
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Healthcare System (MVAHCS), Minneapolis, MN
| | - M Driscoll
- VA Connecticut Healthcare System, West Haven, CT
- Yale School of Medicine, New Haven, CT
| | - R Evans
- Integrative Health & Wellbeing Research Program, Bakken Center for Spirituality & Healing, University of Minnesota, Minneapolis, MN
- University of Minnesota School of Nursing, Minneapolis, MN
| | - J E Ferguson
- University of Minnesota Medical School, Minneapolis, MN
| | - A Haley
- Integrative Health & Wellbeing Research Program, Bakken Center for Spirituality & Healing, University of Minnesota, Minneapolis, MN
- University of Minnesota School of Nursing, Minneapolis, MN
| | - S Hennessy
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Healthcare System (MVAHCS), Minneapolis, MN
| | - L A Meis
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Healthcare System (MVAHCS), Minneapolis, MN
- University of Minnesota Medical School, Minneapolis, MN
- Women's Health Sciences Division, National Center for PTSD, Boston, MA
| | - D J Burgess
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Healthcare System (MVAHCS), Minneapolis, MN
- University of Minnesota Medical School, Minneapolis, MN
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Taub C, Gordon KS, Goulet J, Lee A, Mayhew M, Von Korff M, DeBar L, Kerns RD. Graded chronic pain scale revised: validation in a Veteran sample. PAIN MEDICINE (MALDEN, MASS.) 2023; 24:1169-1175. [PMID: 37220899 PMCID: PMC10546477 DOI: 10.1093/pm/pnad068] [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] [Received: 01/25/2023] [Revised: 05/11/2023] [Accepted: 05/18/2023] [Indexed: 05/25/2023]
Abstract
OBJECTIVE The Graded Chronic Pain Scale (GCPS) is frequently used in pain research and treatment to classify mild, bothersome, and high impact chronic pain. This study's objective was to validate the revised version of the GCPS (GCPS-R) in a US Veterans Affairs (VA) healthcare sample to support its use in this high-risk population. METHODS Data were collected from Veterans (n = 794) via self-report (GCPS-R and relevant health questionnaires) and electronic health record extraction (demographics and opioid prescriptions). Logistic regression, adjusting for age and gender, was used to test for differences in health indicators by pain grade. Adjusted odds ratio (AOR) with 95% confidence intervals (CIs) were reported with CIs not including an AOR of 1 indicating that the difference exceeded chance. RESULTS In this population, the prevalence of chronic pain (pain present most or every day, prior 3 months) was 49.3%: 7.1% with mild chronic pain (mild pain intensity and lower interference with activities); 23.3% bothersome chronic pain (moderate to severe pain intensity with lower interference); and 21.1% high impact chronic pain (higher interference). Results of this study mirrored findings in the non-VA validation study; differences between bothersome and high impact were consistent for activity limitations and present but not fully consistent for psychological variables. Those with bothersome chronic pain or high impact chronic pain were more likely to receive long-term opioid therapy compared to those with no/mild chronic pain. CONCLUSIONS Findings highlight categorical differences captured with the GCPS-R, and convergent validity supports use of the GCPS-R in US Veterans.
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Affiliation(s)
- Chloe Taub
- Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, United States
- Blue Note Therapeutics, San Fransisco, CA 94104, United States
| | - Kirsha S Gordon
- Pain Research, Informatics, Multimorbidiities, and Education (PRIME) Center of Innovation, VA Connecticut Healthcare System, West Haven, CT 06516, United States
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT 06511, United States
| | - Joseph Goulet
- Pain Research, Informatics, Multimorbidiities, and Education (PRIME) Center of Innovation, VA Connecticut Healthcare System, West Haven, CT 06516, United States
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT 06511, United States
| | - Allison Lee
- Pain Research, Informatics, Multimorbidiities, and Education (PRIME) Center of Innovation, VA Connecticut Healthcare System, West Haven, CT 06516, United States
- Departments of Psychiatry, Neurology, and Psychology, Yale University, New Haven, CT 06511, United States
| | - Meghan Mayhew
- Kaiser Permanente Center for Health Research, Portland, OR 97227, United States
| | - Michael Von Korff
- Kaiser Permanente Washington Health Research Institute, Seattle, WA 98101, United States
| | - Lynn DeBar
- Kaiser Permanente Center for Health Research, Portland, OR 97227, United States
- Kaiser Permanente Washington Health Research Institute, Seattle, WA 98101, United States
| | - Robert D Kerns
- Pain Research, Informatics, Multimorbidiities, and Education (PRIME) Center of Innovation, VA Connecticut Healthcare System, West Haven, CT 06516, United States
- Departments of Psychiatry, Neurology, and Psychology, Yale University, New Haven, CT 06511, United States
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O'Connor V, Rowland JA, Naylor JC, Magnante AT, Craig KM, Miskey HM, Martindale SL. Time doesn't heal all: PTSD symptoms exacerbate the relationship between age and pain intensity. Front Psychiatry 2023; 14:1221762. [PMID: 37575582 PMCID: PMC10415104 DOI: 10.3389/fpsyt.2023.1221762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 07/17/2023] [Indexed: 08/15/2023] Open
Abstract
Objective Posttraumatic stress disorder (PTSD) symptoms and pain interfere with daily functioning and quality of life for many combat Veterans. As individuals age, pain symptoms tend to increase whereas PTSD symptoms tend to decrease. PTSD symptoms exacerbate pain, but the nature of this relationship across the aging process is unclear. The purpose of this study was to determine how PTSD symptoms affect the association between age and pain intensity. Methods Participants in this cross-sectional study included 450 Veterans (80% male) who served after September 11, 2001. PTSD and pain intensity ratings were assessed by the PTSD Checklist for DSM-5 (PCL-5) and the Brief Pain Inventory (BPI), respectively. Hierarchical multiple linear regression evaluated main and interaction effects between age, PTSD symptoms, and pain intensity. Results Age (B = 0.04, p < 0.001) and PTSD symptoms (B = 0.05, p < 0.001) were positively associated with pain intensity. Age and PTSD symptoms were inversely correlated (r = -0.16, p < 0.001). PTSD symptoms exacerbated the relationship between age and pain intensity (ΔR2 = 0.01, p = 0.036). Specifically, when greater PTSD symptoms were reported at older ages, pain intensity was significantly higher. Conclusion Results of these analyses suggests that age is important when considering the effects of PTSD symptoms on pain intensity ratings. Specifically, pain intensity ratings are higher in older Veterans with PTSD symptoms. These findings underscore the importance for clinical providers to evaluate trauma history and PTSD symptoms in older Veterans reporting pain symptoms.
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Affiliation(s)
- Victoria O'Connor
- W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC, United States
- Veterans Integrated Service Networks (VISN)-6 Mid-Atlantic Mental Illness, Research Education and Clinical Center (MIRECC), Durham, NC, United States
- Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Jared A Rowland
- W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC, United States
- Veterans Integrated Service Networks (VISN)-6 Mid-Atlantic Mental Illness, Research Education and Clinical Center (MIRECC), Durham, NC, United States
- Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Jennifer C Naylor
- Veterans Integrated Service Networks (VISN)-6 Mid-Atlantic Mental Illness, Research Education and Clinical Center (MIRECC), Durham, NC, United States
- Durham Veterans Affairs Health Care System, Durham, NC, United States
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, United States
| | - Anna T Magnante
- W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC, United States
- Veterans Integrated Service Networks (VISN)-6 Mid-Atlantic Mental Illness, Research Education and Clinical Center (MIRECC), Durham, NC, United States
- Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Katherine M Craig
- W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC, United States
- Veterans Integrated Service Networks (VISN)-6 Mid-Atlantic Mental Illness, Research Education and Clinical Center (MIRECC), Durham, NC, United States
| | - Holly M Miskey
- W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC, United States
- Veterans Integrated Service Networks (VISN)-6 Mid-Atlantic Mental Illness, Research Education and Clinical Center (MIRECC), Durham, NC, United States
- Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Sarah L Martindale
- W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC, United States
- Veterans Integrated Service Networks (VISN)-6 Mid-Atlantic Mental Illness, Research Education and Clinical Center (MIRECC), Durham, NC, United States
- Wake Forest School of Medicine, Winston-Salem, NC, United States
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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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Levis M, Levy J, Dufort V, Russ CJ, Shiner B. Dynamic suicide topic modelling: Deriving population-specific, psychosocial and time-sensitive suicide risk variables from Electronic Health Record psychotherapy notes. Clin Psychol Psychother 2023; 30:795-810. [PMID: 36797651 PMCID: PMC11172400 DOI: 10.1002/cpp.2842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 02/14/2023] [Indexed: 02/18/2023]
Abstract
In the machine learning subfield of natural language processing, a topic model is a type of unsupervised method that is used to uncover abstract topics within a corpus of text. Dynamic topic modelling (DTM) is used for capturing change in these topics over time. The study deploys DTM on corpus of electronic health record psychotherapy notes. This retrospective study examines whether DTM helps distinguish closely matched patients that did and did not die by suicide. Cohort consists of United States Department of Veterans Affairs (VA) patients diagnosed with Posttraumatic Stress Disorder (PTSD) between 2004 and 2013. Each case (those who died by suicide during the year following diagnosis) was matched with five controls (those who remained alive) that shared psychotherapists and had similar suicide risk based on VA's suicide prediction algorithm. Cohort was restricted to patients who received psychotherapy for 9+ months after initial PTSD diagnoses (cases = 77; controls = 362). For cases, psychotherapy notes from diagnosis until death were examined. For controls, psychotherapy notes from diagnosis until matched case's death date were examined. A Python-based DTM algorithm was utilized. Derived topics identified population-specific themes, including PTSD, psychotherapy, medication, communication and relationships. Control topics changed significantly more over time than case topics. Topic differences highlighted engagement, expressivity and therapeutic alliance. This study strengthens groundwork for deriving population-specific, psychosocial and time-sensitive suicide risk variables.
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Affiliation(s)
- Maxwell Levis
- White River Junction VA Medical Center, Hartford, Vermont, USA
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Joshua Levy
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Vincent Dufort
- White River Junction VA Medical Center, Hartford, Vermont, USA
| | - Carey J. Russ
- White River Junction VA Medical Center, Hartford, Vermont, USA
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Brian Shiner
- White River Junction VA Medical Center, Hartford, Vermont, USA
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
- National Center for PTSD Executive Division, Hartford, Vermont, 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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Xi D, Berger A, Shurtleff D, Zia FZ, Belouin S. National Institutes of Health psilocybin research speaker series: State of the science, regulatory and policy landscape, research gaps, and opportunities. Neuropharmacology 2023; 230:109467. [PMID: 36858149 PMCID: PMC10163373 DOI: 10.1016/j.neuropharm.2023.109467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 02/08/2023] [Accepted: 02/16/2023] [Indexed: 03/02/2023]
Abstract
The U.S. National Institutes of Health (NIH) convened a seminal first ever psychedelic drug substance-focused speaker series, from April 22 to June 10, 2021, titled the "NIH Psilocybin Research Speaker Series." This speaker series provided evidence-based scientific information to the public and the scientific community. Its aims were to assess the current state of the science, the regulatory and policy landscape, as well as to identify gaps in knowledge and understanding, ultimately serving to define future research needs. The highlights of the lectures and discussion from 26 national and international distinguished experts served as the basis for this Special Issue of Neuropharmacology. This article is part of the Special Issue on "National Institutes of Health Psilocybin Research Speaker Series".
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Affiliation(s)
- Dan Xi
- National Institutes of Health (NIH), National Cancer Institute (NCI), Division of Cancer Treatment and Diagnosis (DCTD), Office of Cancer Complementary and Alternative Medicine (OCCAM), Rockville, MD, USA.
| | - Ann Berger
- NIH Clinical Research Center, Pain and Palliative Care, Bethesda, MD, USA.
| | - David Shurtleff
- NIH, National Center for Complementary and Integrative Health (NCCIH), Bethesda, MD, USA.
| | - Farah Z Zia
- National Institutes of Health (NIH), National Cancer Institute (NCI), Division of Cancer Treatment and Diagnosis (DCTD), Office of Cancer Complementary and Alternative Medicine (OCCAM), Rockville, MD, USA.
| | - Sean Belouin
- NIH Clinical Research Center, Pain and Palliative Care, Bethesda, MD, USA; United States Public Health Service (USPHS), Germantown, MD, USA; Substance Abuse and Mental Health Services Administration (SAMHSA), Rockville, MD, USA.
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Saconi B, Kuna ST, Polomano RC, Compton PA, Keenan BT, Sawyer AM. Chronic pain is common and worsens daytime sleepiness, insomnia, and quality of life in veterans with obstructive sleep apnea. J Clin Sleep Med 2023; 19:1121-1132. [PMID: 36798982 PMCID: PMC10235723 DOI: 10.5664/jcsm.10516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 02/13/2023] [Accepted: 02/14/2023] [Indexed: 02/18/2023]
Abstract
STUDY OBJECTIVES Chronic noncancer pain (CP) commonly co-occurs with obstructive sleep apnea (OSA) and may contribute to greater symptom burden. The study aims were to (1) characterize CP among veterans with OSA and (2) examine differences in sleepiness (Epworth Sleepiness Scale), insomnia symptoms (Insomnia Severity Index), and quality of life (Short Form Health Survey-20) in veterans with OSA with or without pre-existing CP. METHODS An observational, cross-sectional, study of 111 veterans with newly diagnosed, untreated OSA was conducted. Descriptive statistics characterized the sample and comorbid CP outcomes. Regression analyses were performed to investigate associations between self-reported CP and sleep-related symptoms or quality of life while controlling for potential confounders. RESULTS CP was reported by 69.5% (95% confidence interval: 61.8%, 76.2%) of participants. Having CP was associated with increased Epworth Sleepiness Scale (12.7 ± 5.5 vs 10.2 ± 5.2; P = .021) and Insomnia Severity Index scores (18.1 ± 6.2 vs 13.7 ± 7.4; P = .002), and worse quality of life across all Short Form Health Survey-20 domains. CONCLUSIONS There is a high prevalence of CP among veterans with OSA and symptom burden is higher in patients with OSA and CP. Future investigations should address symptom response and burden to OSA treatment in comorbid OSA and CP to guide outcome expectancies and residual OSA symptom treatment plans. CITATION Saconi B, Kuna ST, Polomano RC, Compton PA, Keenan BT, Sawyer AM. Chronic pain is common and worsens daytime sleepiness, insomnia, and quality of life in veterans with obstructive sleep apnea. J Clin Sleep Med. 2023;19(6):1121-1132.
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Affiliation(s)
- Bruno Saconi
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Samuel T. Kuna
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
- University of Pennsylvania Perelman School of Medicine Center for Sleep and Circadian Neurobiology, Philadelphia, Pennsylvania
| | - Rosemary C. Polomano
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Peggy A. Compton
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Brendan T. Keenan
- Division of Sleep Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Amy M. Sawyer
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
- Division of Sleep Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Haun JN, Fowler CA, Venkatachalam HH, Saenger MS, Alman AC, Smith BM, Schneider T, Benzinger R, Stroupe K, French DD. Empower Veterans Program (EVP): a chronic pain management program demonstrates positive outcomes among veterans. BMC Health Serv Res 2023; 23:431. [PMID: 37138319 PMCID: PMC10155644 DOI: 10.1186/s12913-023-09327-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 03/22/2023] [Indexed: 05/05/2023] Open
Abstract
BACKGROUND Chronic pain is a highly prevalent health condition among veterans. Traditional pharmacological interventions present unique challenges for chronic pain management including prescription opioid addiction and overdose. In alignment with the 2016 Comprehensive Addiction and Recovery Act and VA's Stepped Care Model to meet veterans' pain management needs, the Offices of Rural Health and Pain Management, Opioid Safety, and Prescription Drug Monitoring Program (PMOP) funded an enterprise-wide initiative to implement a Step 3 integrated tele-pain program: Empower Veterans Program (EVP). EVP provides veterans with chronic pain self-care skills using a whole health driven approach to pain management. OBJECTIVES The Comprehensive Addiction and Recovery Act prompted the strategic approach to offer non-pharmacological options to meet veterans' pain management needs. EVP, a 10-week interdisciplinary group medical appointment, leverages Acceptance and Commitment Therapy, Mindful Movement, and Whole Health to provide veterans with chronic pain self-care skills. This evaluation was conducted to describe participant characteristics, graduation, and satisfaction rates; and assess pre-post patient-reported outcomes (PRO) associated with EVP participation. METHODS A sample of 639 veterans enrolled in EVP between May, 2015 and December, 2017 provided data to conduct descriptive analyses to assess participant demographics, graduation, and satisfaction rates. PRO data were analyzed using a within-participants pre-post design, and linear mixed-effects models were used to examine pre-post changes in PRO. RESULTS Of 639 participants, 444 (69.48%) graduated EVP. Participant median program satisfaction rating was 8.41 (Interquartile Range: 8.20-9.20). Results indicate pre-post EVP improvements (Bonferroni-adjusted p < .003) in the three primary pain outcomes (intensity, interference, catastrophizing), and 12 of 17 secondary outcomes, including physical, psychological, health-related quality of life (HRQoL), acceptance, and mindfulness measures. DISCUSSION Data suggest that EVP has significant positive outcomes in pain, psychological, physical, HRQoL, acceptance, and mindfulness measures for veterans with chronic pain through non-pharmacological means. Future evaluations of intervention dosing effect and long-term effectiveness of the program is needed.
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Grants
- OMAT ID# 16403,16404, 16405, 16489, 16490 U.S. Department of Veterans Affairs
- OMAT ID# 16403,16404, 16405, 16489, 16490 U.S. Department of Veterans Affairs
- OMAT ID# 16403,16404, 16405, 16489, 16490 U.S. Department of Veterans Affairs
- OMAT ID# 16403,16404, 16405, 16489, 16490 U.S. Department of Veterans Affairs
- OMAT ID# 16403,16404, 16405, 16489, 16490 U.S. Department of Veterans Affairs
- OMAT ID# 16403,16404, 16405, 16489, 16490 U.S. Department of Veterans Affairs
- OMAT ID# 16403,16404, 16405, 16489, 16490 U.S. Department of Veterans Affairs
- OMAT ID# 16403,16404, 16405, 16489, 16490 U.S. Department of Veterans Affairs
- OMAT ID# 16403,16404, 16405, 16489, 16490 U.S. Department of Veterans Affairs
- OMAT ID# 16403,16404, 16405, 16489, 16490 U.S. Department of Veterans Affairs
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Affiliation(s)
- Jolie N Haun
- Research and Development Service, James A. Haley Veterans' Hospital, 8900 Grand Oak Circle, Tampa, FL, 33637, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah, 295 Chipeta Way, Salt Lake City, UT, 84132, USA
| | - Christopher A Fowler
- Research and Development Service, James A. Haley Veterans' Hospital, 8900 Grand Oak Circle, Tampa, FL, 33637, USA.
- Department of Psychiatry and Behavioral Neurosciences, University of South Florida, 3515 E. Fletcher Ave, Tampa, FL, 33613, USA.
| | - Hari H Venkatachalam
- Research and Development Service, James A. Haley Veterans' Hospital, 8900 Grand Oak Circle, Tampa, FL, 33637, USA
| | - Michael S Saenger
- Anesthesia Service Line, Atlanta Veterans Administration Health Care System, 1670 Clairmont Rd, Decatur, GA, 30033, USA
- Division of Internal Medicine, School of Medicine, Emory University, 201 Dowman Dr, Atlanta, GA, 30322, USA
| | - Amy C Alman
- Research and Development Service, James A. Haley Veterans' Hospital, 8900 Grand Oak Circle, Tampa, FL, 33637, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah, 295 Chipeta Way, Salt Lake City, UT, 84132, USA
| | - Bridget M Smith
- Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital, 5000 South 5th Ave, Hines, IL, 60141, USA
| | - Tali Schneider
- Research and Development Service, James A. Haley Veterans' Hospital, 8900 Grand Oak Circle, Tampa, FL, 33637, USA
| | - Rachel Benzinger
- Research and Development Service, James A. Haley Veterans' Hospital, 8900 Grand Oak Circle, Tampa, FL, 33637, USA
| | - Kevin Stroupe
- Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital, 5000 South 5th Ave, Hines, IL, 60141, USA
| | - Dustin D French
- Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital, 5000 South 5th Ave, Hines, IL, 60141, USA
- Center for Health Services and Outcomes Research, Feinberg School of Medicine, Northwestern University, 633 N. St. Clair St. Suite 2000, Chicago, IL, 60611, USA
- Departments of Ophthalmology and Medical Social Sciences, Feinberg School of Medicine, Northwestern University, 645 N. Michigan Ave. Suite 440, Chicago, IL, 60611, USA
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Taylor KA, Kapos FP, Sharpe JA, Kosinski AS, Rhon DI, Goode AP. Seventeen-Year National Pain Prevalence Trends Among U.S. Military Veterans. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.03.27.23287408. [PMID: 37034604 PMCID: PMC10081421 DOI: 10.1101/2023.03.27.23287408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
Importance U.S. military veterans experience higher pain prevalence and severity than nonveterans. However, it is unclear how these differences have changed over time. Previous studies are limited to veterans receiving care from the Veterans Health Administration. Objective To characterize pain prevalence trends in the overall population of U.S. veterans compared to nonveterans, using nationally-representative data. Design Repeated cross-sectional study. Data: National Health Interview Survey, 2002-2018. Analysis: January 2023. Setting Population-based survey of noninstitutionalized U.S. adults. Participants Across the 17-year period, mean annual weighted population was 229.7 million adults (unweighted sample total: n=506,639; unweighted sample annual mean: n=29,802). Exposure Veteran status. Main Outcomes Crude and demographics-adjusted pain prevalence trend differences between veterans and nonveterans across five pain variables (severe headache or migraine, facial pain, neck pain, low back pain, and joint pain) and two composite variables (any pain [≥1 prevalent pain] and multiple pains [≥2 prevalent pains]). Results Weighted proportion of veterans varied from 11.48% in 2002 (highest) to 8.41% in 2017 (lowest). Across the study period, crude prevalence was generally similar or higher among veterans than nonveterans for all pain variables except for severe headache or migraine and facial pain. When equalizing age, sex, race, and ethnicity, pain prevalence among veterans remained similar or higher than nonveterans for all pain variables. From 2002 to 2018 there was an absolute increase (95% CI) in pain prevalence among veterans (severe headache or migraine: 2.0% [1.6% to 2.4%]; facial pain: 1.9% [1.4% to 2.4%]; neck pain: 4.7% [4.1% to 5.2%]; joint pain: 11.4% [10.8% to 11.9%]; low back pain: 10.3% [9.5% to 11.1%]; any pain: 10.0% [9.6% to 10.4%]; and multiple pains: 9.9% [9.2% to 10.6%]. Crude and adjusted analyses indicated prevalence of all pain variables increased more among veterans than nonveterans from 2002 to 2018. Conclusion and Relevance Veterans had similar or higher adjusted prevalence and higher rates of increase over time for all pain variables compared to nonveterans. Continued pain prevalence increase among veterans may impact healthcare utilization (within and outside of the VHA), underscoring the need for improved pain prevention and care programs for these individuals with disproportionate pain burden.
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Affiliation(s)
- Kenneth Adam Taylor
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Flavia Penteado Kapos
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington
| | - Jason Arthur Sharpe
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs (VA) Healthcare System, Durham, North Carolina
| | - Andrzej Stanislaw Kosinski
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Daniel I Rhon
- Department of Rehabilitation Medicine, School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Adam Payne Goode
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
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Ward R, Rauch SAM, Axon RN, Saenger MS. Evaluation of a non-pharmacological interdisciplinary pain rehabilitation and functional restoration program for chronic pain in veterans. Health Serv Res 2023; 58:365-374. [PMID: 36064854 PMCID: PMC10012215 DOI: 10.1111/1475-6773.14062] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To conduct a quality improvement evaluation of the Empower Veterans Program (EVP), an interdisciplinary pain rehabilitation/functional restoration program option for functional restoration for high-impact chronic pain, offered in a large metro-area Veterans Health Administration (VHA) system. DATA SOURCES VHA Corporate Data Warehouse electronic medical record data for patients treated by EVP between 2015 and 2019. EVALUATION DESIGN This retrospective design first compared EVP patients considered engaged or not engaged in completing treatment in terms of demographic characteristics and post-treatment changes in clinical measures related to opioid use and mental health. We then compared mortality risk between matched groups of treated and untreated patients with chronic pain and concurrent opioid prescriptions using propensity score matching and Cox proportional hazards methods. "Treated" in the matched groups was defined as any level of EVP participation (i.e., both engaged and not engaged). DATA COLLECTION/EXTRACTION METHODS We first identified 1053 EVP patients with 1 year of pre-and post-treatment follow-time and determined their engagement level. From those with chronic pain and prescription opioids, we matched 237 EVP patients to 375 untreated patients. PRINCIPAL FINDINGS Engaged patients (57.4% of treated patients), were somewhat older than the non-engaged (mean age 57.1 vs. 53.7, Cohen's D = 0.30), and achieved lower mean PHQ9 depression scores in the post-treatment year (9.2 vs. 10.6, Cohen's D = 0.20). Participation in EVP was associated with a 65% lower mortality risk among Veterans with chronic pain and opioid use when compared to the untreated patients: (HR: 0.35, 95% CI: 0.17, 0.75). CONCLUSIONS EVP was associated with a large reduction in mortality risk for Veterans with both chronic pain and opioid use. This result could inform the decision process in a VA station or region when considering providing or expanding access to an interdisciplinary rehabilitation/functional restoration program for chronic pain.
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Affiliation(s)
- Ralph Ward
- Health Equity and Rural Outreach Center of InnovationRalph H. Johnson Veterans Affairs Medical CenterCharlestonSouth CarolinaUSA
- Department of Public Health SciencesMedical University of South CarolinaCharlestonSouth CarolinaUSA
| | - Sheila A. M. Rauch
- Mental Health Service LineVA Atlanta Healthcare SystemAtlantaGeorgiaUSA
- Department of Psychiatry and Behavioral SciencesEmory University School of MedicineAtlantaGeorgiaUSA
| | - Robert Neal Axon
- Health Equity and Rural Outreach Center of InnovationRalph H. Johnson Veterans Affairs Medical CenterCharlestonSouth CarolinaUSA
- College of MedicineMedical University of South CarolinaCharlestonSouth CarolinaUSA
| | - Michael S. Saenger
- Anesthesia Service LineVA Atlanta Healthcare SystemAtlantaGeorgiaUSA
- Department of MedicineEmory University School of MedicineAtlantaGeorgiaUSA
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Edmond SN, Snow JL, Pomeranz J, Van Cleve R, Black AC, Compton P, Becker WC. Delphi study to explore a new diagnosis for "ineffective" long-term opioid therapy for chronic pain. Pain 2023; 164:870-876. [PMID: 36448976 DOI: 10.1097/j.pain.0000000000002783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 09/02/2022] [Indexed: 12/02/2022]
Abstract
ABSTRACT A challenge in clinical, research, and policy spheres is determining whether and how to apply the Diagnostic and Statistical Manual-5 Opioid Use Disorder criteria to patients receiving long-term opioid therapy (LTOT) for the management of chronic pain. This study explored perspectives on the merits of creating a new diagnostic entity to characterize the problems that arise for certain patients prescribed LTOT and develop consensus on its definition and diagnostic criteria. We conducted 3 rounds of online surveys and held one discussion-based workshop to explore a new diagnostic entity and generate consensus with subject matter experts (n = 51) in pain and opioid use disorder, including a wide range of professional disciplines. The first survey included open-ended questions and rapid qualitative analysis to identify potential diagnostic criteria. Rounds 2 and 3 involved rating potential diagnostic criteria on a Likert-type scale to achieve consensus. The workshop was a facilitated conversation aimed at further refining criteria. Three-quarters of Delphi panelists were in favor of a new diagnostic entity; consensus was reached for 19 potential diagnostic criteria including benefits of LTOT no longer outweighing harms and a criterion related to difficulty tapering. A subgroup of expert panelists further refined the new diagnostic entity definition and criteria. Consensus on potential criteria for the new diagnostic entity was reached and further refined by a subgroup of experts. This Delphi study represents the opinions of a small group of subject matter experts; perspectives from other experts and additional stakeholder groups (including patients) are warranted.
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Affiliation(s)
- Sara N Edmond
- Pain Research Informatics Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, United States
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States
| | - Jennifer L Snow
- Pain Research Informatics Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, United States
| | - Jamie Pomeranz
- Department of Occupational Therapy, University of Florida, Gainesville, FL, United States
| | - Raymond Van Cleve
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, CA, United States
- Stanford University, Stanford, CA, United States
| | - Anne C Black
- Pain Research Informatics Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, United States
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States
| | - Peggy Compton
- Department of Family and Community Health, University of Pennsylvania, Philadelphia, PA, United States
| | - William C Becker
- Pain Research Informatics Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, United States
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States
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Goldsmith ES, Miller WA, Koffel E, Ullman K, Landsteiner A, Stroebel B, Hill J, Ackland PE, Wilt TJ, Duan-Porter W. Barriers and facilitators of evidence-based psychotherapies for chronic pain in adults: A systematic review. THE JOURNAL OF PAIN 2023; 24:742-769. [PMID: 36934826 DOI: 10.1016/j.jpain.2023.02.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 02/20/2023] [Accepted: 02/24/2023] [Indexed: 03/21/2023]
Abstract
Cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), and mindfulness-based stress reduction (MBSR) have demonstrated effectiveness for improving outcomes in chronic pain. These evidence-based psychotherapies (EBPs) remain underutilized in clinical practice, however. To identify research gaps and next steps for improving uptake of EBPs, we conducted a systematic review of patient-, provider-, and system-level barriers and facilitators of their use for chronic pain. We searched MEDLINE, Embase, PsycINFO, and CINAHL databases databases from inception through September 2022. Prespecified eligibility criteria included outpatient treatment of adults with chronic pain; examination of barriers and facilitators and/or evaluation of implementation strategies; conducted in the United States (US), United Kingdom (UK), Ireland, Canada or Australia; and publication in English. Two reviewers independently assessed eligibility and rated quality. We conducted a qualitative synthesis of results using a best-fit framework approach building upon domains of the Consolidated Framework for Implementation Research (CFIR). We identified 34 eligible studies (33 moderate or high quality), most (n=28) of which addressed patient-level factors. Shared barriers across EBPs included variable patient buy-in to therapy rationale and competing responsibilities for patients; shared facilitators included positive group or patient-therapist dynamics. Most studies examining ACT and all examining MBSR assessed only group formats. No studies compared barriers, facilitators, or implementation strategies of group CBT to individual CBT, or of telehealth to in-person EBPs. Conceptual mismatches of patient knowledge and beliefs with therapy principles were largely analyzed qualitatively, and studies did not explore how these mismatches were addressed to support engagement. Future research on EBPs for chronic pain in real-world practice settings is needed to explore provider and system-level barriers and facilitators, heterogeneity of effects and uptake, and both effects and uptake of EBPs delivered in various formats, including group vs. individual therapy and telehealth or asynchronous digital approaches. Perspective This systematic review synthesizes evidence on barriers and facilitators to uptake of cognitive behavioral therapy, acceptance and commitment therapy, and mindfulness-based stress reduction for chronic pain. Findings can guide future implementation work to increase availability and use of evidence-based psychotherapies for treatment of chronic pain. Registration: PROSPERO number CRD42021252038.
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Affiliation(s)
- Elizabeth S Goldsmith
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA; Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA.
| | - Wendy A Miller
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA; Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Erin Koffel
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
| | - Kristen Ullman
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA; Veterans Affairs Evidence Synthesis Program, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
| | - Adrienne Landsteiner
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA; Veterans Affairs Evidence Synthesis Program, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
| | - Benjamin Stroebel
- Department of Dermatology, University of California - San Francisco School of Medicine, San Francisco, CA, USA
| | - Jessica Hill
- Department of Clinical Psychology, Binghamton University, Binghamton, NY, USA
| | - Princess E Ackland
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA; Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Timothy J Wilt
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA; Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA; Veterans Affairs Evidence Synthesis Program, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA; Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Wei Duan-Porter
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA; Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA; Veterans Affairs Evidence Synthesis Program, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
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