1
|
Strong C, Burns SP, Arewasikporn A, Suri P, Hawkins EJ, Leipertz S, Haselkorn J, Turner AP. Chronic opioid prescription in veterans with spinal cord injury: Prevalence and associated factors. J Spinal Cord Med 2024:1-11. [PMID: 39051861 DOI: 10.1080/10790268.2024.2378556] [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] [Indexed: 07/27/2024] Open
Abstract
OBJECTIVE Chronic opioid use presents long-term health risks for individuals with spinal cord injury (SCI). The purpose of the study was to characterize patterns and correlates of the chronic prescription of opioids among individuals with SCI in a population of Veterans receiving care though the Veteran's Health Administration. DESIGN A retrospective, longitudinal cohort study examined the US Department of Veterans Affairs electronic medical record data of veterans with SCI. The annual prevalence of prescription opioid use by type (any, acute, chronic, incident chronic) was calculated for each study year (2015-2017). Multivariable models examined associations with demographics and pre-existing medical comorbidities. SETTING US Department of Veterans Affairs, Veteran's Health Administration. PARTICIPANTS National sample of Veterans with SCI (N = 10,811). MAIN OUTCOME MEASURE Chronic prescription opioid use (≥90 days). RESULTS All types of prescription opioid use declined across the three study years (chronic opioid use prevalence = 33.2%, 31.7%, and 29.7%, respectively). Past history of depression, COPD, diabetes, pain condition, opioid use and tobacco use disorders were associated with a greater likelihood of current chronic prescription opioid use. Non-white race, hyperlipidemia, dementia, and tetraplegia were associated with a lower likelihood of current chronic prescription opioid use. When added to the multivariable model, prior chronic opioid prescription use was robustly associated with current chronic prescription opioid use, but most other factors were no longer significantly associated with current opioid use. CONCLUSIONS This study demonstrates opioid reduction over time from 2015 to 2017, however, chronic prescription opioid use remains common among a substantial minority of Veterans with SCI. Several demographics and comorbidities may provide clinicians with important insights into factors associated with chronic prescription opioid use, with past chronic prescription opioid use being the most important.
Collapse
Affiliation(s)
- Cameron Strong
- VA Puget Sound Health Care System, Seattle, Washington, USA
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Stephen P Burns
- VA Puget Sound Health Care System, Seattle, Washington, USA
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Anne Arewasikporn
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Pradeep Suri
- VA Puget Sound Health Care System, Seattle, Washington, USA
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
- Clinical Learning, Evidence, and Research (CLEAR) Center, University of Washington, Seattle, Washington, USA
| | - Eric J Hawkins
- VA Puget Sound Health Care System, Seattle, Washington, USA
- Center of Excellence in Substance Addiction Treatment and Education, Seattle, Washington, USA
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington, USA
| | - Steve Leipertz
- VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Jodie Haselkorn
- VA Puget Sound Health Care System, Seattle, Washington, USA
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Aaron P Turner
- VA Puget Sound Health Care System, Seattle, Washington, USA
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| |
Collapse
|
2
|
Ferguson JE, Hagel Campbell E, Bangerter A, Cross LJS, Allen KD, Behrens K, Branson M, Calvert C, Friedman JK, Hennessy S, Meis LA, Taylor BC, Burgess DJ. Email recruitment for chronic pain clinical trials: results from the LAMP trial. Trials 2024; 25:491. [PMID: 39030622 PMCID: PMC11264665 DOI: 10.1186/s13063-024-08301-8] [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: 08/28/2023] [Accepted: 06/28/2024] [Indexed: 07/21/2024] Open
Abstract
BACKGROUND Recruitment for clinical trials and large-scale studies is challenging, especially for patients with complex conditions like chronic pain. Email recruitment has the potential to increase efficiency, to reduce costs, and to improve access for underrepresented patient populations. The objective of this study was to examine the effectiveness, efficiency, and equitability of email versus postal mail recruitment for the Learning to Apply Mindfulness to Pain (LAMP) study, a three-site clinical trial of mindfulness-based interventions for chronic pain. METHODS Patients with chronic pain diagnoses were recruited from three United States Department of Veterans Affairs (VA) facilities using the VA electronic health record (EHR). Recruitment materials were sent using either postal mail (n = 7986) or email (n = 19,333). Patients in the email recruitment group were also mailed introductory postcards before any emails. Mailing addresses and email addresses were obtained from the EHR. Effectiveness was measured by the response rate of patients who logged into the secure LAMP study website. Efficiency was measured by the number of days from when the recruitment materials were sent to when patients logged into the LAMP portal as well as the estimated costs of each recruitment approach. To assess equitability, we examined whether email recruitment was less effective for underrepresented populations, based on demographic information from the EHR. RESULTS Effectiveness-unadjusted response rates were greater for email versus postal-mail recruitment (18.9% versus 6.3%), and adjusted response rates were over three times greater for email recruitment (RR = 3.5, 95% CI 3.1-3.8) based on a multivariable analysis controlling for age, gender, race, ethnicity, rurality, and site. Efficiency-email recruitment had a significantly lower mean response time (1 day versus 8 days) and a lower cost. Equity-email recruitment led to higher response rates for all subpopulations, including older, non-White, Hispanic, rural, and female Veterans. CONCLUSIONS Email recruitment is an effective, efficient, and equitable way to recruit VA patients to large-scale, chronic pain clinical trials. TRIAL REGISTRATION Clinical Trial Registration Number: NCT04526158. Patient enrollment began on December 4, 2020.
Collapse
Affiliation(s)
- John E Ferguson
- Divisions of PM&R and Rehabilitation Science, Department of Rehabilitation Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Emily Hagel Campbell
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, 55417, USA
| | - Ann Bangerter
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, 55417, USA
| | - Lee J S Cross
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, 55417, USA.
| | - Kelli D Allen
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
- Thurston Arthritis Research Center, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Kimberly Behrens
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, 55417, USA
| | - Mariah Branson
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, 55417, USA
| | - Collin Calvert
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, 55417, USA
- University of Minnesota Medical School, Minneapolis, MN, USA
| | - Jessica K Friedman
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Health Care System, Los Angeles, CA, USA
| | - Sierra Hennessy
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, 55417, USA
| | - Laura A Meis
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, 55417, USA
- University of Minnesota Medical School, Minneapolis, MN, USA
- National Center for Post Traumatic Stress Disorder Women's Health Sciences Division, Veterans Affairs, MA, Boston, USA
| | - Brent C Taylor
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, 55417, USA
- University of Minnesota Medical School, Minneapolis, MN, USA
| | - Diana J Burgess
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, 55417, USA
- University of Minnesota Medical School, Minneapolis, MN, USA
| |
Collapse
|
3
|
Bradford AC, Nguyen T, Schulson L, Dick A, Gupta S, Simon K, Stein BD. High-Dose Opioid Prescribing in Individuals with Acute Pain: Assessing the Effects of US State Opioid Policies. J Gen Intern Med 2024:10.1007/s11606-024-08947-9. [PMID: 39028403 DOI: 10.1007/s11606-024-08947-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 07/08/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND How state opioid policy environments with multiple concurrent policies affect opioid prescribing to individuals with acute pain is unknown. OBJECTIVE To examine how prescription drug monitoring programs (PDMPs), pain management clinic regulations, initial prescription duration limits, and mandatory continued medical education affected total and high-dose prescribing. DESIGN A county-level multiple-policy difference-in-difference event study framework. SUBJECTS A total of 2,425,643 individuals in a large national commercial insurance deidentified claims database (aged 12-64 years) with acute pain diagnoses and opioid prescriptions from 2007 to 2019. MAIN MEASURES The total number of acute pain opioid treatment episodes and number of episodes containing high-dose (> 90 morphine equivalent daily dosage (MEDD)) prescriptions. KEY RESULTS Approximately 7.5% of acute pain episodes were categorized as high-dose episodes. Prescription duration limits were associated with increases in the number of total episodes; no other policy was found to have a significant impact. Beginning five quarters after implementation, counties in states with pain management clinic regulations experienced a sustained 50% relative decline in the number of episodes containing > 90 MEDD prescriptions (95 CIs: (Q5: - 0.506, - 0.144; Q12: - 1.000, - 0.290)). Mandated continuing medical education regarding the treatment of pain was associated with a 50-75% relative increase in number of high-dose episodes following the first year-and-a-half of enactment (95 CIs: (Q7: 0.351, 0.869; Q12: 0.413, 1.107)). Initial prescription duration limits were associated with an initial relative reduction of 25% in high-dose prescribing, with the effect increasing over time (95 CI: (Q12: - 0.967, - 0.335). There was no evidence that PDMPs affected high-dose opioids dispensed to individuals with acute pain. Other high-risk prescribing indicators were explored as well; no consistent policy impacts were found. CONCLUSIONS State opioid policies may have differential effects on high-dose opioid dispensing in individuals with acute pain. Policymakers should consider effectiveness of individual policies in the presence of other opioid policies to address the ongoing opioid crisis.
Collapse
Affiliation(s)
- Ashley C Bradford
- School of Public Policy, Georgia Institute of Technology, Atlanta, GA, USA.
| | - Thuy Nguyen
- School of Public Health, Department of Health Management and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Lucy Schulson
- RAND Corporation, Boston, MA, USA
- Department of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | | | - Sumedha Gupta
- Department of Economics, Indiana University, Indianapolis, IN, USA
| | - Kosali Simon
- O'Neill School of Public and Environmental Affairs, Indiana University, Bloomington, IN, USA
| | | |
Collapse
|
4
|
Daniels SI, Cave S, Wagner TH, Perez TA, Edmond SN, Becker WC, Midboe AM. Implementation, intervention, and downstream costs for implementation of a multidisciplinary complex pain clinic in the Veterans Health Administration. Health Serv Res 2024. [PMID: 38956400 DOI: 10.1111/1475-6773.14345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2024] Open
Abstract
OBJECTIVE To determine the budget impact of implementing multidisciplinary complex pain clinics (MCPCs) for Veterans Health Administration (VA) patients living with complex chronic pain and substance use disorder comorbidities who are on risky opioid regimens. DATA SOURCES AND STUDY SETTING We measured implementation costs for three MCPCs over 2 years using micro-costing methods. Intervention and downstream costs were obtained from the VA Managerial Cost Accounting System from 2 years prior to 2 years after opening of MCPCs. STUDY DESIGN Staff at the three VA sites implementing MCPCs were supported by Implementation Facilitation. The intervention cohort was patients at MCPC sites who received treatment based on their history of chronic pain and risky opioid use. Intervention costs and downstream costs were estimated with a quasi-experimental study design using a propensity score-weighted difference-in-difference approach. The healthcare utilization costs of treated patients were compared with a control group having clinically similar characteristics and undergoing the standard route of care at neighboring VA medical centers. Cancer and hospice patients were excluded. DATA COLLECTION/EXTRACTION METHODS Activity-based costing data acquired from MCPC sites were used to estimate implementation costs. Intervention and downstream costs were extracted from VA administrative data. PRINCIPAL FINDINGS Average Implementation Facilitation costs ranged from $380 to $640 per month for each site. Upon opening of three MCPCs, average intervention costs per patient were significantly higher than the control group at two intervention sites. Downstream costs were significantly higher at only one of three intervention sites. Site-level differences were due to variation in inpatient costs, with some confounding likely due to the COVID-19 pandemic. This evidence suggests that necessary start-up investments are required to initiate MCPCs, with allocations of funds needed for implementation, intervention, and downstream costs. CONCLUSIONS Incorporating implementation, intervention, and downstream costs in this evaluation provides a thorough budget impact analysis, which decision-makers may use when considering whether to expand effective programming.
Collapse
Affiliation(s)
- Sarah I Daniels
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, California, USA
| | - Shayna Cave
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, California, USA
| | - Todd H Wagner
- Health Economics and Research Center, Center for Policy Evaluation, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
- Department of Surgery, Stanford University, Palo Alto, California, USA
| | - Taryn A Perez
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, California, USA
| | - Sara N Edmond
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center for Innovation, VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Yale School of Medicine, New Haven, Connecticut, USA
| | - William C Becker
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center for Innovation, VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Yale School of Medicine, New Haven, Connecticut, USA
| | - Amanda M Midboe
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, California, USA
- Department of Public Health Sciences, Division of Health Policy and Management, University of California Davis-School of Medicine, Davis, California, USA
| |
Collapse
|
5
|
Hadlandsmyth K, Zhuang C, Driscoll MA, Lund BC. Comorbid Chronic Pain and Post-traumatic Stress Disorder: Current Rates and Psychiatric Comorbidities Among U.S. Military Veterans. Mil Med 2024:usae313. [PMID: 38869274 DOI: 10.1093/milmed/usae313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 05/21/2024] [Accepted: 06/04/2024] [Indexed: 06/14/2024] Open
Abstract
INTRODUCTION This study reports rates of comorbid chronic pain and post-traumatic stress disorder (PTSD) among U.S. military veterans and rates of psychiatric comorbidities among those with both chronic pain and PTSD. MATERIALS AND METHODS This study utilized National Veterans Affairs (VA) administrative data to identify all veterans treated for chronic pain or PTSD in 2023. Multivariable logistic regression models determined the likelihood of each psychiatric comorbidity for those with chronic pain and PTSD relative to those with chronic pain only and separately to those with PTSD only, after adjusting for demographic variables and all other psychiatric comorbidities. RESULTS Of the 5,846,453 service users of the VA in 2023, a total of 2,091,391 (35.8%) met the criteria for chronic pain and 850,191 (14.5%) met the criteria for PTSD. Furthermore, 21.6% of those with chronic pain also had PTSD and over half (53.2%) of those with PTSD also met the criteria for chronic pain (n = 452,113). Veterans with chronic pain and PTSD were significantly more likely to be women, Black or African American, Hispanic or Latina, and urban dwelling. Veterans with chronic pain and PTSD had significantly higher rates of all selected comorbidities relative to veterans with chronic pain only. CONCLUSIONS Patients with comorbid chronic pain and PTSD may benefit from tailored treatments to address the additive impact of these conditions.
Collapse
Affiliation(s)
- Katherine Hadlandsmyth
- VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Iowa City, Iowa City VA Health Care System, Iowa City, IA 52246, USA
- Center for Access & Delivery Research and Evaluation (CADRE), 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
| | - Caywin Zhuang
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA
| | - Mary A Driscoll
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT 06516, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, CT 06511, USA
| | - Brian C Lund
- VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Iowa City, Iowa City VA Health Care System, Iowa City, IA 52246, USA
- Center for Access & Delivery Research and Evaluation (CADRE), 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
| |
Collapse
|
6
|
Myers LC, Soltesz L, Bosch N, Daly KA, Devis Y, Rucci J, Stevens J, Wunsch H, Jafarzadeh SR, Campbell CI, Liu VX, Walkey AJ. Intravenous Opioid Administration During Mechanical Ventilation and Use After Hospital Discharge. JAMA Netw Open 2024; 7:e2417292. [PMID: 38874921 PMCID: PMC11179130 DOI: 10.1001/jamanetworkopen.2024.17292] [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] [Received: 11/29/2023] [Accepted: 04/17/2024] [Indexed: 06/15/2024] Open
Abstract
Importance Guidelines recommend an analgesia-first strategy for sedation during mechanical ventilation, but associations between opioids provided during mechanical ventilation and posthospitalization opioid-related outcomes are unclear. Objective To evaluate associations between an intravenous opioid dose received during mechanical ventilation and postdischarge opioid-related outcomes in medical (nonsurgical) patients. Design, Setting, and Participants This retrospective cohort study evaluated adults receiving mechanical ventilation lasting 24 hours or more for acute respiratory failure and surviving hospitalization. Participants from 21 Kaiser Permanente Northern California hospitals from January 1, 2012, to December 31, 2019, were included. Data were analyzed from October 1, 2020, to October 31, 2023. Exposures Terciles of median daily intravenous fentanyl equivalents during mechanical ventilation. Main Outcomes and Measures The primary outcome was the first filled opioid prescription in 1 year after discharge. Secondary outcomes included persistent opioid use and opioid-associated complications. Secondary analyses tested for interaction between opioid doses during mechanical ventilation, prior opioid use, and posthospitalization opioid use. Estimates were based on multivariable-adjusted time-to-event analyses, with death as a competing risk, and censored for hospice or palliative care referral, rehospitalization with receipt of opioid, or loss of Kaiser Permanente plan membership. Results The study included 6746 patients across 21 hospitals (median age, 67 years [IQR, 57-76 years]; 53.0% male). Of the participants, 3114 (46.2%) filled an opioid prescription in the year prior to admission. The median daily fentanyl equivalent during mechanical ventilation was 200 μg (IQR, 40-1000 μg), with terciles of 0 to 67 μg, more than 67 to 700 μg, and more than 700 μg. Compared with patients who did not receive opioids during mechanical ventilation (n = 1013), a higher daily opioid dose was associated with opioid prescriptions in the year after discharge (n = 2942 outcomes; tercile 1: adjusted hazard ratio [AHR], 1.00 [95% CI, 0.85-1.17], tercile 2: AHR, 1.20 [95% CI, 1.03-1.40], and tercile 3: AHR, 1.25 [95% CI, 1.07-1.47]). Higher doses of opioids during mechanical ventilation were also associated with persistent opioid use after hospitalization (n = 1410 outcomes; tercile 3 vs no opioids: odds ratio, 1.44 [95% CI, 1.14-1.83]). No interaction was observed between opioid dose during mechanical ventilation, prior opioid use, and posthospitalization opioid use. Conclusions and Relevance In this retrospective cohort study of patients receiving mechanical ventilation, opioids administered during mechanical ventilation were associated with opioid prescriptions following hospital discharge. Additional studies to evaluate risks and benefits of strategies using lower opioid doses are warranted.
Collapse
Affiliation(s)
- Laura C Myers
- The Permanente Medical Group, Kaiser Permanente Northern California, Oakland
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Lauren Soltesz
- The Permanente Medical Group, Kaiser Permanente Northern California, Oakland
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Nicholas Bosch
- Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Kathleen A Daly
- The Permanente Medical Group, Kaiser Permanente Northern California, Oakland
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Ycar Devis
- Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Justin Rucci
- Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | | | - Hannah Wunsch
- Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - S Reza Jafarzadeh
- Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Cynthia I Campbell
- Division of Research, Kaiser Permanente Northern California, Oakland
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco
| | - Vincent X Liu
- The Permanente Medical Group, Kaiser Permanente Northern California, Oakland
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Allan J Walkey
- Division of Health Systems Science, Department of Medicine, University of Massachusetts Chan Medical School, Worcester
| |
Collapse
|
7
|
Kasanagottu K, Anderson TS, Trivedi S, Ngo LH, Schnipper JL, McCarthy EP, Herzig SJ. Racial and Ethnic Disparities in Opioid Prescribing on Hospital Discharge Among Older Adults: A National Retrospective Cohort Study. J Gen Intern Med 2024; 39:1444-1451. [PMID: 38424348 PMCID: PMC11169105 DOI: 10.1007/s11606-024-08687-w] [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] [Received: 07/25/2023] [Accepted: 02/16/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND Disparities in opioid prescribing among racial and ethnic groups have been observed in outpatient and emergency department settings, but it is unknown whether similar disparities exist at discharge among hospitalized older adults. OBJECTIVE To determine filled opioid prescription rates on hospital discharge by race/ethnicity among Medicare beneficiaries. DESIGN Retrospective cohort study. PARTICIPANTS Medicare beneficiaries 65 years or older discharged from hospital in 2016, without opioid fills in the 90 days prior to hospitalization (opioid-naïve). MAIN MEASURES Race/ethnicity was categorized by the Research Triangle Institute (RTI), grouped as Asian/Pacific Islander, Black, Hispanic, other (American Indian/Alaska Native/unknown/other), and White. The primary outcome was an opioid prescription claim within 2 days of hospital discharge. The secondary outcome was total morphine milligram equivalents (MMEs) among adults with a filled opioid prescription. KEY RESULTS Among 316,039 previously opioid-naïve beneficiaries (mean age, 76.8 years; 56.2% female), 49,131 (15.5%) filled an opioid prescription within 2 days of hospital discharge. After adjustment, Black beneficiaries were 6% less likely (relative risk [RR] 0.94, 95% CI 0.91-0.97) and Asian/Pacific Islander beneficiaries were 9% more likely (RR 1.09, 95% CI 1.03-1.14) to have filled an opioid prescription when compared to White beneficiaries. Among beneficiaries with a filled opioid prescription, mean total MMEs were lower among Black (356.9; adjusted difference - 4%, 95% CI - 7 to - 1%), Hispanic (327.0; adjusted difference - 7%, 95% CI - 10 to - 4%), and Asian/Pacific Islander (328.2; adjusted difference - 8%, 95% CI - 12 to - 4%) beneficiaries when compared to White beneficiaries (409.7). CONCLUSIONS AND RELEVANCE Black older adults were less likely to fill a new opioid prescription after hospital discharge when compared to White older adults and received lower total MMEs. The factors contributing to these differential prescribing patterns should be investigated further.
Collapse
Affiliation(s)
- Koushik Kasanagottu
- Division of General Medicine, Beth Israel Deaconess Medical Center, 1309 Beacon Street, Brookline, MA, 02246, USA.
- Department of Medicine, Harvard Medical School, Boston, MA, USA.
| | - Timothy S Anderson
- Division of General Medicine, Beth Israel Deaconess Medical Center, 1309 Beacon Street, Brookline, MA, 02246, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Shrunjal Trivedi
- Division of General Medicine, Beth Israel Deaconess Medical Center, 1309 Beacon Street, Brookline, MA, 02246, USA
| | - Long H Ngo
- Division of General Medicine, Beth Israel Deaconess Medical Center, 1309 Beacon Street, Brookline, MA, 02246, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Jeffrey L Schnipper
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Ellen P McCarthy
- Division of General Medicine, Beth Israel Deaconess Medical Center, 1309 Beacon Street, Brookline, MA, 02246, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - Shoshana J Herzig
- Division of General Medicine, Beth Israel Deaconess Medical Center, 1309 Beacon Street, Brookline, MA, 02246, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
8
|
Johnson NL, Steffensmeier KS, Garvin LA, Adamowicz JL, Obrecht AA, Rothmiller SJ, Sibenaller Z, Stout L, Driscoll MA, Hadlandsmyth K. "It Made Me Not Want to See him…": The Role of Patient-Provider Communication in Influencing Rural-Dwelling Women Veterans' Motivation to Seek Health Care for Managing Chronic Pain. HEALTH COMMUNICATION 2024; 39:1161-1174. [PMID: 37161286 DOI: 10.1080/10410236.2023.2207280] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Despite being high health care utilizers, many women Veterans perceive their pain condition to be poorly understood by their providers, which can be a strong demotivator for seeking care. We set out to understand the priorities rural-dwelling women Veterans have for using health care for their chronic pain, and interviewed participants about their experiences with (and priorities for seeking) health care for their chronic pain. Self-Determination Theory identifies three sources of motivation (autonomy, competence, relatedness), all of which were represented through two themes that reflect rural women Veterans' rationale for decision-making to obtain health care for chronic pain: role of trust and competing priorities. Women described their priorities for chronic pain management in terms of their competing priorities for work, education, and supporting their family, but most expressed a desire to function in their daily life and relationships. Second, women discussed the role of trust in their provider as a source of motivation, and the role of patient-provider communication skills and gender played in establishing trust. Rural women Veterans often discussed core values that stemmed from facets of their identity (e.g. gender, military training, ethnicity) that also influenced their decision-making. Our findings provide insight for how providers may use Motivational Interviewing and discuss chronic pain treatment options so that rural-dwelling women Veterans feel autonomous, competent, and understood in their decision-making about their chronic pain. We also discuss importance of acknowledging the effects of disenfranchising talk and perpetuating gendered stereotypes related to chronic pain and theoretical implications of this work.
Collapse
Affiliation(s)
- Nicole L Johnson
- Office of Rural Health, Veterans Rural Health Resource Center, Iowa City VA Health Care System
- Center for Access & Delivery Research and Evaluation, Iowa City VA Health Care System
| | - Kenda Stewart Steffensmeier
- Office of Rural Health, Veterans Rural Health Resource Center, Iowa City VA Health Care System
- Center for Access & Delivery Research and Evaluation, Iowa City VA Health Care System
| | | | - Jenna L Adamowicz
- Office of Rural Health, Veterans Rural Health Resource Center, Iowa City VA Health Care System
- Center for Access & Delivery Research and Evaluation, Iowa City VA Health Care System
- Department of Psychological and Brain Sciences, University of Iowa
| | - Ashlie A Obrecht
- Department of Primary Care, Veteran Affairs Central Iowa Health Care System
| | - Shamira J Rothmiller
- Office of Rural Health, Veterans Rural Health Resource Center, Iowa City VA Health Care System
- Center for Access & Delivery Research and Evaluation, Iowa City VA Health Care System
| | - Zita Sibenaller
- Department of Psychological and Brain Sciences, University of Iowa
| | - Lori Stout
- Department of Anesthesia, University of Iowa
| | - Mary A Driscoll
- Pain Research, Informatics, Multimorbidities, and Education Center, VA Connecticut Healthcare System
| | - Katherine Hadlandsmyth
- Office of Rural Health, Veterans Rural Health Resource Center, Iowa City VA Health Care System
- Center for Access & Delivery Research and Evaluation, Iowa City VA Health Care System
- Department of Anesthesia, University of Iowa
| |
Collapse
|
9
|
Hoffman KL, Milazzo F, Williams NT, Samples H, Olfson M, Diaz I, Doan L, Cerda M, Crystal S, Rudolph KE. Independent and joint contributions of physical disability and chronic pain to incident opioid use disorder and opioid overdose among Medicaid patients. Psychol Med 2024; 54:1419-1430. [PMID: 37974483 PMCID: PMC10994776 DOI: 10.1017/s003329172300332x] [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: 11/19/2023]
Abstract
BACKGROUND Chronic pain has been extensively explored as a risk factor for opioid misuse, resulting in increased focus on opioid prescribing practices for individuals with such conditions. Physical disability sometimes co-occurs with chronic pain but may also represent an independent risk factor for opioid misuse. However, previous research has not disentangled whether disability contributes to risk independent of chronic pain. METHODS Here, we estimate the independent and joint adjusted associations between having a physical disability and co-occurring chronic pain condition at time of Medicaid enrollment on subsequent 18-month risk of incident opioid use disorder (OUD) and non-fatal, unintentional opioid overdose among non-elderly, adult Medicaid beneficiaries (2016-2019). RESULTS We find robust evidence that having a physical disability approximately doubles the risk of incident OUD or opioid overdose, and physical disability co-occurring with chronic pain increases the risks approximately sixfold as compared to having neither chronic pain nor disability. In absolute numbers, those with neither a physical disability nor chronic pain condition have a 1.8% adjusted risk of incident OUD over 18 months of follow-up, those with physical disability alone have an 2.9% incident risk, those with chronic pain alone have a 3.6% incident risk, and those with co-occurring physical disability and chronic pain have a 11.1% incident risk. CONCLUSIONS These findings suggest that those with a physical disability should receive increased attention from the medical and healthcare communities to reduce their risk of opioid misuse and attendant negative outcomes.
Collapse
Affiliation(s)
- Katherine L. Hoffman
- Department of Epidemiology, Mailman School of Public Health, Columbia University
| | - Floriana Milazzo
- Department of Epidemiology, Mailman School of Public Health, Columbia University
| | - Nicholas T. Williams
- Department of Epidemiology, Mailman School of Public Health, Columbia University
| | | | - Mark Olfson
- Department of Epidemiology, Mailman School of Public Health, Columbia University
| | - Ivan Diaz
- New York University Grossman School of Medicine
| | - Lisa Doan
- New York University Grossman School of Medicine
| | | | | | - Kara E. Rudolph
- Department of Epidemiology, Mailman School of Public Health, Columbia University
| |
Collapse
|
10
|
Reed DE, Engel CC, DeFaccio R, Gaj L, Douglas JH, Williams RM, Etingen B, Kroenke K, Bokhour BG, Zeliadt SB. Examining the Veterans Health Administration whole health model of care within the context of posttraumatic stress disorder. Psychol Serv 2024; 21:224-234. [PMID: 38079475 PMCID: PMC11139595 DOI: 10.1037/ser0000822] [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: 06/01/2024]
Abstract
The Veterans Health Administration's Whole Health system of care focuses on offering veterans holistic health approaches and tailoring health care to individual's goals and preferences. The present study assessed factors associated with Whole Health use and its potential benefits among veterans with posttraumatic stress disorder (PTSD) receiving Veterans Health Administration care. This cohort study used retrospective electronic health records combined with survey data (baseline, 6 months) from 18 Veterans Affairs Whole Health pilot implementation sites and compared patient-reported outcomes between veterans who used Whole Health services versus those who did not, among veterans with (n = 1,326) and without (n = 3,243) PTSD. Patient-reported outcomes assessed were pain (PEG), patient-reported outcomes measurement information system physical and mental health functioning, and a one-item global meaning and purpose assessment. Veterans with PTSD were more likely to have used Whole Health (38% vs. 21%) than those without PTSD. Veterans with PTSD who used Whole Health services experienced small improvements over 6 months in physical (Cohen's d = .12) and mental (Cohen's d = .15) health functioning. Veterans without PTSD who used Whole Health services experienced small improvements in physical health (Cohen's d = .09) but not mental health (Cohen's d = .04). Veterans with PTSD were frequently connected with Whole Health services even though implementation efforts were not explicitly focused on reaching this population. Results suggest Whole Health may play an important role in how veterans with PTSD engage with health care. (PsycInfo Database Record (c) 2024 APA, all rights reserved).
Collapse
Affiliation(s)
- David E Reed
- Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development, VA Puget Sound Health Care
| | - Charles C Engel
- Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development, VA Puget Sound Health Care
| | - Rian DeFaccio
- Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development, VA Puget Sound Health Care
| | - Lauren Gaj
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System
| | - Jamie H Douglas
- Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development, VA Puget Sound Health Care
| | | | - Bella Etingen
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. Veterans Affairs Hospital
| | | | - Barbara G Bokhour
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System
| | - Steven B Zeliadt
- Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development, VA Puget Sound Health Care
| |
Collapse
|
11
|
Sanchez JG, Rancu AL, Diatta FH, Jonnalagadda A, Dhodapkar MM, Knoedler L, Kauke-Navarro M, Grauer JN. Increased Risk of 90-Day Complications in Patients With Fibromyalgia Undergoing Total Shoulder Arthroplasty. J Am Acad Orthop Surg Glob Res Rev 2024; 8:01979360-202405000-00007. [PMID: 38722914 PMCID: PMC11081627 DOI: 10.5435/jaaosglobal-d-24-00102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 03/25/2024] [Indexed: 05/13/2024]
Abstract
INTRODUCTION Anatomic and reverse total shoulder arthroplasties (TSAs) are effective treatment options for end-stage glenohumeral osteoarthritis. Those undergoing TSA may also have fibromyalgia, a musculoskeletal condition. However, the association of fibromyalgia with shorter and longer term outcomes after TSA has not been well characterized. METHODS Patients undergoing TSA for osteoarthritis indications were identified in the PearlDiver M165 database from January 2016 to October 2022. Exclusion criteria included age younger than 18 years, shoulder infection, neoplasm, or trauma within 90 days before surgery, and inactivity in the database within 90 days of surgery. Patients with fibromyalgia were matched in a 1:4 ratio to patients without based on age, sex, and Elixhauser Comorbidity Index. Ninety-day adverse events were compared using univariable and multivariable analyses. Five-year revision-free survival was compared using the log-rank test. RESULTS Of 163,565 TSA patients, fibromyalgia was identified for 9,035 (5.52%). After matching, cohorts of 30,770 non-fibromyalgia patients and 7,738 patients with fibromyalgia were identified. Multivariable analyses demonstrated patients with fibromyalgia were at independently increased odds ratios (ORs) for the following 90-day complications (decreasing OR order): urinary tract infection (OR = 4.49), wound dehiscence (OR = 3.63), pneumonia (OR = 3.46), emergency department visit (OR = 3.45), sepsis (OR = 3.15), surgical site infection (OR = 2.82), cardiac events (OR = 2.72), acute kidney injury (OR = 2.65), deep vein thrombosis (OR = 2.48), hematoma (OR = 2.03), and pulmonary embolism (OR = 2.01) (P < 0.05 for each). These individual complications contributed to the increased odds of aggregated minor adverse events (OR = 3.68), all adverse events (OR = 3.48), and severe adverse events (OR = 2.68) (P < 0.05 for each). No statistically significant difference was observed in 5-year revision-free survival between groups. DISCUSSION This study found TSA patients with fibromyalgia to be at increased risk of adverse events within 90 days of surgery. Proper surgical planning and patient counseling are crucial to this population. Nonetheless, it was reassuring that those with fibromyalgia had similar 5-year revision-free survival compared with those without.
Collapse
Affiliation(s)
- Joshua G. Sanchez
- From the Yale Department of Orthopaedics and Rehabilitation (Mr. Sanchez, Mr. Rancu, Mr. Jonnalagadda, Ms. Dhodapkar, and Dr. Grauer), and the Yale Department of Plastic and Reconstructive Surgery, New Haven, CT (Dr. Diatta, Mr. Knoedler, and Dr. Kauke-Navarro)
| | - Albert L. Rancu
- From the Yale Department of Orthopaedics and Rehabilitation (Mr. Sanchez, Mr. Rancu, Mr. Jonnalagadda, Ms. Dhodapkar, and Dr. Grauer), and the Yale Department of Plastic and Reconstructive Surgery, New Haven, CT (Dr. Diatta, Mr. Knoedler, and Dr. Kauke-Navarro)
| | - Fortunay H. Diatta
- From the Yale Department of Orthopaedics and Rehabilitation (Mr. Sanchez, Mr. Rancu, Mr. Jonnalagadda, Ms. Dhodapkar, and Dr. Grauer), and the Yale Department of Plastic and Reconstructive Surgery, New Haven, CT (Dr. Diatta, Mr. Knoedler, and Dr. Kauke-Navarro)
| | - Anshu Jonnalagadda
- From the Yale Department of Orthopaedics and Rehabilitation (Mr. Sanchez, Mr. Rancu, Mr. Jonnalagadda, Ms. Dhodapkar, and Dr. Grauer), and the Yale Department of Plastic and Reconstructive Surgery, New Haven, CT (Dr. Diatta, Mr. Knoedler, and Dr. Kauke-Navarro)
| | - Meera M. Dhodapkar
- From the Yale Department of Orthopaedics and Rehabilitation (Mr. Sanchez, Mr. Rancu, Mr. Jonnalagadda, Ms. Dhodapkar, and Dr. Grauer), and the Yale Department of Plastic and Reconstructive Surgery, New Haven, CT (Dr. Diatta, Mr. Knoedler, and Dr. Kauke-Navarro)
| | - Leonard Knoedler
- From the Yale Department of Orthopaedics and Rehabilitation (Mr. Sanchez, Mr. Rancu, Mr. Jonnalagadda, Ms. Dhodapkar, and Dr. Grauer), and the Yale Department of Plastic and Reconstructive Surgery, New Haven, CT (Dr. Diatta, Mr. Knoedler, and Dr. Kauke-Navarro)
| | - Martin Kauke-Navarro
- From the Yale Department of Orthopaedics and Rehabilitation (Mr. Sanchez, Mr. Rancu, Mr. Jonnalagadda, Ms. Dhodapkar, and Dr. Grauer), and the Yale Department of Plastic and Reconstructive Surgery, New Haven, CT (Dr. Diatta, Mr. Knoedler, and Dr. Kauke-Navarro)
| | - Jonathan N. Grauer
- From the Yale Department of Orthopaedics and Rehabilitation (Mr. Sanchez, Mr. Rancu, Mr. Jonnalagadda, Ms. Dhodapkar, and Dr. Grauer), and the Yale Department of Plastic and Reconstructive Surgery, New Haven, CT (Dr. Diatta, Mr. Knoedler, and Dr. Kauke-Navarro)
| |
Collapse
|
12
|
Hadlandsmyth K, Driscoll MA, Johnson NL, Mares JG, Mengeling MA, Thomas EBK, Norman SB, Lund BC. Veterans with chronic pain: Examining gender differences in pain type, overlap, and the impact of post-traumatic stress disorder. Eur J Pain 2024. [PMID: 38450917 DOI: 10.1002/ejp.2258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 02/08/2024] [Accepted: 02/26/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND Women are more likely to experience multiple overlapping pain conditions (MOPCs) relative to men. Post-traumatic stress disorder can negatively impact the severity and trajectory of chronic pain and its treatment. Specific associations between gender, post-traumatic stress disorder (PTSD), and MOPCs require further examination. METHODS A cohort of all Veterans in 2021 who met criteria for one or more of 12 chronic pain types was created using national Veterans Health Administration administrative data. MOPCs were defined as the number of pain types for which each patient met criteria. Multivariable logistic regression models estimated gender differences in frequency for each of the 12 pain subtypes, after controlling for demographics and comorbidities. Negative binomial regression was used to estimate gender differences in the count of MOPCs and to explore moderation effects between gender and PTSD. RESULTS The cohort included 1,936,859 Veterans with chronic pain in 2021, which included 12.5% women. Among those with chronic pain, women Veterans had higher rates of MOPCs (mean = 2.3) relative to men (mean = 1.9): aIRR = 1.31, 95% CI: 1.30-1.32. PTSD also served as an independent risk factor for MOPCs in adjusted analysis (aIRR = 1.23, 95% CI: 1.23-1.24). The interaction term between gender and PTSD was not significant (p = 0.87). Independent of PTSD, depressive disorders also served as a strong risk factor for MOPCs (aIRR = 1.37, 95% CI: 1.36-1.37). CONCLUSIONS Individuals with MOPCs and PTSD may have complex treatment needs. They may benefit from highly coordinated trauma-sensitive care and integrated interventions that simultaneously address pain and PTSD. SIGNIFICANCE Women were significantly more likely than men to experience MOPCs. PTSD was also significantly, independently, associated with MOPCs. Patients, particularly women, may benefit from tailored interventions that address both trauma and MOPCs.
Collapse
Affiliation(s)
- Katherine Hadlandsmyth
- VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Iowa City (VRHRC-IC), Iowa City VA Health Care System, Iowa City, Iowa, USA
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa, USA
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Mary A Driscoll
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
| | - Nicole L Johnson
- VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Iowa City (VRHRC-IC), Iowa City VA Health Care System, Iowa City, Iowa, USA
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa, USA
| | - Jasmine G Mares
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa, USA
| | - Michelle A Mengeling
- VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Iowa City (VRHRC-IC), Iowa City VA Health Care System, Iowa City, Iowa, USA
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa, USA
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Emily B K Thomas
- VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Iowa City (VRHRC-IC), Iowa City VA Health Care System, Iowa City, Iowa, USA
- Department of Psychological and Brain Sciences, University of Iowa College of Liberal Arts and Sciences, Iowa City, Iowa, USA
| | - Sonya B Norman
- National Center for PTSD, White River Junction, Vermont, USA
- University of California San Diego School of Medicine, La Jolla, California, USA
| | - Brian C Lund
- VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Iowa City (VRHRC-IC), Iowa City VA Health Care System, Iowa City, Iowa, USA
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa, USA
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, Iowa, USA
| |
Collapse
|
13
|
Thornton JD, Varisco T, Prachet B, Olateju O, Shrestha M, Shen C. Productivity Loss Among Opioid and Benzodiazepine Users in the United States: A Medical Expenditure Panel Survey From 2010 to 2019. J Occup Environ Med 2024; 66:226-233. [PMID: 38151973 PMCID: PMC10922134 DOI: 10.1097/jom.0000000000003029] [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: 12/29/2023]
Abstract
OBJECTIVE The aim of the study is to estimate the association between productivity losses and the use of prescription opioids and benzodiazepines among employed US adults with painful conditions. METHODS Using Medical Expenditures Panel Survey (2010-2019), we used two-part (logistic regression and generalized linear model with zero-truncated negative binomial link) model to compare missed workdays due to illness or injury among employed adults with a painful condition. RESULTS Of the eligible sample of 57,413 working US individuals, 14.65% were prescription opioid users, 2.95% were benzodiazepine users, and 1.59% were both opioid and benzodiazepine users. The predicted missed workdays were 5.75 (95% Confidence Limit [CL]: 5.58-5.92) days for benzodiazepine users, 13.06 (95% CL: 12.88-13.23) days among opioid users, and 15.18 (95% CL: 14.46-15.90) days for opioid and benzodiazepine concomitant users. CONCLUSIONS Concomitant use of prescription opioids and benzodiazepines was significantly associated with having more missed workdays among employed adults with documented painful conditions.
Collapse
Affiliation(s)
- J. Douglas Thornton
- Prescription Drug Misuse Education and Research Center, College of Pharmacy, University of Houston, Houston, Texas, USA
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, Texas, USA
| | - Tyler Varisco
- Prescription Drug Misuse Education and Research Center, College of Pharmacy, University of Houston, Houston, Texas, USA
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, Texas, USA
| | - Bhatt Prachet
- Prescription Drug Misuse Education and Research Center, College of Pharmacy, University of Houston, Houston, Texas, USA
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, Texas, USA
| | - Olajumoke Olateju
- Prescription Drug Misuse Education and Research Center, College of Pharmacy, University of Houston, Houston, Texas, USA
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, Texas, USA
| | - Mina Shrestha
- Prescription Drug Misuse Education and Research Center, College of Pharmacy, University of Houston, Houston, Texas, USA
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, Texas, USA
| | - Chan Shen
- Division of Outcomes Research and Quality, College of Medicine, Pennsylvania State University, Hershey, PA, USA
| |
Collapse
|
14
|
Wei YJ, Winterstein AG, Schmidt S, Fillingim RB, Daniels MJ, Solberg L, DeKosky ST. Pain intensity, physical function, and depressive symptoms associated with discontinuing long-term opioid therapy in older adults with Alzheimer's disease and related dementias. Alzheimers Dement 2024; 20:1026-1037. [PMID: 37855270 PMCID: PMC10916940 DOI: 10.1002/alz.13489] [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: 06/07/2023] [Revised: 07/31/2023] [Accepted: 09/02/2023] [Indexed: 10/20/2023]
Abstract
INTRODUCTION Limited evidence exists on the associations of discontinuing versus continuing long-term opioid therapy (LTOT) with pain intensity, physical function, and depression among patients with Alzheimer's disease and related dementias (ADRD). METHODS A cohort study among 138,059 older residents with mild-to-moderate ADRD and receipt of LTOT was conducted using a 100% Medicare nursing home sample. Discontinuation of LTOT was defined as no opioid refills for ≥ 60 days. Outcomes were worsening pain, physical function, and depression from baseline to quarterly assessments during 1- and 2-year follow-ups. RESULTS The adjusted odds of worsening pain and depressive symptoms were 29% and 5% lower at the 1-year follow-up and 35% and 9% lower at the 2-year follow-up for residents who discontinued versus continued LTOT, with no difference in physical function. DISCUSSION Discontinuing LTOT was associated with lower short- and long-term worsening pain and depressive symptoms than continuing LTOT among older residents with ADRD. HIGHLIGHTS Discontinuing long-term opioid therapy (LTOT) was associated with lower short- and long-term worsening pain. Discontinuing LTOT was related to lower short- and long-term worsening depression. Discontinuing LTOT was not associated with short- and long-term physical function.
Collapse
Affiliation(s)
- Yu‐Jung Jenny Wei
- Division of Outcomes and Translational SciencesCollege of PharmacyThe Ohio State UniversityColumbusOhioUSA
| | - Almut G. Winterstein
- Department of Pharmaceutical Outcomes and PolicyCollege of PharmacyUniversity of FloridaGainesvilleFloridaUSA
- Center for Drug Evaluation and SafetyUniversity of FloridaGainesvilleFloridaUSA
- Department of EpidemiologyColleges of Medicine and Public Health & Health ProfessionsUniversity of FloridaGainesvilleFloridaUSA
| | - Siegfried Schmidt
- Department of Community Health and Family MedicineCollege of MedicineUniversity of FloridaGainesvilleFloridaUSA
| | - Roger B. Fillingim
- Pain Research and Intervention Center of ExcellenceUniversity of FloridaGainesvilleFloridaUSA
| | - Michael J. Daniels
- Department of StatisticsCollege of Liberal Arts and SciencesUniversity of FloridaGainesvilleFloridaUSA
| | - Laurence Solberg
- North Florida/South Georgia Veterans Health SystemMalcom Randall Department of Veterans Affairs Medical CenterGeriatrics Research, Education, Clinical Center (GRECC)GainesvilleFloridaUSA
| | - Steven T. DeKosky
- Department of NeurologyMcKnight Brain InstituteUniversity of FloridaGainesvilleFloridaUSA
| |
Collapse
|
15
|
Javier SJ, Carey EP, Gunzburger E, Chen HYP, Zeliadt SB, Williams EC, Chen JA. Pain Care Disparities and the Use of Virtual Care Among Racial-Ethnic Minority Groups During COVID-19. J Gen Intern Med 2024; 39:68-78. [PMID: 38252245 PMCID: PMC10937888 DOI: 10.1007/s11606-023-08473-0] [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] [Received: 04/21/2023] [Accepted: 10/10/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND AND OBJECTIVE COVID-19 led to an unprecedented reliance on virtual modalities to maintain care continuity for patients living with chronic pain. We examined whether there were disparities in virtual specialty pain care for racial-ethnic minority groups during COVID-19. DESIGN AND PARTICIPANTS This was a retrospective national cohort study with two comparison groups: primary care patients with chronic pain seen immediately prior to COVID-19 (3/1/19-2/29/20) (N = 1,649,053) and a cohort of patients seen in the year prior (3/1/18-2/28-19; n = 1,536,954). MAIN MEASURES We assessed use of telehealth (telephone or video) specialty pain care, in-person care specialty pain care, and any specialty pain care for both groups at 6 months following cohort inclusion. We used quasi-Poisson regressions to test associations between patient race and ethnicity and receipt of care. KEY RESULTS Prior to COVID-19, there were Black-White (RR = 0.64, 95% CI [0.62, 0.67]) and Asian-White (RR = 0.63, 95% CI [0.54, 0.75]) disparities in telehealth use, and these lessened during COVID-19 (Black-White: RR = 0.75, 95% CI [0.73, 0.77], Asian-White: RR = 0.81, 95% CI [0.74, 0.89]) but did not disappear. Individuals identifying as American Indian/Alaska Native used telehealth less than White individuals during early COVID-19 (RR = 0.98, 95% CI [0.85, 1.13] to RR = 0.87, 95% CI [0.79, 0.96]). Hispanic/Latinx individuals were less likely than non-Hispanic/Latinx individuals to use telehealth prior to COVID-19 but more likely during early COVID-19 (RR = 0.70, 95% CI [0.66, 0.75] to RR = 1.06, 95% CI [1.02, 1.09]). Disparities in virtual pain care occurred over the backdrop of overall decreased specialty pain care during the early phase of the pandemic (raw decrease of n = 17,481 specialty care encounters overall from pre-COVID to COVID-era), including increased disparities in any VA specialty pain care for Black (RR = 0.81, 95% CI [0.80, 0.83] to RR = 0.79, 95% CI [0.77, 0.80]) and Asian (RR = 0.91, 95% CI [0.86, 0.97] to RR = 0.88, 95% CI [0.82, 0.94]) individuals. CONCLUSIONS Disparities in virtual specialty pain care were smaller during the early phases of the COVID-19 pandemic than prior to the pandemic but did not disappear entirely, despite the rapid growth in telehealth. Targeted efforts to increase access to specialty pain care need to be concentrated among racial-ethnic minority groups.
Collapse
Affiliation(s)
- Sarah J Javier
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Healthcare System, 795 Willow Road (152-MPD), Menlo Park, CA, 94025, USA.
- Stanford University School of Medicine, Stanford, CA, USA.
| | - Evan P Carey
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Denver, CO, USA
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Elise Gunzburger
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Denver, CO, USA
| | - Huang-Yuan P Chen
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Denver, CO, USA
| | - Steven B Zeliadt
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, USA
| | - Emily C Williams
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, USA
| | - Jessica A Chen
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
- Department of Psychiatry and Behavioral Science, University of Washington, Seattle, WA, USA
| |
Collapse
|
16
|
Ford MA, Lapham GT, Matson TE, Luce C, Oliver MM, Binswanger IA. Comparing Cannabis Use for Pain to Use for Other Reasons in Primary Care Patients. J Am Board Fam Med 2024; 36:996-1007. [PMID: 37907351 PMCID: PMC11124549 DOI: 10.3122/jabfm.2023.230163r1] [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] [Received: 04/27/2023] [Revised: 07/17/2023] [Accepted: 07/24/2023] [Indexed: 11/02/2023] Open
Abstract
BACKGROUND Medical cannabis is commonly used for chronic pain, but little is known about differences in characteristics, cannabis use patterns, and perceived helpfulness among primary care patients who use cannabis for pain versus nonpain reasons. METHODS Among 1688 patients who completed a 2019 cannabis survey administered in a health system in Washington state, where recreational use is legal, participants who used cannabis for pain (n = 375) were compared with those who used cannabis for other reasons (n = 558) using survey and electronic health record data. We described group differences in participant characteristics, use patterns, and perceptions and applied adjusted multinomial logistic and modified Poisson regression. RESULTS Participants who used cannabis for pain were significantly more likely to report using applied (50.7% vs 10.6%) and beverage cannabis products (19.2% vs 11.6%), more frequent use (47.1% vs 33.1% for use ≥2 times per day; 81.6% vs 69.7% for use 4 to 7 days per week), and smoking tobacco cigarettes (19.2% vs 12.2%) than those who used cannabis for other reasons. They were also significantly more likely to perceive cannabis as very/extremely helpful (80.5% vs 72.7%), and significantly less likely to use cannabis for nonmedical reasons (4.8% vs 58.8%) or report cannabis use disorder symptoms (51.7% vs 61.1%). DISCUSSION Primary care patients who use cannabis for pain use it more frequently, often in applied and ingested forms, and have more co-use of tobacco, which may differentially impact safety and effectiveness. These findings suggest the need for different approaches to counseling in clinical care.
Collapse
Affiliation(s)
- Morgan A Ford
- From the Kaiser Permanente Colorado Institute for Health Research, Aurora, CO (MAF, IAB), Kaiser Permanente Washington Health Research Institute, Seattle, WA (GTL, TEM, CL, MMO), Department of Health Systems and Population Health, University of Washington, Seattle, WA (GTL), Colorado Permanente Medical Group, Aurora, CO (IAB), Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO (IAB), Department of Health Systems Sciences, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA (IAB)
| | - Gwen T Lapham
- From the Kaiser Permanente Colorado Institute for Health Research, Aurora, CO (MAF, IAB), Kaiser Permanente Washington Health Research Institute, Seattle, WA (GTL, TEM, CL, MMO), Department of Health Systems and Population Health, University of Washington, Seattle, WA (GTL), Colorado Permanente Medical Group, Aurora, CO (IAB), Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO (IAB), Department of Health Systems Sciences, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA (IAB)
| | - Theresa E Matson
- From the Kaiser Permanente Colorado Institute for Health Research, Aurora, CO (MAF, IAB), Kaiser Permanente Washington Health Research Institute, Seattle, WA (GTL, TEM, CL, MMO), Department of Health Systems and Population Health, University of Washington, Seattle, WA (GTL), Colorado Permanente Medical Group, Aurora, CO (IAB), Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO (IAB), Department of Health Systems Sciences, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA (IAB)
| | - Casey Luce
- From the Kaiser Permanente Colorado Institute for Health Research, Aurora, CO (MAF, IAB), Kaiser Permanente Washington Health Research Institute, Seattle, WA (GTL, TEM, CL, MMO), Department of Health Systems and Population Health, University of Washington, Seattle, WA (GTL), Colorado Permanente Medical Group, Aurora, CO (IAB), Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO (IAB), Department of Health Systems Sciences, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA (IAB)
| | - Malia M Oliver
- From the Kaiser Permanente Colorado Institute for Health Research, Aurora, CO (MAF, IAB), Kaiser Permanente Washington Health Research Institute, Seattle, WA (GTL, TEM, CL, MMO), Department of Health Systems and Population Health, University of Washington, Seattle, WA (GTL), Colorado Permanente Medical Group, Aurora, CO (IAB), Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO (IAB), Department of Health Systems Sciences, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA (IAB)
| | - Ingrid A Binswanger
- From the Kaiser Permanente Colorado Institute for Health Research, Aurora, CO (MAF, IAB), Kaiser Permanente Washington Health Research Institute, Seattle, WA (GTL, TEM, CL, MMO), Department of Health Systems and Population Health, University of Washington, Seattle, WA (GTL), Colorado Permanente Medical Group, Aurora, CO (IAB), Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO (IAB), Department of Health Systems Sciences, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA (IAB)
| |
Collapse
|
17
|
Koo H, Jeong KH, Jeon N, Jung SY. Factors associated with the use of traditional doses of amitriptyline for chronic pain management: A cross-sectional study. Medicine (Baltimore) 2024; 103:e36790. [PMID: 38181253 PMCID: PMC10766233 DOI: 10.1097/md.0000000000036790] [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: 03/08/2023] [Accepted: 12/05/2023] [Indexed: 01/07/2024] Open
Abstract
There are studies on the effect of low-dose amitriptyline on pain control, but there is a lack of studies on the use of amitriptyline for chronic pain and the factors associated with the prescription of traditional doses. We used a national sample cohort of patients aged ≥ 18 years who were prescribed amitriptyline along with chronic pain, without psychiatric disorders, between 2002 to 2015. We categorized the prescriptions into 2 groups according to the daily dose: low doses (≤25 mg) and traditional doses (>25 mg). Multivariable logistic regression models were used to identify factors associated with traditional dose prescriptions. Among 177,769 prescriptions for amitriptyline, 15,119 (8.5%) were prescribed for chronic pain. The prevalence of prescriptions and proportion of traditional doses of amitriptyline tended to decrease during the study period. Male sex (odds ratio [OR] 1.09, 95% confidence interval [CI] 1.05-1.13); age 65-80 years (OR 1.12, 95% CI 1.08-1.16), especially ≥ 80 years (OR 1.55, 95% CI 1.45-1.65); headaches (OR 1.18, 95% CI 1.10-1.27), receiving medical aids (OR 2.58, 95% CI 2.46-2.71); and being prescribed benzodiazepines or zolpidem concomitantly (OR 1.10, 95% CI 1.06-1.15) were significantly associated with traditional dose prescriptions of amitriptyline. Although traditional dose prescriptions of amitriptyline have been declining, close monitoring is still required in the presence of the above-mentioned factors.
Collapse
Affiliation(s)
- Hyunji Koo
- College of Pharmacy, Chung-Ang University, Seoul, Korea
| | | | - Nakyung Jeon
- College of Pharmacy, Pusan National University, Pusan, Korea
| | - Sun-Young Jung
- College of Pharmacy, Chung-Ang University, Seoul, Korea
- Department of Global Innovative Drugs, Graduate School of Chung-Ang University, Chung-Ang University, Seoul, Korea
| |
Collapse
|
18
|
Bokhour BG, DeFaccio R, Gaj L, Barker A, Deeney C, Coggeshall S, Gelman H, Taylor SL, Thomas E, Zeliadt SB. Changes in Patient-Reported Outcomes Associated with Receiving Whole Health in the Veteran Health Administration (VHA)'s National Demonstration Project. J Gen Intern Med 2024; 39:84-94. [PMID: 37653207 PMCID: PMC10817883 DOI: 10.1007/s11606-023-08376-0] [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] [Received: 04/25/2023] [Accepted: 08/10/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Whole Health (WH) is a patient-centered model of care being implemented by the Veterans Health Administration. Little is known about how use of WH services impacts patients' health and well-being. OBJECTIVE We sought to assess the association of WH utilization with pain and other patient-reported outcomes (PRO) over 6 months. DESIGN A longitudinal observational cohort evaluation, comparing changes in PRO surveys for WH users and Conventional Care (CC) users. Inverse probability of treatment weighting was used to balance the two groups on observed demographic and clinical characteristics. PARTICIPANTS A total of 9689 veterans receiving outpatient care at 18 VA medical centers piloting WH. INTERVENTIONS WH services included goal-setting clinical encounters, Whole Health coaching, personal health planning, and well-being services. MAIN OUTCOME MEASURES The primary outcome was change in pain intensity and interference at 6 months using the 3-item PEG. Secondary outcomes included satisfaction, experiences of care, patient engagement in healthcare, and well-being. KEY RESULTS By 6 months,1053 veterans had utilized WH and 3139 utilized only CC. Baseline pain PEG scores were 6.2 (2.5) for WH users and 6.4 (2.3) for CC users (difference p = 0.028), improving by - 2.4% (p = 0.006) and - 2.3% (p < 0.001), respectively. In adjusted analyses, WH use was unassociated with greater improvement in PEG scores compared to CC - 1.0% (- 2.9%, 1.2%). Positive trends were observed for 8 of 15 exploratory outcomes for WH compared to CC. WH use was associated with greater improvements at 6 months in likelihood to recommend VA 2.0% (0.9%, 3.3%); discussions of goals 11.8% (8.2%, 15.5%); perceptions of healthcare interactions 2.5% (0.4%, 4.6%); and engagement in health behaviors 2.2% (0.3%, 3.9%). CONCLUSION This study provides early evidence supporting the delivery of WH patient-centered care services to improve veterans' experiences of and engagement in care. These are important first-line impacts towards the goals of better overall health and well-being outcomes for Veterans.
Collapse
Affiliation(s)
- Barbara G Bokhour
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA.
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, USA.
| | - Rian DeFaccio
- VA Center of Innovation (COIN) for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, Seattle, WA, USA
| | - Lauren Gaj
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Anna Barker
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Christine Deeney
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Scott Coggeshall
- VA Center of Innovation (COIN) for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, Seattle, WA, USA
| | - Hannah Gelman
- VA Center of Innovation (COIN) for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, Seattle, WA, USA
| | - Stephanie L Taylor
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Medicine, Department of Health Policy and Management, UCLA, Los Angeles, CA, USA
| | - Eva Thomas
- VA Center of Innovation (COIN) for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, Seattle, WA, USA
| | - Steven B Zeliadt
- VA Center of Innovation (COIN) for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, Seattle, WA, USA
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, USA
| |
Collapse
|
19
|
Perry A, Wheeler-Martin K, Terlizzi K, Krawczyk N, Jent V, Hasin DS, Neighbors C, Mannes ZL, Doan LV, Pamplin II JR, Townsend TN, Crystal S, Martins SS, Cerdá M. Evaluating chronic pain as a risk factor for COVID-19 complications among New York State Medicaid beneficiaries: a retrospective claims analysis. PAIN MEDICINE (MALDEN, MASS.) 2023; 24:1296-1305. [PMID: 37651585 PMCID: PMC10690846 DOI: 10.1093/pm/pnad121] [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: 03/01/2023] [Revised: 08/10/2023] [Accepted: 08/28/2023] [Indexed: 09/02/2023]
Abstract
OBJECTIVE To assess whether chronic pain increases the risk of COVID-19 complications and whether opioid use disorder (OUD) differentiates this risk among New York State Medicaid beneficiaries. DESIGN, SETTING, AND SUBJECTS This was a retrospective cohort study of New York State Medicaid claims data. We evaluated Medicaid claims from March 2019 through December 2020 to determine whether chronic pain increased the risk of COVID-19 emergency department (ED) visits, hospitalizations, and complications and whether this relationship differed by OUD status. We included beneficiaries 18-64 years of age with 10 months of prior enrollment. Patients with chronic pain were propensity score-matched to those without chronic pain on demographics, utilization, and comorbidities to control for confounders and were stratified by OUD. Complementary log-log regressions estimated hazard ratios (HRs) of COVID-19 ED visits and hospitalizations; logistic regressions estimated odds ratios (ORs) of hospital complications and readmissions within 0-30, 31-60, and 61-90 days. RESULTS Among 773 880 adults, chronic pain was associated with greater hazards of COVID-related ED visits (HR = 1.22 [95% CI: 1.16-1.29]) and hospitalizations (HR = 1.19 [95% CI: 1.12-1.27]). Patients with chronic pain and OUD had even greater hazards of hospitalization (HR = 1.25 [95% CI: 1.07-1.47]) and increased odds of hepatic- and cardiac-related events (OR = 1.74 [95% CI: 1.10-2.74]). CONCLUSIONS Chronic pain increased the risk of COVID-19 ED visits and hospitalizations. Presence of OUD further increased the risk of COVID-19 hospitalizations and the odds of hepatic- and cardiac-related events. Results highlight intersecting risks among a vulnerable population and can inform tailored COVID-19 management.
Collapse
Affiliation(s)
- Allison Perry
- Center for Opioid Epidemiology and Policy, Department of Population Health, NYU Grossman School of Medicine, New York, NY 10016, United States
| | - Katherine Wheeler-Martin
- Center for Opioid Epidemiology and Policy, Department of Population Health, NYU Grossman School of Medicine, New York, NY 10016, United States
| | - Kelly Terlizzi
- Department of Population Health, NYU Grossman School of Medicine, New York, NY 10016, United States
| | - Noa Krawczyk
- Center for Opioid Epidemiology and Policy, Department of Population Health, NYU Grossman School of Medicine, New York, NY 10016, United States
| | - Victoria Jent
- Center for Opioid Epidemiology and Policy, Department of Population Health, NYU Grossman School of Medicine, New York, NY 10016, United States
| | - Deborah S Hasin
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY 10032, United States
| | - Charles Neighbors
- Department of Population Health, NYU Grossman School of Medicine, New York, NY 10016, United States
| | - Zachary L Mannes
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY 10032, United States
| | - Lisa V Doan
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Grossman School of Medicine, New York, NY 10016, United States
| | - John R Pamplin II
- Center for Opioid Epidemiology and Policy, Department of Population Health, NYU Grossman School of Medicine, New York, NY 10016, United States
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY 10032, United States
| | - Tarlise N Townsend
- Center for Opioid Epidemiology and Policy, Department of Population Health, NYU Grossman School of Medicine, New York, NY 10016, United States
| | - Stephen Crystal
- Center for Health Services Research, Rutgers Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, NJ 08901, United States
| | - Silvia S Martins
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY 10032, United States
| | - Magdalena Cerdá
- Center for Opioid Epidemiology and Policy, Department of Population Health, NYU Grossman School of Medicine, New York, NY 10016, United States
| |
Collapse
|
20
|
Perry A, Wheeler-Martin K, Hasin DS, Terlizzi K, Mannes ZL, Jent V, Townsend TN, Pamplin JR, Crystal S, Martins SS, Cerdá M, Krawczyk N. Utilization and disparities in medication treatment for opioid use disorder among patients with comorbid opioid use disorder and chronic pain during the COVID-19 pandemic. Drug Alcohol Depend 2023; 253:111023. [PMID: 37984034 PMCID: PMC10841620 DOI: 10.1016/j.drugalcdep.2023.111023] [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] [Received: 04/06/2023] [Revised: 10/10/2023] [Accepted: 10/31/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND The COVID-19 pandemic's impact on utilization of medications for opioid use disorder (MOUD) among patients with opioid use disorder (OUD) and chronic pain is unclear. METHODS We analyzed New York State (NYS) Medicaid claims from pre-pandemic (August 2019-February 2020) and pandemic (March 2020-December 2020) periods for beneficiaries with and without chronic pain. We calculated monthly proportions of patients with OUD diagnoses in 6-month-lookback windows utilizing MOUD and proportions of treatment-naïve patients initiating MOUD. We used interrupted time series to assess changes in MOUD utilization and initiation rates by medication type and by race/ethnicity. RESULTS Among 20,785 patients with OUD and chronic pain, 49.3% utilized MOUD (versus 60.3% without chronic pain). The pandemic did not affect utilization in either group but briefly disrupted initiation among patients with chronic pain (β=-0.009; 95% CI [-0.015, -0.002]). Overall MOUD utilization was not affected by the pandemic for any race/ethnicity but opioid treatment program (OTP) utilization was briefly disrupted for non-Hispanic Black individuals (β=-0.007 [-0.013, -0.001]). The pandemic disrupted overall MOUD initiation in non-Hispanic Black (β=-0.007 [-0.012, -0.002]) and Hispanic individuals (β=-0.010 [-0.019, -0.001]). CONCLUSIONS Adults with chronic pain who were enrolled in NYS Medicaid before the COVID-19 pandemic had lower MOUD utilization than those without chronic pain. MOUD initiation was briefly disrupted, with disparities especially in racial/ethnic minority groups. Flexible MOUD policy initiatives may have maintained overall treatment utilization, but disparities in initiation and care continuity remain for patients with chronic pain, and particularly for racial/ethnic minoritized subgroups.
Collapse
Affiliation(s)
- Allison Perry
- Center for Opioid Epidemiology and Policy, Department of Population Health, NYU Grossman School of Medicine, New York, NY, United States.
| | - Katherine Wheeler-Martin
- Center for Opioid Epidemiology and Policy, Department of Population Health, NYU Grossman School of Medicine, New York, NY, United States
| | - Deborah S Hasin
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, United States
| | - Kelly Terlizzi
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, United States
| | - Zachary L Mannes
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, United States
| | - Victoria Jent
- Center for Opioid Epidemiology and Policy, Department of Population Health, NYU Grossman School of Medicine, New York, NY, United States
| | - Tarlise N Townsend
- Center for Opioid Epidemiology and Policy, Department of Population Health, NYU Grossman School of Medicine, New York, NY, United States
| | - John R Pamplin
- Center for Opioid Epidemiology and Policy, Department of Population Health, NYU Grossman School of Medicine, New York, NY, United States; Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, United States
| | - Stephen Crystal
- Rutgers Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, NJ, United States
| | - Silvia S Martins
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, United States
| | - Magdalena Cerdá
- Center for Opioid Epidemiology and Policy, Department of Population Health, NYU Grossman School of Medicine, New York, NY, United States
| | - Noa Krawczyk
- Center for Opioid Epidemiology and Policy, Department of Population Health, NYU Grossman School of Medicine, New York, NY, United States
| |
Collapse
|
21
|
Mannes ZL, Wheeler-Martin K, Terlizzi K, Hasin DS, Perry A, Pamplin JR, Crystal S, Cerdá M, Martins SS. Risks of opioid overdose among New York State Medicaid recipients with chronic pain before and during the COVID-19 pandemic. Prev Med 2023; 177:107789. [PMID: 38016582 PMCID: PMC10842754 DOI: 10.1016/j.ypmed.2023.107789] [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] [Received: 08/01/2023] [Revised: 10/27/2023] [Accepted: 11/22/2023] [Indexed: 11/30/2023]
Abstract
OBJECTIVE The COVID-19 pandemic contributed to healthcare disruptions for patients with chronic pain. Following initial disruptions, national policies were enacted to expand access to long-term opioid therapy (LTOT) for chronic pain and opioid use disorder (OUD) treatment services, which may have modified risk of opioid overdose. We examined associations between LTOT and/or OUD with fatal and non-fatal opioid overdoses, and whether the pandemic moderated overdose risk in these groups. METHODS We analyzed New York State Medicaid claims data (3/1/2019-12/31/20) of patients with chronic pain (N = 236,391). We used generalized estimating equations models to assess associations between LTOT and/or OUD (neither LTOT or OUD [ref], LTOT only, OUD only, and LTOT and OUD) and the pandemic (03/2020-12/2020) with opioid overdose. RESULTS The pandemic did not significantly (ns) affect opioid overdose among patients with LTOT and/or OUD. While patients with LTOT (vs. no LTOT) had a slight increase in opioid overdose during the pandemic (pre-pandemic: aOR:1.65, 95% CI:1.05, 2.57; pandemic: aOR:2.43, CI:1.75,3.37, ns), patients with OUD had a slightly attenuated odds of overdose during the pandemic (pre-pandemic: aOR:5.65, CI:4.73, 6.75; pandemic: aOR:5.16, CI:4.33, 6.14, ns). Patients with both LTOT and OUD also experienced a slightly reduced odds of opioid overdose during the pandemic (pre-pandemic: aOR:5.82, CI:3.58, 9.44; pandemic: aOR:3.70, CI:2.11, 6.50, ns). CONCLUSIONS Findings demonstrated no significant effect of the pandemic on opioid overdose among people with chronic pain and LTOT and/or OUD, suggesting pandemic policies expanding access to chronic pain and OUD treatment services may have mitigated the risk of opioid overdose.
Collapse
Affiliation(s)
- Zachary L Mannes
- Department of Emergency Medicine, Columbia University Irving Medical Center, 630 West 168th Street, New York, NY 10032, USA; Department of Epidemiology, Columbia University Mailman School of Public Health, 722 West 168th St., New York, NY 10032, USA
| | - Katherine Wheeler-Martin
- Center for Opioid Epidemiology and Policy, Division of Epidemiology, Department of Population Health, New York University Grossman School of Medicine, 180 Madison Avenue, New York, NY 10016, USA
| | - Kelly Terlizzi
- Department of Population Health, NYU Grossman School of Medicine, 550 1st Ave., New York, NY 10016, USA
| | - Deborah S Hasin
- Department of Epidemiology, Columbia University Mailman School of Public Health, 722 West 168th St., New York, NY 10032, USA; Department of Psychiatry, Columbia University Irving Medical Center, 1051 Riverside Dr, New York, NY 10032, USA; New York State Psychiatric Institute, 1051 Riverside Dr, New York, NY 10032, USA
| | - Allison Perry
- Center for Opioid Epidemiology and Policy, Division of Epidemiology, Department of Population Health, New York University Grossman School of Medicine, 180 Madison Avenue, New York, NY 10016, USA
| | - John R Pamplin
- Department of Epidemiology, Columbia University Mailman School of Public Health, 722 West 168th St., New York, NY 10032, USA
| | - Stephen Crystal
- Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy, and Aging Research, Rutgers University, 112 Paterson Street, New Brunswick, NJ 08901, USA; Department of Health Behavior, Society and Policy, School of Public Health, Rutgers University, 683 Hoes Ln W, Piscataway, NJ 08854, USA; School of Social Work, Rutgers University, 120 Albany St, New Brunswick, NJ 08901, USA
| | - Magdalena Cerdá
- Center for Opioid Epidemiology and Policy, Division of Epidemiology, Department of Population Health, New York University Grossman School of Medicine, 180 Madison Avenue, New York, NY 10016, USA
| | - Silvia S Martins
- Department of Epidemiology, Columbia University Mailman School of Public Health, 722 West 168th St., New York, NY 10032, USA.
| |
Collapse
|
22
|
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.
Collapse
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
| |
Collapse
|
23
|
Turner AP, Arewasikporn A, Hawkins EJ, Suri P, Burns SP, Leipertz SL, Haselkorn JK. Risk Factors for Chronic Prescription Opioid Use in Multiple Sclerosis. Arch Phys Med Rehabil 2023; 104:1850-1856. [PMID: 37137460 DOI: 10.1016/j.apmr.2023.04.012] [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: 06/13/2022] [Revised: 01/31/2023] [Accepted: 04/10/2023] [Indexed: 05/05/2023]
Abstract
OBJECTIVE To characterize patterns of prescription opioid use among individuals with multiple sclerosis (MS) and identify risk factors associated with chronic use. DESIGN Retrospective longitudinal cohort study examining US Department of Veterans Affairs electronic medical record data of Veterans with MS. The annual prevalence of prescription opioid use by type (any, acute, chronic, incident chronic) was calculated for each study year (2015-2017). Multivariable logistic regression was used to identify demographics and medical, mental health, and substance use comorbidities in 2015-2016 associated with chronic prescription opioid use in 2017. SETTING US Department of Veterans Affairs, Veteran's Health Administration. PARTICIPANTS National sample of Veterans with MS (N=14,974). MAIN OUTCOME MEASURE Chronic prescription opioid use (≥90 days). RESULTS All types of prescription opioid use declined across the 3 study years (chronic opioid use prevalence=14.6%, 14.0%, and 12.2%, respectively). In multivariable logistic regression, prior chronic opioid use, history of pain condition, paraplegia or hemiplegia, post-traumatic stress disorder, and rural residence were associated with greater risk of chronic prescription opioid use. History of dementia and psychotic disorder were both associated with lower risk of chronic prescription opioid use. CONCLUSION Despite reductions over time, chronic prescription opioid use remains common among a substantial minority of Veterans with MS and is associated with multiple biopsychosocial factors that are important for understanding risk for long-term use.
Collapse
Affiliation(s)
- Aaron P Turner
- VA Puget Sound Health Care System, Seattle, WA; VA MS Center of Excellence West, Seattle, WA; Center of Excellence in Substance Addiction Treatment and Education, Seattle, WA; Department of Rehabilitation Medicine, University of Washington, Seattle, WA.
| | | | - Eric J Hawkins
- VA Puget Sound Health Care System, Seattle, WA; Center of Excellence in Substance Addiction Treatment and Education, Seattle, WA; Health Services Research & Development (HSR&D), Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA; Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA
| | - Pradeep Suri
- VA Puget Sound Health Care System, Seattle, WA; Department of Rehabilitation Medicine, University of Washington, Seattle, WA; Clinical Learning, Evidence, and Research Center (CLEAR), University of Washington, Seattle, WA
| | - Stephen P Burns
- VA Puget Sound Health Care System, Seattle, WA; Department of Rehabilitation Medicine, University of Washington, Seattle, WA
| | - Steve L Leipertz
- VA Puget Sound Health Care System, Seattle, WA; VA MS Center of Excellence West, Seattle, WA
| | - Jodie K Haselkorn
- VA Puget Sound Health Care System, Seattle, WA; VA MS Center of Excellence West, Seattle, WA; Department of Rehabilitation Medicine, University of Washington, Seattle, WA
| |
Collapse
|
24
|
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.
Collapse
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
| |
Collapse
|
25
|
Livne O, Mannes ZL, McDowell YE, Shmulewitz D, Malte CA, Saxon AJ, Hasin DS. Mental and Physical Health Conditions Among U.S. Veterans with Cannabis Use and Cannabis Use Disorders. CURRENT ADDICTION REPORTS 2023; 10:441-457. [PMID: 38149223 PMCID: PMC10751043 DOI: 10.1007/s40429-023-00490-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2023] [Indexed: 12/28/2023]
Abstract
Purpose of Review Veterans are a large population that is disproportionately affected by various physical and mental health conditions. The primary aim of this review is to provide a concise overview of recent literature on the prevalence of cannabis use and cannabis use disorder (CUD) among US Veterans, and associations with mental and physical health conditions. We also addressed gaps in the literature by investigating associations between CUD and mental and physical health conditions in 2019 data from the Veterans Health Administration (VHA; N=5,657,277). Recent Findings In total, 25 studies were reviewed. In 2019, the prevalence of Veteran cannabis use ranged from 11.9%-18.7%. Cannabis use and CUD were associated with bipolar disorders, psychotic disorders, suicidality, pain conditions, and other substance use, but less consistently associated with depressive disorders, anxiety disorders, and posttraumatic stress disorder. Analyses of 2019 VHA data indicated that CUD was strongly associated with a broad array of physical and mental health conditions and mortality. Summary Cannabis use and CUD are prevalent and highly comorbid with other conditions among US Veterans. Harm reduction methods tailored to these populations are needed.
Collapse
Affiliation(s)
- Ofir Livne
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA
- New York State Psychiatric Institute, New York, NY, USA
| | - Zachary L. Mannes
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA
- New York State Psychiatric Institute, New York, NY, USA
| | - Yoanna E. McDowell
- Health Services Research & Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) 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
| | - Dvora Shmulewitz
- New York State Psychiatric Institute, New York, NY, USA
- Department of Psychiatry, Columbia University Irving Medical Center, New York, NY, USA
| | - Carol A. Malte
- Health Services Research & Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) 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
| | - Andrew J. Saxon
- Health Services Research & Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) 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
- Department of Psychiatry & Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
| | - Deborah S. Hasin
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA
- New York State Psychiatric Institute, New York, NY, USA
- Department of Psychiatry, Columbia University Irving Medical Center, New York, NY, USA
| |
Collapse
|
26
|
Pratt AA, Hadlandsmyth K, Mengeling MA, Thomas EBK, Miell K, Norman SB, Lund BC. The Impact of Comorbid Chronic Pain on Pharmacotherapy for Veterans with Post-Traumatic Stress Disorder. J Clin Med 2023; 12:4763. [PMID: 37510878 PMCID: PMC10380889 DOI: 10.3390/jcm12144763] [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: 04/18/2023] [Revised: 06/22/2023] [Accepted: 07/13/2023] [Indexed: 07/30/2023] Open
Abstract
OBJECTIVE Chronic pain can worsen PTSD symptomatology and may increase the risk of the prescription of multiple central nervous system (CNS)-active medications. The objective is to determine the impact of chronic pain on the number of CNS medications, including psychiatric medications, as well as the amount of medication changes. METHODS Veterans Affairs (VA) administrative data were used to identify VA-served Veterans with PTSD (N = 637,428) who had chronic pain (50.3%) and did not have chronic pain (49.7%) in 2020. The outcomes included the number of changes in psychiatric medications and the number of currently prescribed CNS-active mediations during a one-year observation period. RESULTS The number of changes in psychiatric medications was significantly higher for those with chronic pain (mean (M) = 1.8) versus those without chronic pain (M = 1.6) (Z = 38.4, p < 0.001). The mean number of concurrent CNS-active medications were significantly higher for those with chronic pain (M = 2.7) versus those without chronic pain (M = 2.0) (Z = 179.7, p < 0.001). These differences persisted after adjustment for confounding factors using negative binomial regression. CONCLUSIONS Veterans with comorbid chronic pain and PTSD are at increased risk for a higher number of medication changes and for receiving CNS-active polytherapy.
Collapse
Affiliation(s)
- Alessandra A Pratt
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, 601 Highway 6 West, Building 42, Iowa City, IA 52246, USA
| | - Katherine Hadlandsmyth
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, 601 Highway 6 West, Building 42, Iowa City, IA 52246, USA
- VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Iowa City (VRHRC-IC), Iowa City VA Health Care System, 601 Highway 6 West, Iowa City, IA 52246, USA
- Department of Anesthesia, University of Iowa Carver College of Medicine, 200 Hawkins Drive, Iowa City, IA 52242, USA
| | - Michelle A Mengeling
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, 601 Highway 6 West, Building 42, Iowa City, IA 52246, USA
- VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Iowa City (VRHRC-IC), Iowa City VA Health Care System, 601 Highway 6 West, Iowa City, IA 52246, USA
- Department of Internal Medicine, University of Iowa Carver College of Medicine, 200 Hawkins Drive, Iowa City, IA 52242, USA
| | - Emily B K Thomas
- VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Iowa City (VRHRC-IC), Iowa City VA Health Care System, 601 Highway 6 West, Iowa City, IA 52246, USA
- Department of Psychological and Brain Sciences, University of Iowa College of Liberal Arts and Sciences, 340 Iowa Ave, Iowa City, IA 52246, USA
| | - Kelly Miell
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, 601 Highway 6 West, Building 42, Iowa City, IA 52246, USA
| | - Sonya B Norman
- National Center for PTSD, 215 North Main Street, White River Junction, VT 05009, USA
- Department of Psychiatry, University of California San Diego School of Medicine, 9500 Gilman Drive, La Jolla, CA 92093, USA
| | - Brian C Lund
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, 601 Highway 6 West, Building 42, Iowa City, IA 52246, USA
- VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Iowa City (VRHRC-IC), Iowa City VA Health Care System, 601 Highway 6 West, Iowa City, IA 52246, USA
- Department of Biostatistics, University of Iowa College of Public Health, 145 N Riverside Drive, Iowa City, IA 52242, USA
| |
Collapse
|
27
|
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.
Collapse
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
| |
Collapse
|
28
|
Mayhew M, Balderson BH, Cook AJ, Dickerson JF, Elder CR, Firemark AJ, Haller IV, Justice M, Keefe FJ, McMullen CK, O'Keeffe-Rosetti MC, Owen-Smith AA, Rini C, Schneider JL, Von Korff M, Wandner LD, DeBar LL. Comparing the clinical and cost-effectiveness of remote (telehealth and online) cognitive behavioral therapy-based treatments for high-impact chronic pain relative to usual care: study protocol for the RESOLVE multisite randomized control trial. Trials 2023; 24:196. [PMID: 36927459 PMCID: PMC10018633 DOI: 10.1186/s13063-023-07165-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 02/13/2023] [Indexed: 03/18/2023] Open
Abstract
BACKGROUND Cognitive behavioral therapy for chronic pain (CBT-CP) is an effective but underused treatment for high-impact chronic pain. Increased access to CBT-CP services for pain is of critical public health importance, particularly for rural and medically underserved populations who have limited access due to these services being concentrated in urban and high income areas. Making CBT-CP widely available and more affordable could reduce barriers to CBT-CP use. METHODS As part of the National Institutes of Health Helping to End Addiction Long-term® (NIH HEAL) initiative, we designed and implemented a comparative effectiveness, 3-arm randomized control trial comparing remotely delivered telephonic/video and online CBT-CP-based services to usual care for patients with high-impact chronic pain. The RESOLVE trial is being conducted in 4 large integrated healthcare systems located in Minnesota, Georgia, Oregon, and Washington state and includes demographically diverse populations residing in urban and rural areas. The trial compares (1) an 8-session, one-on-one, professionally delivered telephonic/video CBT-CP program; and (2) a previously developed and tested 8-session online CBT-CP-based program (painTRAINER) to (3) usual care augmented by a written guide for chronic pain management. Participants are followed for 1 year post-allocation and are assessed at baseline, and 3, 6, and 12 months post-allocation. The primary outcome is minimal clinically important difference (MCID; ≥ 30% reduction) in pain severity (composite of pain intensity and pain-related interference) assessed by a modified 11-item version of the Brief Pain Inventory-Short Form at 3 months. Secondary outcomes include pain severity, pain intensity, and pain-related interference scores, quality of life measures, and patient global impression of change at 3, 6, and 12 months. Cost-effectiveness is assessed by incremental cost per additional patient with MCID in primary outcome and by cost per quality-adjusted life year achieved. Outcome assessment is blinded to group assignment. DISCUSSION This large-scale trial provides a unique opportunity to rigorously evaluate and compare the clinical and cost-effectiveness of 2 relatively low-cost and scalable modalities for providing CBT-CP-based treatments to persons with high-impact chronic pain, including those residing in rural and other medically underserved areas with limited access to these services. TRIAL REGISTRATION ClinicalTrials.gov NCT04523714. This trial was registered on 24 August 2020.
Collapse
Affiliation(s)
- Meghan Mayhew
- Kaiser Permanente Center for Health Research, Portland, USA.
| | | | - Andrea J Cook
- Kaiser Permanente Washington Health Research Institute, Seattle, USA
| | | | | | | | | | - Morgan Justice
- Kaiser Permanente Washington Health Research Institute, Seattle, USA
| | - Francis J Keefe
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, USA
| | | | | | - Ashli A Owen-Smith
- Georgia State University and Center for Health Research and Evaluation Kaiser Permanente Georgia, Atlanta, USA
| | - Christine Rini
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine and Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, USA
| | | | - Michael Von Korff
- Kaiser Permanente Washington Health Research Institute, Seattle, USA
| | - Laura D Wandner
- National Institute of Neurological Disorders and Stroke, Bethesda, USA
| | - Lynn L DeBar
- Kaiser Permanente Center for Health Research, Portland, USA
| |
Collapse
|
29
|
Hadlandsmyth K, Driscoll MA, Mares JG, Au V, Miell KR, Lund BC. Rurality impacts pain care for female veterans similarly to male veterans. J Rural Health 2023; 39:313-319. [PMID: 35170073 DOI: 10.1111/jrh.12646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
PURPOSE Rural disparities exist in access to multidisciplinary pain care with higher rates of opioid prescribing in rural regions. Among Veterans, who have prevalent rates of chronic pain, women often evidence complex presentations, multiple comorbidities, and dissatisfaction with care. This study investigates the impact of rurality on pain care for women specifically, and whether this varies from the impact of rurality for men. METHODS A cohort of Veterans with chronic pain in 2018 was built utilizing VA administrative data. Variables of interest included: demographic, comorbidities, medications, and health care utilization for chronic pain. FINDINGS The cohort included 2,261,030 Veterans; 11% (n = 248,977) were women. Significantly fewer women (7%) compared to men (10.7%) received long-term opioids (adjusted OR = 0.77, 95% CI: 0.75-0.78). Men, relative to women, were also more likely to receive gabapentinoids and nonsteroidal ant-inflammatory drugs, whereas women, relative to men, were more likely to receive muscle relaxants and duloxetine. Women were more likely to receive most psychiatric medications. Rural women received more primary care visits compared to urban women (adjusted OR = 1.19, 95% CI: 1.15-1.22), but fewer women's clinic visits (a subset of primary care visits: adjusted OR = 0.69, 95% CI:0.67-0.71) and fewer pain specialty care visits (physical therapy, pain clinic, and mental health visits with pain codes). Rural effects did not vary substantially between women and men. CONCLUSIONS Rural-dwelling Veterans received more pain and psychiatric medications compared to urban Veterans and fewer specialty care visits. Rural Veterans may benefit from increased access to specialty chronic pain care.
Collapse
Affiliation(s)
- Katherine Hadlandsmyth
- Office of Rural Health, Veterans Rural Health Resource Center, Iowa City VA Health Care System, Iowa City, Iowa, USA
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa, USA
- Department of Anesthesia, University of Iowa, Carver College of Medicine, Iowa City, Iowa, USA
| | - Mary A Driscoll
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jasmine G Mares
- Department of Anesthesia, University of Iowa, Carver College of Medicine, Iowa City, Iowa, USA
| | - Vanessa Au
- Office of Rural Health, Veterans Rural Health Resource Center, Iowa City VA Health Care System, Iowa City, Iowa, USA
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa, USA
| | - Kelly Richardson Miell
- Office of Rural Health, Veterans Rural Health Resource Center, Iowa City VA Health Care System, Iowa City, Iowa, USA
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa, USA
| | - Brian C Lund
- Office of Rural Health, Veterans Rural Health Resource Center, Iowa City VA Health Care System, Iowa City, Iowa, USA
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa, USA
| |
Collapse
|
30
|
Hendricks MA, El Ibrahimi S, Ritter GA, Flores D, Fischer MA, Weiss RD, Wright DA, Weiner SG. Association of Household Opioid Availability With Opioid Overdose. JAMA Netw Open 2023; 6:e233385. [PMID: 36930154 PMCID: PMC10024199 DOI: 10.1001/jamanetworkopen.2023.3385] [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: 03/18/2023] Open
Abstract
IMPORTANCE Previous studies that examined the role of household opioid prescriptions in opioid overdose risk were limited to commercial claims, did not include fatal overdoses, and had limited inclusion of household prescription characteristics. Broader research is needed to expand understanding of the risk of overdose. OBJECTIVE To assess the role of household opioid availability and other household prescription factors associated with individuals' odds of fatal or nonfatal opioid overdose. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study assessing patient outcomes from January 1, 2015, through December 31, 2018, was conducted on adults in the Oregon Comprehensive Opioid Risk Registry database in households of at least 2 members. Data analysis was performed between October 16, 2020, and January 26, 2023. EXPOSURES Household opioid prescription availability and household prescription characteristics. MAIN OUTCOMES AND MEASURES Opioid overdoses were captured from insurance claims, death records, and hospital discharge data. Household opioid prescription availability and prescription characteristics for individuals and households were modeled as 6-month cumulative time-dependent measures, updated monthly. To assess the association between household prescription availability, household prescription characteristics, and overdose, multilevel logistic regression models were developed, adjusting for demographic, clinical, household, and prescription characteristics. RESULTS The sample included 1 691 856 individuals in 1 187 140 households, of which most were women (53.2%), White race (70.7%), living in metropolitan areas (75.8%), and having commercial insurance (51.8%), no Elixhauser comorbidities (69.5%), and no opioid prescription fills in the study period (57.0%). A total of 28 747 opioid overdose events were observed during the study period (0.0526 per 100 person-months). Relative to individuals without personal or household opioid fills, the odds of opioid-related overdose increased by 60% when another household member had an opioid fill in the past 6 months (adjusted odds ratio [aOR], 1.60; 95% CI, 1.54-1.66) and were highest when both the individual and another household member had opioid fills in the preceding 6 months (aOR, 6.25; 95% CI, 6.09-6.40). CONCLUSIONS AND RELEVANCE In this cohort study of adult Oregon residents in households of at least 2 members, the findings suggest that household prescription availability is associated with increased odds of opioid overdose for others in the household, even if they do not have their own opioid prescription. These findings underscore the importance of educating patients about proper opioid disposal and the risks of household opioids.
Collapse
Affiliation(s)
| | - Sanae El Ibrahimi
- Division of Research and Evaluation, Comagine Health, Portland, Oregon
- School of Public Health, Department of Epidemiology and Biostatistics, University of Nevada, Las Vegas
| | - Grant A. Ritter
- Schneider Institutes for Health Policy, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts
| | - Diana Flores
- Division of Research and Evaluation, Comagine Health, Portland, Oregon
| | - Michael A. Fischer
- Section of General Internal Medicine, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Roger D. Weiss
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
- Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont, Massachusetts
| | - Dagan A. Wright
- Injury and Violence Prevention Program–Public Health Division–Oregon Health Authority, Portland
| | - Scott G. Weiner
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| |
Collapse
|
31
|
Thapa I, De Souza E, Ward A, Bambos N, Anderson TA. Association of Common Pediatric Surgeries With New Onset Chronic Pain in Patients 0-21 Years of Age in the United States. THE JOURNAL OF PAIN 2023; 24:320-331. [PMID: 36216129 DOI: 10.1016/j.jpain.2022.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 08/24/2022] [Accepted: 09/13/2022] [Indexed: 11/07/2022]
Abstract
Chronic pain (CP) is a major public health issue. While new onset CP is known to occur frequently after some pediatric surgeries, its incidence after the most common pediatric surgeries is unknown. This retrospective cohort study used insurance claims data from 2002 to 2017 for patients 0 to 21 years of age. The primary outcome was CP 90 to 365 days after each of the 20 most frequent surgeries in 5 age categories (identified using CP ICD codes). Multivariable logistic regression identified surgeries and risk factors associated with CP after surgery. A total of 424,590 surgical patients aged 0 to 21 were included, 22,361 of whom developed CP in the 90 to 365 days after surgery. The incidences of CP after surgery were: 1.1% in age group 0 to 1 years; 3.0% in 2 to 5 years; 5.6% in 6 to 11 years; 10.1% in 12 to 18 years; 9.9% in 19 to 21 years. Some surgeries and patient variables were associated with CP. Approximately 1 in 10 adolescents who underwent the most common surgeries developed CP, as did a striking percentage of children in other age groups. Given the long-term consequences of CP, resources should be allocated toward identification of high-risk pediatric patients and strategies to prevent CP after surgery. PERSPECTIVE: This study identifies the incidences of and risk factors for chronic pain after common surgeries in patients 0 to 21 years of age. Our findings suggest that resources should be allocated toward the identification of high-risk pediatric patients and strategies to prevent CP after surgery.
Collapse
Affiliation(s)
- Isha Thapa
- Department of Management Science and Engineering, Stanford University, Stanford, California.
| | - Elizabeth De Souza
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Andrew Ward
- Department of Electrical Engineering, Stanford University, Stanford, California
| | - Nicholas Bambos
- Department of Electrical Engineering and Department of Management Science & Engineering, Stanford University, Stanford, California
| | - Thomas Anthony Anderson
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| |
Collapse
|
32
|
Mares JG, Lund BC, Adamowicz JL, Burgess DJ, Rothmiller SJ, Hadlandsmyth K. Differences in chronic pain care receipt among veterans from differing racialized groups and the impact of rural versus urban residence. J Rural Health 2023. [PMID: 36695646 DOI: 10.1111/jrh.12744] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
PURPOSE The current study aimed to identify differences in Veterans Affairs (VA) chronic pain care for Black, Asian, and Hispanic Americans, compared to non-Hispanic White Americans, and examine the intersection of race and rurality. METHODS Using national administrative data, all veterans who presented to the VA for chronic pain in 2018 were included. Demographic and comorbidity variables were built from 2018 data and health care utilization variables from 2019 data. Multivariate log-binomial regression models examined differences between racialized groups, and interactions with rural/urban residence, for each health care utilization variable. FINDINGS The full cohort included 2,135,216 veterans with chronic pain. There were no differences between racialized groups in pain-related primary care visits. Black Americans were less likely to receive pain clinic visits (aRR = 0.87, CI: 0.86-0.88). Rurality further decreased the likelihood of Black Americans visiting a pain clinic. Black, Hispanic, and Asian Americans were more likely to receive pain-related physical therapy visits relative to White Americans. Black and Hispanic Americans were more likely to present to emergency/urgent care for chronic pain. While there were no differences in pain-related primary care visits, the decreased likelihood of pain clinic visits and increased use of emergency department/urgent care among Black Americans could indicate inadequate management of chronic pain. CONCLUSIONS Tailored strategies are needed to provide equitable care that meets the needs of patients from racialized groups while accounting for systemic and cultural factors.
Collapse
Affiliation(s)
- Jasmine G Mares
- Office of Rural Health, Veterans Rural Resource Center, Iowa City VA Health Care System, Iowa City, Iowa, USA.,Department of Anesthesia, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Brian C Lund
- Office of Rural Health, Veterans Rural Resource Center, Iowa City VA Health Care System, Iowa City, Iowa, USA.,Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa, USA.,Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, Iowa, USA
| | - Jenna L Adamowicz
- Office of Rural Health, Veterans Rural Resource Center, Iowa City VA Health Care System, Iowa City, Iowa, USA.,Department of Psychological & Brain Sciences, University of Iowa, Iowa City, Iowa, USA
| | - Diana J Burgess
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA.,Center for Care Delivery and Outcomes Research, Veterans Affairs Medical Center, Minneapolis, Minnesota, USA
| | - Shamira J Rothmiller
- Office of Rural Health, Veterans Rural Resource Center, Iowa City VA Health Care System, Iowa City, Iowa, USA.,Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa, USA.,Department of Counselor Education, University of Iowa, Iowa City, Iowa, USA
| | - Katherine Hadlandsmyth
- Office of Rural Health, Veterans Rural Resource Center, Iowa City VA Health Care System, Iowa City, Iowa, USA.,Department of Anesthesia, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA.,Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa, USA
| |
Collapse
|
33
|
Risk of cardiovascular events according to the tricyclic antidepressant dosage in patients with chronic pain: a retrospective cohort study. Eur J Clin Pharmacol 2023; 79:159-171. [PMID: 36443528 DOI: 10.1007/s00228-022-03421-z] [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: 05/24/2022] [Accepted: 11/07/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE We aimed to examine the risk of cardiovascular adverse events by tricyclic antidepressant (TCA) dosage among patients with chronic pain. METHODS A retrospective cohort study was conducted using a nationwide sample cohort. Among patients aged ≥ 18 years with a chronic pain diagnosis and no history of cardiovascular events, we extracted users and non-users of TCAs through 1:1 propensity score matching. TCA users were categorized into three groups according to the mean defined daily dose (DDD): very low doses (< 0.15 DDD), low doses (0.15-0.34 DDD), and traditional doses (≥ 0.34 DDD). A 6-month follow-up was conducted with an intention-to-treat approach. We examined the hazard ratio of cardiovascular adverse events using Cox proportional hazards analysis. RESULTS In total, 16,660 matched patients were followed up (8330 TCA users and 8330 non-users). TCA use did not significantly increase cardiovascular adverse events (hazard ratio [HR] 1.12, 95% confidence interval [CI] 0.94-1.33). Low-dose (0.15-0.34 DDD) TCAs (HR 1.37, 95% CI 1.08-1.74), particularly low-dose (0.15-0.34 DDD) nortriptyline (HR 2.11, 95% CI 1.44-3.08), was associated with an increased risk of cardiovascular adverse events. Administration of TCAs at the traditional dose (≥ 0.34 DDD) increased the risk of ischemic stroke (HR 2.08, 95% CI 1.11-3.88). CONCLUSION Close monitoring of patients on long-term, low-dose use of TCAs should be conducted to avoid an increase in the cumulative dose, which increases the risk of cardiovascular adverse events.
Collapse
|
34
|
Wartko PD, Qiu H, Idu AE, Yu O, McCormack J, Matthews AG, Bobb JF, Saxon AJ, Campbell CI, Liu D, Braciszewski JM, Murphy SM, Burganowski RP, Murphy MT, Horigian VE, Hamilton LK, Lee AK, Boudreau DM, Bradley KA. Baseline representativeness of patients in clinics enrolled in the PRimary care Opioid Use Disorders treatment (PROUD) trial: comparison of trial and non-trial clinics in the same health systems. BMC Health Serv Res 2022; 22:1593. [PMID: 36581845 PMCID: PMC9801668 DOI: 10.1186/s12913-022-08915-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 11/30/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Pragmatic primary care trials aim to test interventions in "real world" health care settings, but clinics willing and able to participate in trials may not be representative of typical clinics. This analysis compared patients in participating and non-participating clinics from the same health systems at baseline in the PRimary care Opioid Use Disorders treatment (PROUD) trial. METHODS This observational analysis relied on secondary electronic health record and administrative claims data in 5 of 6 health systems in the PROUD trial. The sample included patients 16-90 years at an eligible primary care visit in the 3 years before randomization. Each system contributed 2 randomized PROUD trial clinics and 4 similarly sized non-trial clinics. We summarized patient characteristics in trial and non-trial clinics in the 2 years before randomization ("baseline"). Using mixed-effect regression models, we compared trial and non-trial clinics on a baseline measure of the primary trial outcome (clinic-level patient-years of opioid use disorder (OUD) treatment, scaled per 10,000 primary care patients seen) and a baseline measure of the secondary trial outcome (patient-level days of acute care utilization among patients with OUD). RESULTS Patients were generally similar between the 10 trial clinics (n = 248,436) and 20 non-trial clinics (n = 341,130), although trial clinics' patients were slightly younger, more likely to be Hispanic/Latinx, less likely to be white, more likely to have Medicaid/subsidized insurance, and lived in less wealthy neighborhoods. Baseline outcomes did not differ between trial and non-trial clinics: trial clinics had 1.0 more patient-year of OUD treatment per 10,000 patients (95% CI: - 2.9, 5.0) and a 4% higher rate of days of acute care utilization than non-trial clinics (rate ratio: 1.04; 95% CI: 0.76, 1.42). CONCLUSIONS trial clinics and non-trial clinics were similar regarding most measured patient characteristics, and no differences were observed in baseline measures of trial primary and secondary outcomes. These findings suggest trial clinics were representative of comparably sized clinics within the same health systems. Although results do not reflect generalizability more broadly, this study illustrates an approach to assess representativeness of clinics in future pragmatic primary care trials.
Collapse
Affiliation(s)
- Paige D Wartko
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Ste 1600, Seattle, WA, 98101, United States.
| | - Hongxiang Qiu
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Ste 1600, Seattle, WA, 98101, United States
- Department of Biostatistics, University of Washington, 1705 NE Pacific Street, Seattle, WA, 98195, United States
- Department of Statistics and Data Science, University of Pennsylvania, 3451 Walnut St Philadelphia, Philadelphia, PA, 19104, United States
| | - Abisola E Idu
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Ste 1600, Seattle, WA, 98101, United States
| | - Onchee Yu
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Ste 1600, Seattle, WA, 98101, United States
| | - Jennifer McCormack
- The Emmes Company, 401 N Washington St #700, Rockville, MD, 20850, United States
| | - Abigail G Matthews
- The Emmes Company, 401 N Washington St #700, Rockville, MD, 20850, United States
| | - Jennifer F Bobb
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Ste 1600, Seattle, WA, 98101, United States
| | - Andrew J Saxon
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care System, 1660 S Columbian Way, Seattle, WA, 98108, United States
| | - Cynthia I Campbell
- Kaiser Permanente Northern California Division of Research, 2000 Broadway, Oakland, CA, 94612, United States
| | - David Liu
- National Institute on Drug Abuse Center for Clinical Trials Network, Three White Flint North, 11601 Landsdown Street, North Bethesda, MD, 20852, United States
| | | | - Sean M Murphy
- Department of Population Health Sciences, Weill Cornell Medical College, 1300 York Ave, New York, NY, 10065, United States
| | - Rachael P Burganowski
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Ste 1600, Seattle, WA, 98101, United States
| | - Mark T Murphy
- MultiCare Health System, 315 Martin Luther King Jr. Way, Tacoma, WA, 98415, United States
| | - Viviana E Horigian
- Department of Public Health Sciences, Miller School of Medicine, University of Miami, 1120 NW 14th St, CRB 919, Miami, FL, 33136, United States
| | - Leah K Hamilton
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Ste 1600, Seattle, WA, 98101, United States
| | - Amy K Lee
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Ste 1600, Seattle, WA, 98101, United States
| | - Denise M Boudreau
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Ste 1600, Seattle, WA, 98101, United States
- Genentech, 1 DNA Way, South San Francisco, CA, 94080, United States
| | - Katharine A Bradley
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Ste 1600, Seattle, WA, 98101, United States
| |
Collapse
|
35
|
Sico JJ, Seng EK, Wang K, Skanderson M, Schindler EAD, Ney JP, Lorenze N, Kimber A, Lindsey H, Grinberg AS, Kuruvilla D, Higgins DS, Graham G, Sandbrink F, Scholten J, Shapiro RE, Lipton RB, Fenton BT. Characteristics and Gender Differences of Headache in the Veterans Health Administration: A National Cohort Study, Fiscal Year 2008-2019. Neurology 2022; 99:e1993-e2005. [PMID: 36100437 PMCID: PMC9651459 DOI: 10.1212/wnl.0000000000200905] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 05/16/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES To determine gender differences in headache types diagnosed, sociodemographic characteristics, military campaign and exposures, and health care utilization among US veterans in the Veterans Health Administration (VHA). METHODS This study used a retrospective cohort design to examine VHA electronic health record (EHR) data. This cohort includes veterans who had at least 1 visit for any headache between fiscal years 2008 and 2019. Headache diagnoses were classified into 8 categories using International Classification of Disease, Clinical Modification codes. Demographics, military-related exposures, comorbidities, and type of provider(s) consulted were extracted from the EHR and compared by gender. Age-adjusted incidence and prevalence rates of medically diagnosed headache disorders were calculated separately for each type of headache. RESULTS Of the 1,524,960 veterans with headache diagnoses included in the cohort, 82.8% were men. Compared with women, men were more often White (70.4% vs 56.7%), older (52.0 ± 16.8 vs 41.9 ± 13.0 years), with higher rates of traumatic brain injury (2.9% vs 1.1%) and post-traumatic stress disorder (23.7% vs 21.7%), and lower rates of military sexual trauma (3.2% vs 33.7%; p < 0.001 for all). Age-adjusted incidence rate of headache of any type was higher among women. Migraine and trigeminal autonomic cephalalgia rates were most stable over time. Men were more likely than women to be diagnosed with headache not otherwise specified (77.4% vs 67.7%) and have higher incidence rates of headaches related to trauma (3.4% vs 1.9% [post-traumatic]; 5.5% vs 5.1% [postwhiplash]; p < 0.001 for all). Men also had fewer headache types diagnosed (mean ± SD; 1.3 ± 0.6 vs 1.5 ± 0.7), had fewer encounters for headache/year (0.8 ± 1.2 vs 1.2 ± 1.6), and fewer visits to headache specialists (20.8% vs 27.4% p < 0.001 for all), compared with women. Emergency department utilization for headache care was high for both genders and higher for women compared with men (20.3% vs 22.9%; p < 0.001). DISCUSSION Among veterans with headache diagnoses, important gender differences exist for men and women veterans receiving headache care within VHA regarding sociodemographic characteristics, headache diagnoses, military exposure, and headache health care utilization. The findings have potential implications for providers and the health care system caring for veterans living with headache.
Collapse
Affiliation(s)
- Jason Jonathon Sico
- From the Neurology Service (J.J.S., E.A.D.S.), Clinical Epidemiology Research Center (CERC) (J.J.S.), Pain Research (J.J.S., M.S., N.L., A.K., H.L., B.T.F.), Informatics, and Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven; Departments of Neurology (J.J.S., N.L., A.K., H.L., E.A.D.S.), Internal Medicine (J.J.S.), Center for Neuroepidemiological and Clinical Neurological Research (J.J.S., E.A.D.S.), Yale Center for Analytic Sciences (K.W.), Yale School of Medicine, New Haven, CT; Veterans Health Administration Headache Centers of Excellence (HCoE) Research and Evaluation Center (J.J.S., E.K.S., K.W., M.S., E.A.D.S., J.P.N., N.L., A.K., H.L., A.S.G., D.K., B.T.F.), Department of Veterans Affairs, Orange, CT; Yeshiva University (E.K.S.), New York City, NY; Neurology Service (J.P.N.), Edith Nourse Rogers Memorial Veterans Hospital Bedford, MA; Department of Neurology (J.P.N.), Boston University School of Medicine, MA; Westport Headache Institute (D.K.), Westport, CT; Albany Stratton VA Medical Center (D.S.H.), NY; Department of Neurology (G.G.), George Washington University, Washington, DC; Department of Neurology (G.G.), University of California San Francisco School of Medicine, Specialty Care Services (G.G.), Veterans Health Administration Pain Management (F.S.), Opioid Safety and PDMP Program, Department of Veterans Affairs, Washington, DC; Departments of Neurology (F.S.), Physical Medicine and Rehabilitation (J.S.), Veterans Affairs Medical Center, Washington, DC; Department of Neurology (R.E.S.), University of Vermont Medical Center, Burlington, VT; Department of Neurology (R.B.L.), Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (R.B.L.), Montefiore Medical Center, Bronx, NY.
| | - Elizabeth K Seng
- From the Neurology Service (J.J.S., E.A.D.S.), Clinical Epidemiology Research Center (CERC) (J.J.S.), Pain Research (J.J.S., M.S., N.L., A.K., H.L., B.T.F.), Informatics, and Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven; Departments of Neurology (J.J.S., N.L., A.K., H.L., E.A.D.S.), Internal Medicine (J.J.S.), Center for Neuroepidemiological and Clinical Neurological Research (J.J.S., E.A.D.S.), Yale Center for Analytic Sciences (K.W.), Yale School of Medicine, New Haven, CT; Veterans Health Administration Headache Centers of Excellence (HCoE) Research and Evaluation Center (J.J.S., E.K.S., K.W., M.S., E.A.D.S., J.P.N., N.L., A.K., H.L., A.S.G., D.K., B.T.F.), Department of Veterans Affairs, Orange, CT; Yeshiva University (E.K.S.), New York City, NY; Neurology Service (J.P.N.), Edith Nourse Rogers Memorial Veterans Hospital Bedford, MA; Department of Neurology (J.P.N.), Boston University School of Medicine, MA; Westport Headache Institute (D.K.), Westport, CT; Albany Stratton VA Medical Center (D.S.H.), NY; Department of Neurology (G.G.), George Washington University, Washington, DC; Department of Neurology (G.G.), University of California San Francisco School of Medicine, Specialty Care Services (G.G.), Veterans Health Administration Pain Management (F.S.), Opioid Safety and PDMP Program, Department of Veterans Affairs, Washington, DC; Departments of Neurology (F.S.), Physical Medicine and Rehabilitation (J.S.), Veterans Affairs Medical Center, Washington, DC; Department of Neurology (R.E.S.), University of Vermont Medical Center, Burlington, VT; Department of Neurology (R.B.L.), Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (R.B.L.), Montefiore Medical Center, Bronx, NY
| | - Kaicheng Wang
- From the Neurology Service (J.J.S., E.A.D.S.), Clinical Epidemiology Research Center (CERC) (J.J.S.), Pain Research (J.J.S., M.S., N.L., A.K., H.L., B.T.F.), Informatics, and Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven; Departments of Neurology (J.J.S., N.L., A.K., H.L., E.A.D.S.), Internal Medicine (J.J.S.), Center for Neuroepidemiological and Clinical Neurological Research (J.J.S., E.A.D.S.), Yale Center for Analytic Sciences (K.W.), Yale School of Medicine, New Haven, CT; Veterans Health Administration Headache Centers of Excellence (HCoE) Research and Evaluation Center (J.J.S., E.K.S., K.W., M.S., E.A.D.S., J.P.N., N.L., A.K., H.L., A.S.G., D.K., B.T.F.), Department of Veterans Affairs, Orange, CT; Yeshiva University (E.K.S.), New York City, NY; Neurology Service (J.P.N.), Edith Nourse Rogers Memorial Veterans Hospital Bedford, MA; Department of Neurology (J.P.N.), Boston University School of Medicine, MA; Westport Headache Institute (D.K.), Westport, CT; Albany Stratton VA Medical Center (D.S.H.), NY; Department of Neurology (G.G.), George Washington University, Washington, DC; Department of Neurology (G.G.), University of California San Francisco School of Medicine, Specialty Care Services (G.G.), Veterans Health Administration Pain Management (F.S.), Opioid Safety and PDMP Program, Department of Veterans Affairs, Washington, DC; Departments of Neurology (F.S.), Physical Medicine and Rehabilitation (J.S.), Veterans Affairs Medical Center, Washington, DC; Department of Neurology (R.E.S.), University of Vermont Medical Center, Burlington, VT; Department of Neurology (R.B.L.), Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (R.B.L.), Montefiore Medical Center, Bronx, NY
| | - Melissa Skanderson
- From the Neurology Service (J.J.S., E.A.D.S.), Clinical Epidemiology Research Center (CERC) (J.J.S.), Pain Research (J.J.S., M.S., N.L., A.K., H.L., B.T.F.), Informatics, and Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven; Departments of Neurology (J.J.S., N.L., A.K., H.L., E.A.D.S.), Internal Medicine (J.J.S.), Center for Neuroepidemiological and Clinical Neurological Research (J.J.S., E.A.D.S.), Yale Center for Analytic Sciences (K.W.), Yale School of Medicine, New Haven, CT; Veterans Health Administration Headache Centers of Excellence (HCoE) Research and Evaluation Center (J.J.S., E.K.S., K.W., M.S., E.A.D.S., J.P.N., N.L., A.K., H.L., A.S.G., D.K., B.T.F.), Department of Veterans Affairs, Orange, CT; Yeshiva University (E.K.S.), New York City, NY; Neurology Service (J.P.N.), Edith Nourse Rogers Memorial Veterans Hospital Bedford, MA; Department of Neurology (J.P.N.), Boston University School of Medicine, MA; Westport Headache Institute (D.K.), Westport, CT; Albany Stratton VA Medical Center (D.S.H.), NY; Department of Neurology (G.G.), George Washington University, Washington, DC; Department of Neurology (G.G.), University of California San Francisco School of Medicine, Specialty Care Services (G.G.), Veterans Health Administration Pain Management (F.S.), Opioid Safety and PDMP Program, Department of Veterans Affairs, Washington, DC; Departments of Neurology (F.S.), Physical Medicine and Rehabilitation (J.S.), Veterans Affairs Medical Center, Washington, DC; Department of Neurology (R.E.S.), University of Vermont Medical Center, Burlington, VT; Department of Neurology (R.B.L.), Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (R.B.L.), Montefiore Medical Center, Bronx, NY
| | - Emmanuelle A D Schindler
- From the Neurology Service (J.J.S., E.A.D.S.), Clinical Epidemiology Research Center (CERC) (J.J.S.), Pain Research (J.J.S., M.S., N.L., A.K., H.L., B.T.F.), Informatics, and Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven; Departments of Neurology (J.J.S., N.L., A.K., H.L., E.A.D.S.), Internal Medicine (J.J.S.), Center for Neuroepidemiological and Clinical Neurological Research (J.J.S., E.A.D.S.), Yale Center for Analytic Sciences (K.W.), Yale School of Medicine, New Haven, CT; Veterans Health Administration Headache Centers of Excellence (HCoE) Research and Evaluation Center (J.J.S., E.K.S., K.W., M.S., E.A.D.S., J.P.N., N.L., A.K., H.L., A.S.G., D.K., B.T.F.), Department of Veterans Affairs, Orange, CT; Yeshiva University (E.K.S.), New York City, NY; Neurology Service (J.P.N.), Edith Nourse Rogers Memorial Veterans Hospital Bedford, MA; Department of Neurology (J.P.N.), Boston University School of Medicine, MA; Westport Headache Institute (D.K.), Westport, CT; Albany Stratton VA Medical Center (D.S.H.), NY; Department of Neurology (G.G.), George Washington University, Washington, DC; Department of Neurology (G.G.), University of California San Francisco School of Medicine, Specialty Care Services (G.G.), Veterans Health Administration Pain Management (F.S.), Opioid Safety and PDMP Program, Department of Veterans Affairs, Washington, DC; Departments of Neurology (F.S.), Physical Medicine and Rehabilitation (J.S.), Veterans Affairs Medical Center, Washington, DC; Department of Neurology (R.E.S.), University of Vermont Medical Center, Burlington, VT; Department of Neurology (R.B.L.), Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (R.B.L.), Montefiore Medical Center, Bronx, NY
| | - John P Ney
- From the Neurology Service (J.J.S., E.A.D.S.), Clinical Epidemiology Research Center (CERC) (J.J.S.), Pain Research (J.J.S., M.S., N.L., A.K., H.L., B.T.F.), Informatics, and Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven; Departments of Neurology (J.J.S., N.L., A.K., H.L., E.A.D.S.), Internal Medicine (J.J.S.), Center for Neuroepidemiological and Clinical Neurological Research (J.J.S., E.A.D.S.), Yale Center for Analytic Sciences (K.W.), Yale School of Medicine, New Haven, CT; Veterans Health Administration Headache Centers of Excellence (HCoE) Research and Evaluation Center (J.J.S., E.K.S., K.W., M.S., E.A.D.S., J.P.N., N.L., A.K., H.L., A.S.G., D.K., B.T.F.), Department of Veterans Affairs, Orange, CT; Yeshiva University (E.K.S.), New York City, NY; Neurology Service (J.P.N.), Edith Nourse Rogers Memorial Veterans Hospital Bedford, MA; Department of Neurology (J.P.N.), Boston University School of Medicine, MA; Westport Headache Institute (D.K.), Westport, CT; Albany Stratton VA Medical Center (D.S.H.), NY; Department of Neurology (G.G.), George Washington University, Washington, DC; Department of Neurology (G.G.), University of California San Francisco School of Medicine, Specialty Care Services (G.G.), Veterans Health Administration Pain Management (F.S.), Opioid Safety and PDMP Program, Department of Veterans Affairs, Washington, DC; Departments of Neurology (F.S.), Physical Medicine and Rehabilitation (J.S.), Veterans Affairs Medical Center, Washington, DC; Department of Neurology (R.E.S.), University of Vermont Medical Center, Burlington, VT; Department of Neurology (R.B.L.), Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (R.B.L.), Montefiore Medical Center, Bronx, NY
| | - Nancy Lorenze
- From the Neurology Service (J.J.S., E.A.D.S.), Clinical Epidemiology Research Center (CERC) (J.J.S.), Pain Research (J.J.S., M.S., N.L., A.K., H.L., B.T.F.), Informatics, and Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven; Departments of Neurology (J.J.S., N.L., A.K., H.L., E.A.D.S.), Internal Medicine (J.J.S.), Center for Neuroepidemiological and Clinical Neurological Research (J.J.S., E.A.D.S.), Yale Center for Analytic Sciences (K.W.), Yale School of Medicine, New Haven, CT; Veterans Health Administration Headache Centers of Excellence (HCoE) Research and Evaluation Center (J.J.S., E.K.S., K.W., M.S., E.A.D.S., J.P.N., N.L., A.K., H.L., A.S.G., D.K., B.T.F.), Department of Veterans Affairs, Orange, CT; Yeshiva University (E.K.S.), New York City, NY; Neurology Service (J.P.N.), Edith Nourse Rogers Memorial Veterans Hospital Bedford, MA; Department of Neurology (J.P.N.), Boston University School of Medicine, MA; Westport Headache Institute (D.K.), Westport, CT; Albany Stratton VA Medical Center (D.S.H.), NY; Department of Neurology (G.G.), George Washington University, Washington, DC; Department of Neurology (G.G.), University of California San Francisco School of Medicine, Specialty Care Services (G.G.), Veterans Health Administration Pain Management (F.S.), Opioid Safety and PDMP Program, Department of Veterans Affairs, Washington, DC; Departments of Neurology (F.S.), Physical Medicine and Rehabilitation (J.S.), Veterans Affairs Medical Center, Washington, DC; Department of Neurology (R.E.S.), University of Vermont Medical Center, Burlington, VT; Department of Neurology (R.B.L.), Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (R.B.L.), Montefiore Medical Center, Bronx, NY
| | - Addison Kimber
- From the Neurology Service (J.J.S., E.A.D.S.), Clinical Epidemiology Research Center (CERC) (J.J.S.), Pain Research (J.J.S., M.S., N.L., A.K., H.L., B.T.F.), Informatics, and Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven; Departments of Neurology (J.J.S., N.L., A.K., H.L., E.A.D.S.), Internal Medicine (J.J.S.), Center for Neuroepidemiological and Clinical Neurological Research (J.J.S., E.A.D.S.), Yale Center for Analytic Sciences (K.W.), Yale School of Medicine, New Haven, CT; Veterans Health Administration Headache Centers of Excellence (HCoE) Research and Evaluation Center (J.J.S., E.K.S., K.W., M.S., E.A.D.S., J.P.N., N.L., A.K., H.L., A.S.G., D.K., B.T.F.), Department of Veterans Affairs, Orange, CT; Yeshiva University (E.K.S.), New York City, NY; Neurology Service (J.P.N.), Edith Nourse Rogers Memorial Veterans Hospital Bedford, MA; Department of Neurology (J.P.N.), Boston University School of Medicine, MA; Westport Headache Institute (D.K.), Westport, CT; Albany Stratton VA Medical Center (D.S.H.), NY; Department of Neurology (G.G.), George Washington University, Washington, DC; Department of Neurology (G.G.), University of California San Francisco School of Medicine, Specialty Care Services (G.G.), Veterans Health Administration Pain Management (F.S.), Opioid Safety and PDMP Program, Department of Veterans Affairs, Washington, DC; Departments of Neurology (F.S.), Physical Medicine and Rehabilitation (J.S.), Veterans Affairs Medical Center, Washington, DC; Department of Neurology (R.E.S.), University of Vermont Medical Center, Burlington, VT; Department of Neurology (R.B.L.), Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (R.B.L.), Montefiore Medical Center, Bronx, NY
| | - Hayley Lindsey
- From the Neurology Service (J.J.S., E.A.D.S.), Clinical Epidemiology Research Center (CERC) (J.J.S.), Pain Research (J.J.S., M.S., N.L., A.K., H.L., B.T.F.), Informatics, and Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven; Departments of Neurology (J.J.S., N.L., A.K., H.L., E.A.D.S.), Internal Medicine (J.J.S.), Center for Neuroepidemiological and Clinical Neurological Research (J.J.S., E.A.D.S.), Yale Center for Analytic Sciences (K.W.), Yale School of Medicine, New Haven, CT; Veterans Health Administration Headache Centers of Excellence (HCoE) Research and Evaluation Center (J.J.S., E.K.S., K.W., M.S., E.A.D.S., J.P.N., N.L., A.K., H.L., A.S.G., D.K., B.T.F.), Department of Veterans Affairs, Orange, CT; Yeshiva University (E.K.S.), New York City, NY; Neurology Service (J.P.N.), Edith Nourse Rogers Memorial Veterans Hospital Bedford, MA; Department of Neurology (J.P.N.), Boston University School of Medicine, MA; Westport Headache Institute (D.K.), Westport, CT; Albany Stratton VA Medical Center (D.S.H.), NY; Department of Neurology (G.G.), George Washington University, Washington, DC; Department of Neurology (G.G.), University of California San Francisco School of Medicine, Specialty Care Services (G.G.), Veterans Health Administration Pain Management (F.S.), Opioid Safety and PDMP Program, Department of Veterans Affairs, Washington, DC; Departments of Neurology (F.S.), Physical Medicine and Rehabilitation (J.S.), Veterans Affairs Medical Center, Washington, DC; Department of Neurology (R.E.S.), University of Vermont Medical Center, Burlington, VT; Department of Neurology (R.B.L.), Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (R.B.L.), Montefiore Medical Center, Bronx, NY
| | - Amy S Grinberg
- From the Neurology Service (J.J.S., E.A.D.S.), Clinical Epidemiology Research Center (CERC) (J.J.S.), Pain Research (J.J.S., M.S., N.L., A.K., H.L., B.T.F.), Informatics, and Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven; Departments of Neurology (J.J.S., N.L., A.K., H.L., E.A.D.S.), Internal Medicine (J.J.S.), Center for Neuroepidemiological and Clinical Neurological Research (J.J.S., E.A.D.S.), Yale Center for Analytic Sciences (K.W.), Yale School of Medicine, New Haven, CT; Veterans Health Administration Headache Centers of Excellence (HCoE) Research and Evaluation Center (J.J.S., E.K.S., K.W., M.S., E.A.D.S., J.P.N., N.L., A.K., H.L., A.S.G., D.K., B.T.F.), Department of Veterans Affairs, Orange, CT; Yeshiva University (E.K.S.), New York City, NY; Neurology Service (J.P.N.), Edith Nourse Rogers Memorial Veterans Hospital Bedford, MA; Department of Neurology (J.P.N.), Boston University School of Medicine, MA; Westport Headache Institute (D.K.), Westport, CT; Albany Stratton VA Medical Center (D.S.H.), NY; Department of Neurology (G.G.), George Washington University, Washington, DC; Department of Neurology (G.G.), University of California San Francisco School of Medicine, Specialty Care Services (G.G.), Veterans Health Administration Pain Management (F.S.), Opioid Safety and PDMP Program, Department of Veterans Affairs, Washington, DC; Departments of Neurology (F.S.), Physical Medicine and Rehabilitation (J.S.), Veterans Affairs Medical Center, Washington, DC; Department of Neurology (R.E.S.), University of Vermont Medical Center, Burlington, VT; Department of Neurology (R.B.L.), Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (R.B.L.), Montefiore Medical Center, Bronx, NY
| | - Deena Kuruvilla
- From the Neurology Service (J.J.S., E.A.D.S.), Clinical Epidemiology Research Center (CERC) (J.J.S.), Pain Research (J.J.S., M.S., N.L., A.K., H.L., B.T.F.), Informatics, and Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven; Departments of Neurology (J.J.S., N.L., A.K., H.L., E.A.D.S.), Internal Medicine (J.J.S.), Center for Neuroepidemiological and Clinical Neurological Research (J.J.S., E.A.D.S.), Yale Center for Analytic Sciences (K.W.), Yale School of Medicine, New Haven, CT; Veterans Health Administration Headache Centers of Excellence (HCoE) Research and Evaluation Center (J.J.S., E.K.S., K.W., M.S., E.A.D.S., J.P.N., N.L., A.K., H.L., A.S.G., D.K., B.T.F.), Department of Veterans Affairs, Orange, CT; Yeshiva University (E.K.S.), New York City, NY; Neurology Service (J.P.N.), Edith Nourse Rogers Memorial Veterans Hospital Bedford, MA; Department of Neurology (J.P.N.), Boston University School of Medicine, MA; Westport Headache Institute (D.K.), Westport, CT; Albany Stratton VA Medical Center (D.S.H.), NY; Department of Neurology (G.G.), George Washington University, Washington, DC; Department of Neurology (G.G.), University of California San Francisco School of Medicine, Specialty Care Services (G.G.), Veterans Health Administration Pain Management (F.S.), Opioid Safety and PDMP Program, Department of Veterans Affairs, Washington, DC; Departments of Neurology (F.S.), Physical Medicine and Rehabilitation (J.S.), Veterans Affairs Medical Center, Washington, DC; Department of Neurology (R.E.S.), University of Vermont Medical Center, Burlington, VT; Department of Neurology (R.B.L.), Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (R.B.L.), Montefiore Medical Center, Bronx, NY
| | - Donald S Higgins
- From the Neurology Service (J.J.S., E.A.D.S.), Clinical Epidemiology Research Center (CERC) (J.J.S.), Pain Research (J.J.S., M.S., N.L., A.K., H.L., B.T.F.), Informatics, and Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven; Departments of Neurology (J.J.S., N.L., A.K., H.L., E.A.D.S.), Internal Medicine (J.J.S.), Center for Neuroepidemiological and Clinical Neurological Research (J.J.S., E.A.D.S.), Yale Center for Analytic Sciences (K.W.), Yale School of Medicine, New Haven, CT; Veterans Health Administration Headache Centers of Excellence (HCoE) Research and Evaluation Center (J.J.S., E.K.S., K.W., M.S., E.A.D.S., J.P.N., N.L., A.K., H.L., A.S.G., D.K., B.T.F.), Department of Veterans Affairs, Orange, CT; Yeshiva University (E.K.S.), New York City, NY; Neurology Service (J.P.N.), Edith Nourse Rogers Memorial Veterans Hospital Bedford, MA; Department of Neurology (J.P.N.), Boston University School of Medicine, MA; Westport Headache Institute (D.K.), Westport, CT; Albany Stratton VA Medical Center (D.S.H.), NY; Department of Neurology (G.G.), George Washington University, Washington, DC; Department of Neurology (G.G.), University of California San Francisco School of Medicine, Specialty Care Services (G.G.), Veterans Health Administration Pain Management (F.S.), Opioid Safety and PDMP Program, Department of Veterans Affairs, Washington, DC; Departments of Neurology (F.S.), Physical Medicine and Rehabilitation (J.S.), Veterans Affairs Medical Center, Washington, DC; Department of Neurology (R.E.S.), University of Vermont Medical Center, Burlington, VT; Department of Neurology (R.B.L.), Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (R.B.L.), Montefiore Medical Center, Bronx, NY
| | - Glenn Graham
- From the Neurology Service (J.J.S., E.A.D.S.), Clinical Epidemiology Research Center (CERC) (J.J.S.), Pain Research (J.J.S., M.S., N.L., A.K., H.L., B.T.F.), Informatics, and Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven; Departments of Neurology (J.J.S., N.L., A.K., H.L., E.A.D.S.), Internal Medicine (J.J.S.), Center for Neuroepidemiological and Clinical Neurological Research (J.J.S., E.A.D.S.), Yale Center for Analytic Sciences (K.W.), Yale School of Medicine, New Haven, CT; Veterans Health Administration Headache Centers of Excellence (HCoE) Research and Evaluation Center (J.J.S., E.K.S., K.W., M.S., E.A.D.S., J.P.N., N.L., A.K., H.L., A.S.G., D.K., B.T.F.), Department of Veterans Affairs, Orange, CT; Yeshiva University (E.K.S.), New York City, NY; Neurology Service (J.P.N.), Edith Nourse Rogers Memorial Veterans Hospital Bedford, MA; Department of Neurology (J.P.N.), Boston University School of Medicine, MA; Westport Headache Institute (D.K.), Westport, CT; Albany Stratton VA Medical Center (D.S.H.), NY; Department of Neurology (G.G.), George Washington University, Washington, DC; Department of Neurology (G.G.), University of California San Francisco School of Medicine, Specialty Care Services (G.G.), Veterans Health Administration Pain Management (F.S.), Opioid Safety and PDMP Program, Department of Veterans Affairs, Washington, DC; Departments of Neurology (F.S.), Physical Medicine and Rehabilitation (J.S.), Veterans Affairs Medical Center, Washington, DC; Department of Neurology (R.E.S.), University of Vermont Medical Center, Burlington, VT; Department of Neurology (R.B.L.), Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (R.B.L.), Montefiore Medical Center, Bronx, NY
| | - Friedhelm Sandbrink
- From the Neurology Service (J.J.S., E.A.D.S.), Clinical Epidemiology Research Center (CERC) (J.J.S.), Pain Research (J.J.S., M.S., N.L., A.K., H.L., B.T.F.), Informatics, and Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven; Departments of Neurology (J.J.S., N.L., A.K., H.L., E.A.D.S.), Internal Medicine (J.J.S.), Center for Neuroepidemiological and Clinical Neurological Research (J.J.S., E.A.D.S.), Yale Center for Analytic Sciences (K.W.), Yale School of Medicine, New Haven, CT; Veterans Health Administration Headache Centers of Excellence (HCoE) Research and Evaluation Center (J.J.S., E.K.S., K.W., M.S., E.A.D.S., J.P.N., N.L., A.K., H.L., A.S.G., D.K., B.T.F.), Department of Veterans Affairs, Orange, CT; Yeshiva University (E.K.S.), New York City, NY; Neurology Service (J.P.N.), Edith Nourse Rogers Memorial Veterans Hospital Bedford, MA; Department of Neurology (J.P.N.), Boston University School of Medicine, MA; Westport Headache Institute (D.K.), Westport, CT; Albany Stratton VA Medical Center (D.S.H.), NY; Department of Neurology (G.G.), George Washington University, Washington, DC; Department of Neurology (G.G.), University of California San Francisco School of Medicine, Specialty Care Services (G.G.), Veterans Health Administration Pain Management (F.S.), Opioid Safety and PDMP Program, Department of Veterans Affairs, Washington, DC; Departments of Neurology (F.S.), Physical Medicine and Rehabilitation (J.S.), Veterans Affairs Medical Center, Washington, DC; Department of Neurology (R.E.S.), University of Vermont Medical Center, Burlington, VT; Department of Neurology (R.B.L.), Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (R.B.L.), Montefiore Medical Center, Bronx, NY
| | - Joel Scholten
- From the Neurology Service (J.J.S., E.A.D.S.), Clinical Epidemiology Research Center (CERC) (J.J.S.), Pain Research (J.J.S., M.S., N.L., A.K., H.L., B.T.F.), Informatics, and Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven; Departments of Neurology (J.J.S., N.L., A.K., H.L., E.A.D.S.), Internal Medicine (J.J.S.), Center for Neuroepidemiological and Clinical Neurological Research (J.J.S., E.A.D.S.), Yale Center for Analytic Sciences (K.W.), Yale School of Medicine, New Haven, CT; Veterans Health Administration Headache Centers of Excellence (HCoE) Research and Evaluation Center (J.J.S., E.K.S., K.W., M.S., E.A.D.S., J.P.N., N.L., A.K., H.L., A.S.G., D.K., B.T.F.), Department of Veterans Affairs, Orange, CT; Yeshiva University (E.K.S.), New York City, NY; Neurology Service (J.P.N.), Edith Nourse Rogers Memorial Veterans Hospital Bedford, MA; Department of Neurology (J.P.N.), Boston University School of Medicine, MA; Westport Headache Institute (D.K.), Westport, CT; Albany Stratton VA Medical Center (D.S.H.), NY; Department of Neurology (G.G.), George Washington University, Washington, DC; Department of Neurology (G.G.), University of California San Francisco School of Medicine, Specialty Care Services (G.G.), Veterans Health Administration Pain Management (F.S.), Opioid Safety and PDMP Program, Department of Veterans Affairs, Washington, DC; Departments of Neurology (F.S.), Physical Medicine and Rehabilitation (J.S.), Veterans Affairs Medical Center, Washington, DC; Department of Neurology (R.E.S.), University of Vermont Medical Center, Burlington, VT; Department of Neurology (R.B.L.), Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (R.B.L.), Montefiore Medical Center, Bronx, NY
| | - Robert E Shapiro
- From the Neurology Service (J.J.S., E.A.D.S.), Clinical Epidemiology Research Center (CERC) (J.J.S.), Pain Research (J.J.S., M.S., N.L., A.K., H.L., B.T.F.), Informatics, and Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven; Departments of Neurology (J.J.S., N.L., A.K., H.L., E.A.D.S.), Internal Medicine (J.J.S.), Center for Neuroepidemiological and Clinical Neurological Research (J.J.S., E.A.D.S.), Yale Center for Analytic Sciences (K.W.), Yale School of Medicine, New Haven, CT; Veterans Health Administration Headache Centers of Excellence (HCoE) Research and Evaluation Center (J.J.S., E.K.S., K.W., M.S., E.A.D.S., J.P.N., N.L., A.K., H.L., A.S.G., D.K., B.T.F.), Department of Veterans Affairs, Orange, CT; Yeshiva University (E.K.S.), New York City, NY; Neurology Service (J.P.N.), Edith Nourse Rogers Memorial Veterans Hospital Bedford, MA; Department of Neurology (J.P.N.), Boston University School of Medicine, MA; Westport Headache Institute (D.K.), Westport, CT; Albany Stratton VA Medical Center (D.S.H.), NY; Department of Neurology (G.G.), George Washington University, Washington, DC; Department of Neurology (G.G.), University of California San Francisco School of Medicine, Specialty Care Services (G.G.), Veterans Health Administration Pain Management (F.S.), Opioid Safety and PDMP Program, Department of Veterans Affairs, Washington, DC; Departments of Neurology (F.S.), Physical Medicine and Rehabilitation (J.S.), Veterans Affairs Medical Center, Washington, DC; Department of Neurology (R.E.S.), University of Vermont Medical Center, Burlington, VT; Department of Neurology (R.B.L.), Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (R.B.L.), Montefiore Medical Center, Bronx, NY
| | - Richard B Lipton
- From the Neurology Service (J.J.S., E.A.D.S.), Clinical Epidemiology Research Center (CERC) (J.J.S.), Pain Research (J.J.S., M.S., N.L., A.K., H.L., B.T.F.), Informatics, and Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven; Departments of Neurology (J.J.S., N.L., A.K., H.L., E.A.D.S.), Internal Medicine (J.J.S.), Center for Neuroepidemiological and Clinical Neurological Research (J.J.S., E.A.D.S.), Yale Center for Analytic Sciences (K.W.), Yale School of Medicine, New Haven, CT; Veterans Health Administration Headache Centers of Excellence (HCoE) Research and Evaluation Center (J.J.S., E.K.S., K.W., M.S., E.A.D.S., J.P.N., N.L., A.K., H.L., A.S.G., D.K., B.T.F.), Department of Veterans Affairs, Orange, CT; Yeshiva University (E.K.S.), New York City, NY; Neurology Service (J.P.N.), Edith Nourse Rogers Memorial Veterans Hospital Bedford, MA; Department of Neurology (J.P.N.), Boston University School of Medicine, MA; Westport Headache Institute (D.K.), Westport, CT; Albany Stratton VA Medical Center (D.S.H.), NY; Department of Neurology (G.G.), George Washington University, Washington, DC; Department of Neurology (G.G.), University of California San Francisco School of Medicine, Specialty Care Services (G.G.), Veterans Health Administration Pain Management (F.S.), Opioid Safety and PDMP Program, Department of Veterans Affairs, Washington, DC; Departments of Neurology (F.S.), Physical Medicine and Rehabilitation (J.S.), Veterans Affairs Medical Center, Washington, DC; Department of Neurology (R.E.S.), University of Vermont Medical Center, Burlington, VT; Department of Neurology (R.B.L.), Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (R.B.L.), Montefiore Medical Center, Bronx, NY
| | - Brenda T Fenton
- From the Neurology Service (J.J.S., E.A.D.S.), Clinical Epidemiology Research Center (CERC) (J.J.S.), Pain Research (J.J.S., M.S., N.L., A.K., H.L., B.T.F.), Informatics, and Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven; Departments of Neurology (J.J.S., N.L., A.K., H.L., E.A.D.S.), Internal Medicine (J.J.S.), Center for Neuroepidemiological and Clinical Neurological Research (J.J.S., E.A.D.S.), Yale Center for Analytic Sciences (K.W.), Yale School of Medicine, New Haven, CT; Veterans Health Administration Headache Centers of Excellence (HCoE) Research and Evaluation Center (J.J.S., E.K.S., K.W., M.S., E.A.D.S., J.P.N., N.L., A.K., H.L., A.S.G., D.K., B.T.F.), Department of Veterans Affairs, Orange, CT; Yeshiva University (E.K.S.), New York City, NY; Neurology Service (J.P.N.), Edith Nourse Rogers Memorial Veterans Hospital Bedford, MA; Department of Neurology (J.P.N.), Boston University School of Medicine, MA; Westport Headache Institute (D.K.), Westport, CT; Albany Stratton VA Medical Center (D.S.H.), NY; Department of Neurology (G.G.), George Washington University, Washington, DC; Department of Neurology (G.G.), University of California San Francisco School of Medicine, Specialty Care Services (G.G.), Veterans Health Administration Pain Management (F.S.), Opioid Safety and PDMP Program, Department of Veterans Affairs, Washington, DC; Departments of Neurology (F.S.), Physical Medicine and Rehabilitation (J.S.), Veterans Affairs Medical Center, Washington, DC; Department of Neurology (R.E.S.), University of Vermont Medical Center, Burlington, VT; Department of Neurology (R.B.L.), Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (R.B.L.), Montefiore Medical Center, Bronx, NY
| |
Collapse
|
36
|
Seng EK, Fenton BT, Wang K, Lipton RB, Ney J, Damush T, Grinberg AS, Skanderson M, Sico JJ. Frequency, Demographics, Comorbidities, and Health Care Utilization by Veterans With Migraine: A VA Nationwide Cohort Study. Neurology 2022; 99:e1979-e1992. [PMID: 36100439 PMCID: PMC9651466 DOI: 10.1212/wnl.0000000000200888] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 05/11/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND AND OBJECTIVE To describe the relative frequency, demographics, comorbidities, and health care utilization of veterans who receive migraine care at the Veteran's Health Administration (VHA) and to evaluate differences by gender. METHODS This study extracted data from VHA administrative sources. Veterans diagnosed with migraine by a health care provider between fiscal year 2008 and 2019 were included. Demographics and military exposures were extracted at cohort entry. Comorbidities were extracted within 18 months of the first migraine diagnosis. Health care utilization and headache comorbidities were extracted across the study period. Differences between men and women were evaluated using χ2 tests and Student t tests. RESULTS More than half a million (n = 567,121) veterans were diagnosed with migraine during the 12-year study period, accounting for 5.3% of the 10.8 million veterans served in the VHA; in the most recent year of the study period (2019), the annual incidence and 1-year period prevalence of medically diagnosed migraine was 2.7% and 13.0% for women and 0.7% and 2.5% for men. In the total cohort diagnosed with migraine, 27.8% were women and 72.2% men. Among those with diagnosed migraine, a higher proportion of men vs women also had a TBI diagnosis (3.9% vs 1.1%; p < 0.001). A higher proportion of women vs men reported military sexual trauma (35.5% vs 3.5%; p < 0.001). Participants with diagnosed migraine had an average of 1.44 (SD 1.73) annual encounters for headache. Primary care was the most common headache care setting (88.1%); almost one-fifth of veterans with diagnosed migraine sought care in the ED at least once during the study period. Common comorbidities were overweight/obesity (80.3%), nonheadache pain disorders (61.7%), and mental health disorders (48.8%). DISCUSSION Migraine is commonly treated in the VHA setting, but likely underascertained. Most people treated for migraine in the VHA are men. Pain comorbidities and psychiatric disorders are common. Future research should identify methods to improve diagnosis and treatment and to reduce use of the emergency department.
Collapse
Affiliation(s)
- Elizabeth K Seng
- From the VA Connecticut Healthcare System (B.T.F., K.W., A.S.G., M.S., J.J.S.), West Haven; Yeshiva University (A.S.G.), Bronx; Albert Einstein College of Medicine (R.B.L.), Bronx; Montefiore Medical Center (R.B.L.), Bronx, NY; Yale School of Medicine (B.T.F., K.W., M.S., J.J.S.), New Haven; Yale School of Public Health (K.W.), New Haven, CT; Bedford VA Medical Center (J.N.); Boston University School of Medicine (J.N.), MA; Richard L. Roudebush VA Medical Center (T.D.), Indianapolis; and Indiana University School of Medicine (T.D.), Indianapolis.
| | - Brenda T Fenton
- From the VA Connecticut Healthcare System (B.T.F., K.W., A.S.G., M.S., J.J.S.), West Haven; Yeshiva University (A.S.G.), Bronx; Albert Einstein College of Medicine (R.B.L.), Bronx; Montefiore Medical Center (R.B.L.), Bronx, NY; Yale School of Medicine (B.T.F., K.W., M.S., J.J.S.), New Haven; Yale School of Public Health (K.W.), New Haven, CT; Bedford VA Medical Center (J.N.); Boston University School of Medicine (J.N.), MA; Richard L. Roudebush VA Medical Center (T.D.), Indianapolis; and Indiana University School of Medicine (T.D.), Indianapolis
| | - Kaicheng Wang
- From the VA Connecticut Healthcare System (B.T.F., K.W., A.S.G., M.S., J.J.S.), West Haven; Yeshiva University (A.S.G.), Bronx; Albert Einstein College of Medicine (R.B.L.), Bronx; Montefiore Medical Center (R.B.L.), Bronx, NY; Yale School of Medicine (B.T.F., K.W., M.S., J.J.S.), New Haven; Yale School of Public Health (K.W.), New Haven, CT; Bedford VA Medical Center (J.N.); Boston University School of Medicine (J.N.), MA; Richard L. Roudebush VA Medical Center (T.D.), Indianapolis; and Indiana University School of Medicine (T.D.), Indianapolis
| | - Richard B Lipton
- From the VA Connecticut Healthcare System (B.T.F., K.W., A.S.G., M.S., J.J.S.), West Haven; Yeshiva University (A.S.G.), Bronx; Albert Einstein College of Medicine (R.B.L.), Bronx; Montefiore Medical Center (R.B.L.), Bronx, NY; Yale School of Medicine (B.T.F., K.W., M.S., J.J.S.), New Haven; Yale School of Public Health (K.W.), New Haven, CT; Bedford VA Medical Center (J.N.); Boston University School of Medicine (J.N.), MA; Richard L. Roudebush VA Medical Center (T.D.), Indianapolis; and Indiana University School of Medicine (T.D.), Indianapolis
| | - John Ney
- From the VA Connecticut Healthcare System (B.T.F., K.W., A.S.G., M.S., J.J.S.), West Haven; Yeshiva University (A.S.G.), Bronx; Albert Einstein College of Medicine (R.B.L.), Bronx; Montefiore Medical Center (R.B.L.), Bronx, NY; Yale School of Medicine (B.T.F., K.W., M.S., J.J.S.), New Haven; Yale School of Public Health (K.W.), New Haven, CT; Bedford VA Medical Center (J.N.); Boston University School of Medicine (J.N.), MA; Richard L. Roudebush VA Medical Center (T.D.), Indianapolis; and Indiana University School of Medicine (T.D.), Indianapolis
| | - Teresa Damush
- From the VA Connecticut Healthcare System (B.T.F., K.W., A.S.G., M.S., J.J.S.), West Haven; Yeshiva University (A.S.G.), Bronx; Albert Einstein College of Medicine (R.B.L.), Bronx; Montefiore Medical Center (R.B.L.), Bronx, NY; Yale School of Medicine (B.T.F., K.W., M.S., J.J.S.), New Haven; Yale School of Public Health (K.W.), New Haven, CT; Bedford VA Medical Center (J.N.); Boston University School of Medicine (J.N.), MA; Richard L. Roudebush VA Medical Center (T.D.), Indianapolis; and Indiana University School of Medicine (T.D.), Indianapolis
| | - Amy S Grinberg
- From the VA Connecticut Healthcare System (B.T.F., K.W., A.S.G., M.S., J.J.S.), West Haven; Yeshiva University (A.S.G.), Bronx; Albert Einstein College of Medicine (R.B.L.), Bronx; Montefiore Medical Center (R.B.L.), Bronx, NY; Yale School of Medicine (B.T.F., K.W., M.S., J.J.S.), New Haven; Yale School of Public Health (K.W.), New Haven, CT; Bedford VA Medical Center (J.N.); Boston University School of Medicine (J.N.), MA; Richard L. Roudebush VA Medical Center (T.D.), Indianapolis; and Indiana University School of Medicine (T.D.), Indianapolis
| | - Melissa Skanderson
- From the VA Connecticut Healthcare System (B.T.F., K.W., A.S.G., M.S., J.J.S.), West Haven; Yeshiva University (A.S.G.), Bronx; Albert Einstein College of Medicine (R.B.L.), Bronx; Montefiore Medical Center (R.B.L.), Bronx, NY; Yale School of Medicine (B.T.F., K.W., M.S., J.J.S.), New Haven; Yale School of Public Health (K.W.), New Haven, CT; Bedford VA Medical Center (J.N.); Boston University School of Medicine (J.N.), MA; Richard L. Roudebush VA Medical Center (T.D.), Indianapolis; and Indiana University School of Medicine (T.D.), Indianapolis
| | - Jason J Sico
- From the VA Connecticut Healthcare System (B.T.F., K.W., A.S.G., M.S., J.J.S.), West Haven; Yeshiva University (A.S.G.), Bronx; Albert Einstein College of Medicine (R.B.L.), Bronx; Montefiore Medical Center (R.B.L.), Bronx, NY; Yale School of Medicine (B.T.F., K.W., M.S., J.J.S.), New Haven; Yale School of Public Health (K.W.), New Haven, CT; Bedford VA Medical Center (J.N.); Boston University School of Medicine (J.N.), MA; Richard L. Roudebush VA Medical Center (T.D.), Indianapolis; and Indiana University School of Medicine (T.D.), Indianapolis
| |
Collapse
|
37
|
Duca LM, Helmick CG, Barbour KE, Nahin RL, Von Korff M, Murphy LB, Theis K, Guglielmo D, Dahlhamer J, Porter L, Falasinnu T, Mackey S. A Review of Potential National Chronic Pain Surveillance Systems in the United States. THE JOURNAL OF PAIN 2022; 23:1492-1509. [PMID: 35421595 PMCID: PMC9464678 DOI: 10.1016/j.jpain.2022.02.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 02/05/2022] [Accepted: 02/24/2022] [Indexed: 04/19/2023]
Abstract
Pain has been established as a major public health problem in the United States (U.S.) with 50 million adults experiencing chronic pain and 20 million afflicted with high-impact chronic pain (ie, chronic pain that interferes with life or work activities). High financial and social costs are associated with chronic pain. Over the past 2 decades, pain management has been complicated by the marked increase in opioids prescribed to treat chronic noncancer pain and by the concurrent opioid crisis. Monitoring the prevalence of chronic pain and pain management is especially important because pain management is changing in uncertain ways. We review potential U.S. chronic pain surveillance systems, present potential difficulties of chronic pain surveillance, and explore how to address chronic pain surveillance in the current opioid era. We consider case definitions, severity, anatomic site, and varieties of chronic pain management strategies in reviewing and evaluating national surveys for chronic pain surveillance. Based on the criteria evaluated, the National Health Interview Survey offers the best single source for pain surveillance as the pain-related questions administered are brief, valid, and cover a broad scope of pain-related phenomena. PERSPECTIVE: This review article describes data sources that can be leveraged to conduct national chronic pain surveillance in the United States, explores case defining or pain-related questions administered, and evaluates them against 8 surveillance attributes.
Collapse
Affiliation(s)
- Lindsey M Duca
- Division of Population Health, Centers for Disease Control and Prevention, Atlanta, Georgia; Epidemic Intelligence Service Officer, Centers for Disease Control and Prevention, Atlanta, Georgia.
| | - Charles G Helmick
- Division of Population Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Kamil E Barbour
- Division of Population Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Richard L Nahin
- National Center for Complementary and Integrative Health, National Institutes of Health, Bethesda, Maryland
| | - Michael Von Korff
- Kaiser Permanente Washington, Health Research Institute, Seattle, Washington
| | - Louise B Murphy
- Division of Population Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Kristina Theis
- Division of Population Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Dana Guglielmo
- Division of Population Health, Centers for Disease Control and Prevention, Atlanta, Georgia; Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee
| | - James Dahlhamer
- National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, Maryland
| | - Linda Porter
- National Institutes of Health, Director of the Office of Pain Policy, Bethesda, Maryland
| | - Titilola Falasinnu
- Departments of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Sean Mackey
- Departments of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| |
Collapse
|
38
|
Zeliadt SB, Douglas JH, Gelman H, Coggeshall S, Taylor SL, Kligler B, Bokhour BG. Effectiveness of a whole health model of care emphasizing complementary and integrative health on reducing opioid use among patients with chronic pain. BMC Health Serv Res 2022; 22:1053. [PMID: 35978421 PMCID: PMC9387037 DOI: 10.1186/s12913-022-08388-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 07/28/2022] [Indexed: 12/21/2022] Open
Abstract
Background The opioid crisis has necessitated new approaches to managing chronic pain. The Veterans Health Administration (VHA) Whole Health model of care, with its focus on patient empowerment and emphasis on nonpharmacological approaches to pain management, is a promising strategy for reducing patients’ use of opioids. We aim to assess whether the VHA’s Whole Health pilot program impacted longitudinal patterns of opioid utilization among patients with chronic musculoskeletal pain. Methods A cohort of 4,869 Veterans with chronic pain engaging in Whole Health services was compared with a cohort of 118,888 Veterans receiving conventional care. All patients were continuously enrolled in VHA care from 10/2017 through 3/2019 at the 18 VHA medical centers participating in the pilot program. Inverse probability of treatment weighting and multivariate analyses were used to adjust for observable differences in patient characteristics between exposures and conventional care. Patients exposed to Whole Health services were offered nine complementary and integrative health therapies alone or in combination with novel Whole Health services including goal-setting clinical encounters, Whole Health coaching, and personal health planning. Main measures The main measure was change over an 18-month period in prescribed opioid doses starting from the six-month period prior to qualifying exposure. Results Prescribed opioid doses decreased by -12.0% in one year among Veterans who began complementary and integrative health therapies compared to similar Veterans who used conventional care; -4.4% among Veterans who used only Whole Health services such as goal setting and coaching compared to conventional care, and -8.5% among Veterans who used both complementary and integrative health therapies combined with Whole Health services compared to conventional care. Conclusions VHA’s Whole Health national pilot program was associated with greater reductions in prescribed opioid doses compared to secular trends associated with conventional care, especially when Veterans were connected with complementary and integrative health therapies. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08388-2.
Collapse
Affiliation(s)
- Steven B Zeliadt
- VA Center of Innovation (COIN) for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, 1660 South Columbian Way, HSR&D S-152, Seattle, WA, 98108, USA. .,Department of Health Services, School of Public Health, University of Washington, 1660 South Columbian Way, HSR&D S-152, Seattle, WA, 98108, USA.
| | - Jamie H Douglas
- VA Center of Innovation (COIN) for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, 1660 South Columbian Way, HSR&D S-152, Seattle, WA, 98108, USA
| | - Hannah Gelman
- VA Center of Innovation (COIN) for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, 1660 South Columbian Way, HSR&D S-152, Seattle, WA, 98108, USA
| | - Scott Coggeshall
- VA Center of Innovation (COIN) for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, 1660 South Columbian Way, HSR&D S-152, Seattle, WA, 98108, USA
| | - Stephanie L Taylor
- Center for the Study of Healthcare Innovation, Implementation and Policy, Greater Los Angeles VA Healthcare System, Los Angeles, CA, USA.,Department of General Internal Medicine and Department of Health Policy and Management, UCLA, Los Angeles, CA, USA
| | - Benjamin Kligler
- Department of Family and Community Medicine, Icahn School of Medicine at Mount Sinai, Brooklyn, NY, USA.,US Department of Veterans Affairs Office of Patient Centered Care and Cultural Transformation, Washington, DC, USA
| | - Barbara G Bokhour
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA.,Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| |
Collapse
|
39
|
Ruskin D, Rasul R, McCann-Pineo M. Predictors of Emergency Department Opioid Use Among Adolescents and Young Adults. Pediatr Emerg Care 2022; 38:e1409-e1416. [PMID: 35686972 PMCID: PMC9351695 DOI: 10.1097/pec.0000000000002777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE It is well established that adolescents and young adults are increasingly vulnerable to the effects of early opioid exposures, with the emergency department (ED) playing a critical role in such introduction. Our objective was to identify predictors of ED opioid administration (ED-RX) and prescribing at discharge (DC-RX) among adolescent and young adults using a machine learning approach. METHODS We conducted a secondary analysis of ED visit data from the National Hospital Ambulatory Medical Care Survey from 2014 to 2018. Visits where patients were aged 10 to 24 years were included. Predictors of ED-RX and DC-RX were identified via machine learning methods. Separate weighted logistic regressions were performed to determine the association between each predictor, and ED-RX and DC-RX, respectively. RESULTS There were 12,693 ED visits identified within the study time frame, with the majority being female (58.6%) and White (70.7%). Approximately 12.3% of all visits were administered an opioid during the ED visit, and 11.5% were prescribed one at discharge. For ED-RX, the strongest predictors were fracture injury (odds ratio [OR], 5.24; 95% confidence interval [CI], 3.73-7.35) and Southern geographic region (OR, 3.01; 95% CI, 2.14-4.22). The use of nonopioid analgesics significantly reduced the odds of ED-RX (OR, 0.46; 95% CI, 0.37-0.57). Fracture injury was also a strong predictor of DC-RX (OR, 5.91; 95% CI, 4.24-8.25), in addition to tooth pain (OR, 5.47; 95% CI, 3.84-7.69). CONCLUSIONS Machine learning methodologies were able to identify predictors of ED-RX and DC-RX, which can be used to inform ED prescribing guidelines and risk mitigation efforts among adolescents and young adults.
Collapse
|
40
|
Irwin MN, Smith MA. Validation of ICD-9 Codes for Identification of Chronic Overlapping Pain Conditions. J Pain Palliat Care Pharmacother 2022; 36:166-177. [PMID: 35900230 DOI: 10.1080/15360288.2022.2089437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Chronic overlapping pain conditions (COPCs) are a collection of chronic pain syndromes that often co-occur and are thought to share underlying nociplastic pathophysiology. Since they can manifest as seemingly unrelated syndromes they have historically been studied in isolation. Use of International Classification of Diseases (ICD) codes in medical records has been proposed as a means to identify and study trends in COPCs at the population level, however validated code sets are needed. Recently, a code set comprising ICD-10 codes as proxies for 11 COPCs was validated. The goal of this project was to validate a code set composed of ICD-9 codes for the identification of COPCs in administrative datasets. Data was extracted using the Electronic Medical Record Search Engine at the University of Michigan Health System from January 1st, 2011 to January 1st, 2015. The source population were patients with one of the candidate ICD-9 codes corresponding to various COPCs. Natural language searches were used as a reference standard. If code sets met a pre-specified threshold of agreement between ICD-9 codes and natural language searches (≥ 70%), they were retained and diagnostic accuracy statistics were calculated for each code set. Validated ICD-9 code sets were generated for 10 of the 11 COPCs evaluated. The majority had high levels of diagnostic accuracy, with all but one code set achieving ≥ 80% specificity, sensitivity, and predictive values. This code set may be used by pain researchers to identify COPCs using ICD-9 codes in administrative datasets.
Collapse
|
41
|
Smith DH, O'Keeffe-Rosetti M, Leo MC, Mayhew M, Benes L, Bonifay A, Deyo RA, Elder CR, Keefe FJ, McMullen C, Owen-Smith A, Trinacty CM, Vollmer WM, DeBar L. Economic Evaluation: A Randomized Pragmatic Trial of a Primary Care-based Cognitive Behavioral Intervention for Adults Receiving Long-term Opioids for Chronic Pain. Med Care 2022; 60:423-431. [PMID: 35352703 PMCID: PMC9106895 DOI: 10.1097/mlr.0000000000001713] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Chronic pain is prevalent and costly; cost-effective nonpharmacological approaches that reduce pain and improve patient functioning are needed. OBJECTIVE Report the incremental cost-effectiveness ratio (ICER), compared with usual care, of cognitive behavioral therapy aimed at improving functioning and pain among patients with chronic pain on long-term opioid treatment. DESIGN Economic evaluation conducted alongside a pragmatic cluster randomized trial. SUBJECTS Adults with chronic pain on long-term opioid treatment (N=814). INTERVENTION A cognitive behavioral therapy intervention teaching pain self-management skills in 12 weekly, 90-minute groups delivered by an interdisciplinary team (behaviorists, nurses) with additional support from physical therapists, and pharmacists. OUTCOME MEASURES Cost per quality adjusted life year (QALY) gained, and cost per additional responder (≥30% improvement on standard scale assessment of Pain, Enjoyment, General Activity, and Sleep). Costs were estimated as-delivered, and replication. RESULTS Per patient intervention replication costs were $2145 ($2574 as-delivered). Those costs were completely offset by lower medical care costs; inclusive of the intervention, total medical care over follow-up was $1841 lower for intervention patients. Intervention group patients also had greater QALY and responder gains than did controls. Supplemental analyses using pain-related medical care costs revealed ICERs of $35,000, and $53,000 per QALY (for replication, and as-delivered intervention costs, respectively); the ICER when excluding patients with outlier follow-up costs was $106,000. LIMITATIONS Limited to 1-year follow-up; identification of pain-related utilization potentially incomplete. CONCLUSION The intervention was the optimal choice at commonly accepted levels of willingness-to-pay for QALY gains; this finding was robust to sensitivity analyses.
Collapse
Affiliation(s)
- David H. Smith
- Kaiser Permanente Center for Health Research, Portland
OR
| | | | - Michael C. Leo
- Kaiser Permanente Center for Health Research, Portland
OR
| | - Meghan Mayhew
- Kaiser Permanente Center for Health Research, Portland
OR
| | - Lindsay Benes
- Kaiser Permanente Center for Health Research, Portland
OR
- Montana State University College of Nursing, Missoula,
MT
| | | | - Richard A. Deyo
- Oregon Health and Science University, School of Medicine,
Portland, OR
| | | | | | | | - Ashli Owen-Smith
- Georgia State University, School of Public Health, Atlanta
GA
- Kaiser Permanente Center for Clinical and Outcomes
Research, Atlanta GA
| | | | | | - Lynn DeBar
- Kaiser Permanente Washington Health Research Institute,
Seattle WA
| |
Collapse
|
42
|
Hadlandsmyth K, Mosher HJ, Bayman EO, Mares JG, Odom AS, Lund BC. Opioid Prescribing Patterns for Acute Pain. Eur J Pain 2022; 26:1523-1531. [PMID: 35607721 DOI: 10.1002/ejp.1980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 05/16/2022] [Accepted: 05/20/2022] [Indexed: 11/07/2022]
Abstract
PURPOSE The current study aimed to identify patients presenting with acute pain who may be at risk for a complicated trajectory, via identifying clusters of early opioid prescribing patterns. METHODS National Veterans Affairs administrative data were utilized to build a cohort of outpatients with acute pain presentations and no more than minimal opioid use in the prior year. Latent Class Analyses (LCA) identified clusters of early opioid prescribing patterns. Risk of progression to long-term opioid use was contrasted between LCA clusters using log-binomial regression, adjusting for confounding variables. RESULTS The 2018 cohort included N = 191,283. Among the 27,890 who received an initial opioid prescription, LCA classes were identified using: first supply day, total days dispensed across 30 days, opioid type, dose, and number of prescriptions across the first 30 days. In the three-class model: class 1 indicated an immediate, low-dose, brief supply; class 2 included delayed, low-dose and longer duration prescriptions; and class 3 included delayed high-dose, and moderate duration. Adjusted relative risk ratios for progression to long-term opioid use in the following year were 3.33 (95% CI: 2.71-4.10) for class 1 (absolute risk 1.1%); 7.76 (95% CI: 6.69-8.99) for class 2 (3.1%); and 6.81 (95% CI: 5.72 - 8.12) for class 3 (2.4%); compared to patients who did not receive an acute opioid prescription (0.3%). CONCLUSIONS These clusters of acute opioid prescribing could facilitate identification of patients who may benefit from enhanced pain care earlier in the pain trajectory and decrease future reliance on long-term opioid therapy.
Collapse
Affiliation(s)
- Katherine Hadlandsmyth
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA.,Office of Rural Health, Veterans Rural Health Resource Center, Iowa City VA Health Care System, Iowa City, IA, USA.,University of Iowa, Carver College of Medicine, Department of Anesthesia, Iowa City, IA, USA
| | - Hilary J Mosher
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA.,Office of Rural Health, Veterans Rural Health Resource Center, Iowa City VA Health Care System, Iowa City, IA, USA.,University of Iowa, Carver College of Medicine, Department of Internal Medicine, Iowa City, USA
| | - Emine O Bayman
- University of Iowa, Carver College of Medicine, Department of Anesthesia, Iowa City, IA, USA.,University of Iowa, College of Public Health, Department of Biostatistics, Iowa City, IA, USA
| | - Jasmine G Mares
- University of Iowa, Carver College of Medicine, Department of Anesthesia, Iowa City, IA, USA
| | - Annie S Odom
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA
| | - Brian C Lund
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA.,Office of Rural Health, Veterans Rural Health Resource Center, Iowa City VA Health Care System, Iowa City, IA, USA
| |
Collapse
|
43
|
Moyo P, Schmidt C, Lee Y, Joshi R, Mukhdomi T, Trivedi A, Shireman TI. Receipt of Physical Therapy and Chiropractic Care by Adults Diagnosed with Chronic Pain: Analysis of the 2016-2018 Rhode Island All Payer Claims Database. RHODE ISLAND MEDICAL JOURNAL (2013) 2022; 105:51-56. [PMID: 35476739 PMCID: PMC9186019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To examine trends and factors associated with physical therapy (PT) and chiropractic care use among Rhode Islanders with private or publicly-funded health insurance who were diagnosed with chronic pain from 2016-2018. METHODS We measured monthly PT and chiropractic care use from the RI All Payer Claims Database, and conducted logistic regression to identify factors associated with utilization. RESULTS There were 284,942 unique adults with chronic pain representing over one-quarter of insured persons in the state. Chiropractic care use remained unchanged but was more prevalent (7.2%) than PT whose use increased minimally from 4.0% (2016) to 4.5% (2018). Traditional Medicare or Medicaid enrollment was associated with lower odds of receiving PT and chiropractic care than in private plans. CONCLUSIONS PT and chiropractic care use varied across payers; however, there were little to no changes in their use over time despite clinical guidelines that encourage non-pharmacologic options to manage chronic pain.
Collapse
Affiliation(s)
- Patience Moyo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
| | - Catherine Schmidt
- Department of Physical Therapy, Massachusetts General Hospital Institute of Health Professions School of Health and Rehabilitation Sciences, Boston, MA
| | - Yoojin Lee
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
| | - Richa Joshi
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
| | - Taif Mukhdomi
- Department of Anesthesiology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI
| | - Amal Trivedi
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
| | - Theresa I Shireman
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
| |
Collapse
|
44
|
Muench J, Hoopes M, Mayhew M, Pisciotta M, Shortreed SM, Livingston CJ, Von Korff M, DeBar LL. Reduction of Long-Term Opioid Prescribing for Back Pain in Community Health Centers After a Medicaid Policy Change. J Am Board Fam Med 2022; 35:352-369. [PMID: 35379722 PMCID: PMC10464932 DOI: 10.3122/jabfm.2022.02.210306] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 09/25/2021] [Accepted: 09/29/2021] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Beginning around 2011, innumerable policies have aimed to improve pain treatment while minimizing harms from excessive use of opioids. It is not known whether changing insurance coverage for specific conditions is an effective strategy. We describe and assess the effect of an innovative Oregon Medicaid back/neck pain coverage policy on opioid prescribing patterns. METHODS This retrospective cohort study uses electronic health record data from a network of community health centers (CHCs) in Oregon to analyze prescription opioid dose changes among patients on long-term opioid treatment (LOT) affected by the policy. RESULTS Of the 1,789 patients on LOT at baseline, 41.6% had an average daily dose of <20 morphine milligram equivalents (MME), 32.3% had ≥20 to <50 MME, 14.5% had ≥50 to <90 MME, and 11.6% ≥90 MME. Around half of each group discontinued opioids within the 18-month policy period. Those who discontinued did so gradually (average of 11 months) regardless of starting dosage. Predictors of discontinuation included: diagnosis of opioid use disorder, older, non-Hispanic white, and less medical complexity. CONCLUSIONS Regardless of starting opioid dose, nearly half of patients affected by the 2016 Oregon Medicaid back/neck pain treatment policy no longer received opioid prescriptions by the end of the 18-month study period; another 30% decreased their dose. Gradual dose reduction was typical. These outcomes suggest that the policy impacted opioid prescribing. Understanding patient experiences resulting from such policies could help clinicians and policy makers navigate the complex balance between potential harms and benefits of LOT.
Collapse
Affiliation(s)
- John Muench
- From the Oregon Health & Science University, Portland, OR (JM); OCHIN, Inc., Portland, OR (MH and MP); Kaiser Permanente Center for Health Research, Portland, OR (MM, SMS, MVK, and LLD); and Oregon Health & Science University, Portland, OR (CJL).
| | - Megan Hoopes
- From the Oregon Health & Science University, Portland, OR (JM); OCHIN, Inc., Portland, OR (MH and MP); Kaiser Permanente Center for Health Research, Portland, OR (MM, SMS, MVK, and LLD); and Oregon Health & Science University, Portland, OR (CJL)
| | - Meghan Mayhew
- From the Oregon Health & Science University, Portland, OR (JM); OCHIN, Inc., Portland, OR (MH and MP); Kaiser Permanente Center for Health Research, Portland, OR (MM, SMS, MVK, and LLD); and Oregon Health & Science University, Portland, OR (CJL)
| | - Maura Pisciotta
- From the Oregon Health & Science University, Portland, OR (JM); OCHIN, Inc., Portland, OR (MH and MP); Kaiser Permanente Center for Health Research, Portland, OR (MM, SMS, MVK, and LLD); and Oregon Health & Science University, Portland, OR (CJL)
| | - Susan M Shortreed
- From the Oregon Health & Science University, Portland, OR (JM); OCHIN, Inc., Portland, OR (MH and MP); Kaiser Permanente Center for Health Research, Portland, OR (MM, SMS, MVK, and LLD); and Oregon Health & Science University, Portland, OR (CJL)
| | - Catherine J Livingston
- From the Oregon Health & Science University, Portland, OR (JM); OCHIN, Inc., Portland, OR (MH and MP); Kaiser Permanente Center for Health Research, Portland, OR (MM, SMS, MVK, and LLD); and Oregon Health & Science University, Portland, OR (CJL)
| | - Michael Von Korff
- From the Oregon Health & Science University, Portland, OR (JM); OCHIN, Inc., Portland, OR (MH and MP); Kaiser Permanente Center for Health Research, Portland, OR (MM, SMS, MVK, and LLD); and Oregon Health & Science University, Portland, OR (CJL)
| | - Lynn L DeBar
- From the Oregon Health & Science University, Portland, OR (JM); OCHIN, Inc., Portland, OR (MH and MP); Kaiser Permanente Center for Health Research, Portland, OR (MM, SMS, MVK, and LLD); and Oregon Health & Science University, Portland, OR (CJL)
| |
Collapse
|
45
|
Reed DE, Bokhour BG, Gaj L, Barker AM, Douglas JH, DeFaccio R, Williams RM, Engel CC, Zeliadt SB. Whole Health Use and Interest Across Veterans With Co-Occurring Chronic Pain and PTSD: An Examination of the 18 VA Medical Center Flagship Sites. Glob Adv Health Med 2022; 11:21649561211065374. [PMID: 35174004 PMCID: PMC8841911 DOI: 10.1177/21649561211065374] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 11/19/2021] [Indexed: 12/16/2022] Open
Abstract
Objective Veterans Healthcare Administration (VHA) conducted a large demonstration project of a holistic Whole Health approach to care in 18 medical centers, which included making complementary and integrative health (CIH) therapies more widely available. This evaluation examines patterns of service use among Veterans with chronic pain, comparing those with and without PTSD. Methods We assessed the use of Whole Health services in a cohort of Veterans with co-occurring chronic pain and PTSD (n = 1698; 28.9%), comparing them to Veterans with chronic musculoskeletal pain only (n = 4170; 71.1%). Data was gathered from VA electronic medical records and survey self-report. Whole Health services were divided into Core Whole Health services (e.g., Whole Health coaching) and CIH services (e.g., yoga). Logistic regression was used to determine whether Veterans with co-occurring chronic pain and PTSD utilized more Whole Health services compared to Veterans with chronic pain but without PTSD. Results A total of 40.1% of Veterans with chronic pain and PTSD utilized Core Whole Health services and 53.2% utilized CIH therapies, compared to 28.3% and 40.0%, respectively, for Veterans with only chronic pain. Adjusting for demographics and additional comorbidities, Veterans with comorbid chronic pain and PTSD were 1.24 ( 95% CI: 1.12, 1.35, P ≤ .001) times more likely than Veterans with chronic pain only to use Core Whole Health services, and 1.23 ( 95% CI: 1.14, 1.31, P ≤ .001) times more likely to use CIH therapies. Survey results also showed high interest levels in Core Whole Health services and CIH therapies among Veterans who were not already using these services. Conclusion Early implementation efforts in VHA led to high rates of use of Core Whole Health and CIH therapy use among Veterans with co-occurring chronic pain and PTSD. Future assessments should examine how well these additional services are meeting the needs of Veterans in both groups.
Collapse
Affiliation(s)
- David E. Reed
- Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, United States
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, United States
| | - Barbara G. Bokhour
- Center for Healthcare Organization and Implementation Research, Bedford, MA, United States
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Boston, MA, United States
| | - Lauren Gaj
- Center for Healthcare Organization and Implementation Research, Bedford, MA, United States
| | - Anna M. Barker
- Center for Healthcare Organization and Implementation Research, Bedford, MA, United States
| | - Jamie H. Douglas
- Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, United States
| | - Rian DeFaccio
- Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, United States
| | - Rhonda M. Williams
- Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, United States
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, United States
| | - Charles C. Engel
- Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, United States
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, United States
| | - Steven B. Zeliadt
- Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, United States
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, United States
| |
Collapse
|
46
|
Weiner SG, El Ibrahimi S, Hendricks MA, Hallvik SE, Hildebran C, Fischer MA, Weiss RD, Boyer EW, Kreiner PW, Wright DA, Flores DP, Ritter GA. Factors Associated With Opioid Overdose After an Initial Opioid Prescription. JAMA Netw Open 2022; 5:e2145691. [PMID: 35089351 PMCID: PMC8800077 DOI: 10.1001/jamanetworkopen.2021.45691] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
IMPORTANCE The opioid epidemic continues to be a public health crisis in the US. OBJECTIVE To assess the patient factors and early time-varying prescription-related factors associated with opioid-related fatal or nonfatal overdose. DESIGN, SETTING, AND PARTICIPANTS This cohort study evaluated opioid-naive adult patients in Oregon using data from the Oregon Comprehensive Opioid Risk Registry, which links all payer claims data to other health data sets in the state of Oregon. The observational, population-based sample filled a first (index) opioid prescription in 2015 and was followed up until December 31, 2018. Data analyses were performed from March 1, 2020, to June 15, 2021. EXPOSURES Overdose after the index opioid prescription. MAIN OUTCOMES AND MEASURES The outcome was an overdose event. The sample was followed up to identify fatal or nonfatal opioid overdoses. Patient and prescription characteristics were identified. Prescription characteristics in the first 6 months after the index prescription were modeled as cumulative, time-dependent measures that were updated monthly through the sixth month of follow-up. A time-dependent Cox proportional hazards regression model was used to assess patient and prescription characteristics that were associated with an increased risk for overdose events. RESULTS The cohort comprised 236 921 patients (133 839 women [56.5%]), of whom 667 (0.3%) experienced opioid overdose. Risk of overdose was highest among individuals 75 years or older (adjusted hazard ratio [aHR], 3.22; 95% CI, 1.94-5.36) compared with those aged 35 to 44 years; men (aHR, 1.29; 95% CI, 1.10-1.51); those who were dually eligible for Medicaid and Medicare Advantage (aHR, 4.37; 95% CI, 3.09-6.18), had Medicaid (aHR, 3.77; 95% CI, 2.97-4.80), or had Medicare Advantage (aHR, 2.18; 95% CI, 1.44-3.31) compared with those with commercial insurance; those with comorbid substance use disorder (aHR, 2.74; 95% CI, 2.15-3.50), with depression (aHR, 1.26; 95% CI, 1.03-1.55), or with 1 to 2 comorbidities (aHR, 1.32; 95% CI, 1.08-1.62) or 3 or more comorbidities (aHR, 1.90; 95% CI, 1.42-2.53) compared with none. Patients were at an increased overdose risk if they filled oxycodone (aHR, 1.70; 95% CI, 1.04-2.77) or tramadol (aHR, 2.80; 95% CI, 1.34-5.84) compared with codeine; used benzodiazepines (aHR, 1.06; 95% CI, 1.01-1.11); used concurrent opioids and benzodiazepines (aHR, 2.11; 95% CI, 1.70-2.62); or filled opioids from 3 or more pharmacies over 6 months (aHR, 1.38; 95% CI, 1.09-1.75). CONCLUSIONS AND RELEVANCE This cohort study used a comprehensive data set to identify patient and prescription-related risk factors that were associated with opioid overdose. These findings may guide opioid counseling and monitoring, the development of clinical decision-making tools, and opioid prevention and treatment resources for individuals who are at greatest risk for opioid overdose.
Collapse
Affiliation(s)
- Scott G. Weiner
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Sanae El Ibrahimi
- Division of Research and Evaluation, Comagine Health, Portland, Oregon
- School of Public Health, Department of Epidemiology and Biostatistics, University of Nevada, Las Vegas
| | | | - Sara E. Hallvik
- Division of Research and Evaluation, Comagine Health, Portland, Oregon
| | - Christi Hildebran
- Division of Research and Evaluation, Comagine Health, Portland, Oregon
| | - Michael A. Fischer
- Section of General Internal Medicine, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Roger D. Weiss
- Harvard Medical School, Boston, Massachusetts
- McLean Hospital, Belmont, Massachusetts
| | - Edward W. Boyer
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Peter W. Kreiner
- Schneider Institutes for Health Policy, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts
| | | | - Diana P. Flores
- Division of Research and Evaluation, Comagine Health, Portland, Oregon
| | - Grant A. Ritter
- Schneider Institutes for Health Policy, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts
| |
Collapse
|
47
|
Tang R, Santosa KB, Vu JV, Lin LA, Lai YL, Englesbe MJ, Brummett CM, Waljee JF. Preoperative Opioid Use and Readmissions Following Surgery. Ann Surg 2022; 275:e99-e106. [PMID: 32187028 PMCID: PMC7935087 DOI: 10.1097/sla.0000000000003827] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To assess the association between preoperative opioid exposure and readmissions following common surgery. SUMMARY BACKGROUND DATA Preoperative opioid use is common, but its effect on opioid-related, pain-related, respiratory-related, and all-cause readmissions following surgery is unknown. METHODS We analyzed claims data from a 20% national Medicare sample of patients ages ≥ 65 with Medicare Part D claims undergoing surgery between January 1, 2009 and November 30, 2016. We grouped patients by the dose, duration, recency, and continuity of preoperative opioid prescription fills. We used logistic regression to examine the association between prior opioid exposure and 30-day readmissions, adjusted for patient risk factors and procedure type. RESULTS Of 373,991 patients, 168,579 (45%) filled a preoperative opioid prescription within 12 months of surgery, ranging from minimal to chronic high use. Preoperative opioid exposure was associated with higher rate of opioid-related readmissions, compared with naive patients [low: aOR=1.63, 95% CI=1.26-2.12; high: aOR=3.70, 95% CI=2.71-5.04]. Preoperative opioid exposure was also associated with higher risk of pain-related readmissions [low: aOR=1.27, 95% CI=1.23-1.32; high: aOR=1.62, 95% CI=1.53-1.71] and respiratory-related readmissions [low: aOR=1.10, 95% CI=1.05-1.16; high: aOR=1.44, 95% CI=1.34-1.55]. Low, moderate, and high chronic preoperative opioid exposures were predictive of all-cause readmissions (low: OR 1.09, 95% CI: 1.06-1.12); high: OR 1.23, 95% CI: 1.18-1.29). CONCLUSIONS Higher levels of preoperative opioid exposure are associated with increased risk of readmissions after surgery. These findings emphasize the importance of screening patients for preoperative opioid exposure and creating risk mitigation strategies for patients.
Collapse
Affiliation(s)
- Ruiqi Tang
- Medical Student, University of Michigan Medical School
| | - Katherine B. Santosa
- House Officer, Section of Plastic Surgery, Department of Surgery, Michigan Medicine
| | | | - Lewei A. Lin
- Assistant Professor, Department of Psychiatry, Michigan Medicine Medicine and Research Investigator, VA Ann Arbor Healthcare System
| | - Yen-Ling Lai
- Analyst, Michigan Opioid Prescribing Engagement Network (Michigan OPEN)
| | - Michael J. Englesbe
- Darling Professor of Surgery, Section of Transplantation, Department of Surgery, Michigan Medicine
| | - Chad M. Brummett
- Associate Professor, Division of Pain Medicine, Department of Anesthesiology, Michigan Medicine
| | - Jennifer F. Waljee
- Associate Professor, Section of Plastic Surgery, Department of Surgery, Michigan Medicine
| |
Collapse
|
48
|
DeBar L, Mayhew M, Benes L, Bonifay A, Deyo RA, Elder CR, Keefe FJ, Leo MC, McMullen C, Owen-Smith A, Smith DH, Trinacty CM, Vollmer WM. A Primary Care-Based Cognitive Behavioral Therapy Intervention for Long-Term Opioid Users With Chronic Pain : A Randomized Pragmatic Trial. Ann Intern Med 2022; 175:46-55. [PMID: 34724405 PMCID: PMC9802183 DOI: 10.7326/m21-1436] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Chronic pain is common, disabling, and costly. Few clinical trials have examined cognitive behavioral therapy (CBT) interventions embedded in primary care settings to improve chronic pain among those receiving long-term opioid therapy. OBJECTIVE To determine the effectiveness of a group-based CBT intervention for chronic pain. DESIGN Pragmatic, cluster randomized controlled trial. (ClinicalTrials.gov: NCT02113592). SETTING Kaiser Permanente health care systems in Georgia, Hawaii, and the Northwest. PARTICIPANTS Adults (aged ≥18 years) with mixed chronic pain conditions receiving long-term opioid therapy. INTERVENTION A CBT intervention teaching pain self-management skills in 12 weekly, 90-minute groups delivered by an interdisciplinary team (behaviorist, nurse, physical therapist, and pharmacist) versus usual care. MEASUREMENTS Self-reported pain impact (primary outcome, as measured by the PEGS scale [pain intensity and interference with enjoyment of life, general activity, and sleep]) was assessed quarterly over 12 months. Pain-related disability, satisfaction with care, and opioid and benzodiazepine use based on electronic health care data were secondary outcomes. RESULTS A total of 850 patients participated, representing 106 clusters of primary care providers (mean age, 60.3 years; 67.4% women); 816 (96.0%) completed follow-up assessments. Intervention patients sustained larger reductions on all self-reported outcomes from baseline to 12-month follow-up; the change in PEGS score was -0.434 point (95% CI, -0.690 to -0.178 point) for pain impact, and the change in pain-related disability was -0.060 point (CI, -0.084 to -0.035 point). At 6 months, intervention patients reported higher satisfaction with primary care (difference, 0.230 point [CI, 0.053 to 0.406 point]) and pain services (difference, 0.336 point [CI, 0.129 to 0.543 point]). Benzodiazepine use decreased more in the intervention group (absolute risk difference, -0.055 [CI, -0.099 to -0.011]), but opioid use did not differ significantly between groups. LIMITATION The inclusion of only patients with insurance in large integrated health care systems limited generalizability, and the clinical effect of change in scores is unclear. CONCLUSION Primary care-based CBT, using frontline clinicians, produced modest but sustained reductions in measures of pain and pain-related disability compared with usual care but did not reduce use of opioid medication. PRIMARY FUNDING SOURCE National Institutes of Health.
Collapse
Affiliation(s)
- Lynn DeBar
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington (L.D.)
| | - Meghan Mayhew
- Kaiser Permanente Center for Health Research, Portland, Oregon (M.M., A.B., C.R.E., M.C.L., C.M., D.H.S., W.M.V.)
| | - Lindsay Benes
- Kaiser Permanente Center for Health Research, Portland, Oregon, and Montana State University College of Nursing, Missoula, Montana (L.B.)
| | - Allison Bonifay
- Kaiser Permanente Center for Health Research, Portland, Oregon (M.M., A.B., C.R.E., M.C.L., C.M., D.H.S., W.M.V.)
| | - Richard A Deyo
- Oregon Health & Science University School of Medicine, Portland, Oregon (R.A.D.)
| | - Charles R Elder
- Kaiser Permanente Center for Health Research, Portland, Oregon (M.M., A.B., C.R.E., M.C.L., C.M., D.H.S., W.M.V.)
| | - Francis J Keefe
- Duke University School of Medicine, Durham, North Carolina (F.J.K.)
| | - Michael C Leo
- Kaiser Permanente Center for Health Research, Portland, Oregon (M.M., A.B., C.R.E., M.C.L., C.M., D.H.S., W.M.V.)
| | - Carmit McMullen
- Kaiser Permanente Center for Health Research, Portland, Oregon (M.M., A.B., C.R.E., M.C.L., C.M., D.H.S., W.M.V.)
| | - Ashli Owen-Smith
- Georgia State University School of Public Health and Kaiser Permanente Center for Clinical and Outcomes Research, Atlanta, Georgia (A.O.)
| | - David H Smith
- Kaiser Permanente Center for Health Research, Portland, Oregon (M.M., A.B., C.R.E., M.C.L., C.M., D.H.S., W.M.V.)
| | | | - William M Vollmer
- Kaiser Permanente Center for Health Research, Portland, Oregon (M.M., A.B., C.R.E., M.C.L., C.M., D.H.S., W.M.V.)
| |
Collapse
|
49
|
Hallvik SE, El Ibrahimi S, Johnston K, Geddes J, Leichtling G, Korthuis PT, Hartung DM. Patient outcomes after opioid dose reduction among patients with chronic opioid therapy. Pain 2022; 163:83-90. [PMID: 33863865 PMCID: PMC8494834 DOI: 10.1097/j.pain.0000000000002298] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 03/18/2021] [Indexed: 01/03/2023]
Abstract
ABSTRACT The net effects of prescribing initiatives that encourage dose reductions are uncertain. We examined whether rapid dose reduction after high-dose chronic opioid therapy (COT) associates with suicide, overdose, or other opioid-related adverse events. This retrospective cohort study included Oregon Medicaid recipients with high-dose COT. Claims were linked with prescription data from the prescription drug monitoring program and death data from vital statistics, 2014 to 2017. Participants were placed into 4 mutually exclusive dose trajectory groups after the high-dose COT period, and Cox proportional hazard models were used to examine the effect of dose changes on patient outcomes in the following year. Of the 14,596 high-dose COT patients, 4191 (28.7%) abruptly discontinued opioid prescriptions, 1648 (11.3%) reduced opioid dose before discontinuing, 6480 (44.4%) had a dose reduction but never discontinued, and 2277 (15.6%) had a stable or increasing dose. Discontinuation, whether abrupt (adjusted hazard ratio [aHR] 3.63; 95% confidence interval [CI] 1.42-9.25) or with dose reduction (aHR 4.47, 95% CI 1.68-11.88) significantly increased risk of suicide compared with those with stable or increasing dose. By contrast, discontinuation or dose reduction reduced the risk of overdose compared with those with a stable or increasing dose (aHR 0.36-0.62, 95% CI 0.20-0.94). Patients with an abrupt discontinuation were more likely to overdose on heroin (vs. prescription opioids) than patients in other groups (P < 0.0001). Our study suggests that patients on COT require careful risk assessment and supportive interventions when considering opioid discontinuation or continuation at a high dose.
Collapse
Affiliation(s)
| | | | - Kirbee Johnston
- Oregon State University / Oregon Health & Science University College of Pharmacy, Portland, OR
| | - Jonah Geddes
- Oregon State University / Oregon Health & Science University College of Pharmacy, Portland, OR
| | | | | | - Daniel M. Hartung
- Oregon State University / Oregon Health & Science University College of Pharmacy, Portland, OR
| |
Collapse
|
50
|
Lee B, Yang KC, Kaminski P, Peng S, Odabas M, Gupta S, Green HD, Ahn YY, Perry BL. Substitution of Nonpharmacologic Therapy With Opioid Prescribing for Pain During the COVID-19 Pandemic. JAMA Netw Open 2021; 4:e2138453. [PMID: 34889946 PMCID: PMC8665369 DOI: 10.1001/jamanetworkopen.2021.38453] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 10/17/2021] [Indexed: 11/14/2022] Open
Abstract
Importance During the pandemic, access to medical care unrelated to COVID-19 was limited because of concerns about viral spread and corresponding policies. It is critical to assess how these conditions affected modes of pain treatment, given the addiction risks of prescription opioids. Objective To assess the trends in opioid prescription and nonpharmacologic therapy (ie, physical therapy and complementary medicine) for pain management during the COVID-19 pandemic in 2020 compared with the patterns in 2019. Design, Setting, and Participants This retrospective, cross-sectional study used weekly claims data from 24 million US patients in a nationwide commercial insurance database (Optum's deidentified Clinformatics Data Mart Database) from January 1, 2019, to September 31, 2020. Among patients with diagnoses of limb, extremity, or joint pain, back pain, and neck pain for each week, patterns of treatment use were identified and evaluated. Data analysis was performed from April 1, 2021, to September 31, 2021. Main Outcomes and Measures The main outcomes of interest were weekly rates of opioid prescriptions, the strength and duration of related opioid prescriptions, and the use of nonpharmacologic therapy. Transition rates between different treatment options before the outbreak and during the early months of the pandemic were also assessed. Results A total of 21 430 339 patients (mean [SD] age, 48.6 [24.0] years; 10 960 507 [51.1%] female; 909 061 [4.2%] Asian, 1 688 690 [7.9%] Black, 2 276 075 [10.6%] Hispanic, 11 192 789 [52.2%] White, and 5 363 724 [25.0%] unknown) were enrolled during the first 3 quarters in 2019 and 20 759 788 (mean [SD] age, 47.0 [23.8] years; 10 695 690 [51.5%] female; 798 037 [3.8%] Asian; 1 508 023 [7.3%] Black, 1 976 248 [9.5%] Hispanic, 10 059 597 [48.5%] White, and 6 417 883 [30.9%] unknown) in the first 3 quarters of 2020. During the COVID-19 pandemic, the proportion of patients receiving a pain diagnosis was smaller than that for the same period in 2019 (mean difference, -15.9%; 95% CI, -16.1% to -15.8%). Patients with pain were more likely to receive opioids (mean difference, 3.5%; 95% CI, 3.3%-3.7%) and less likely to receive nonpharmacologic therapy (mean difference, -6.0%; 95% CI, -6.3% to -5.8%), and opioid prescriptions were longer and more potent during the early pandemic in 2020 relative to 2019 (mean difference, 1.07 days; 95% CI, 1.02-1.17 days; mean difference, 0.96 morphine milligram equivalents; 95% CI, 0.76-1.20). Analysis of individuals' transitions between treatment options for pain found that patients were more likely to transition out of nonpharmacologic therapy, replacing it with opioid prescriptions for pain management during the COVID-19 pandemic than in the year before. Conclusions and Relevance Nonpharmacologic therapy is a benign treatment for pain often recommended instead of opioid therapy. The decrease in nonpharmacologic therapy and increase in opioid prescription during the COVID-19 pandemic found in this cross-sectional study, especially given longer days of prescription and more potent doses, may exacerbate the US opioid epidemic. These findings suggest that it is imperative to investigate the implications of limited medical access on treatment substitution, which may increase patient risk, and implement policies and guidelines to prevent those substitutions.
Collapse
Affiliation(s)
- Byungkyu Lee
- Department of Sociology, Indiana University Bloomington, Bloomington
| | - Kai-Cheng Yang
- Luddy School of Informatics, Computing, and Engineering, Indiana University Bloomington, Bloomington
| | - Patrick Kaminski
- Luddy School of Informatics, Computing, and Engineering, Department of Sociology, Indiana University Bloomington, Bloomington
| | - Siyun Peng
- Department of Sociology, Indiana University Bloomington, Bloomington
| | - Meltem Odabas
- Department of Sociology, Indiana University Bloomington, Bloomington
| | - Sumedha Gupta
- Department of Economics, Indiana University–Purdue University, Indianapolis
| | - Harold D. Green
- Department of Applied Health Science, School of Public Health, Indiana University Bloomington, Bloomington
| | - Yong-Yeol Ahn
- Center for Complex Networks and Systems Research, Luddy School of Informatics, Computing and Engineering, Indiana University Bloomington, Bloomington
- Network Science Institute, Indiana University Bloomington, Bloomington
- Connection Science, Massachusetts Institute of Technology, Cambridge
| | - Brea L. Perry
- Department of Sociology, Network Science Institute, Indiana University Bloomington, Bloomington
| |
Collapse
|