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Nguyen KT, Beauchamp DW, O'Hara RB. A Pathophysiological Approach for Selecting Medications to Treat Nociceptive and Neuropathic Pain in Servicemembers. Mil Med 2024; 189:e1879-e1889. [PMID: 38300182 DOI: 10.1093/milmed/usad506] [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: 05/19/2023] [Revised: 09/12/2023] [Accepted: 01/11/2024] [Indexed: 02/02/2024] Open
Abstract
INTRODUCTION The prevalence of chronic pain of service members (SMs) in the U.S. is estimated to be higher (roughly 31-44%) compared to that of civilian population (26%). This higher prevalence is likely due to the high physical demands related combat and training injuries that are not immediately resolved and worsen over time. Mental Health America reports that chronic pain can lead to other mental health conditions such as severe anxiety, depression, bipolar disorder, and post-traumatic stress disorder. Such mental health conditions can negatively affect job performance, reduce readiness for military duties, and often lead to patterns of misuse of opioid after SMs entering civilian life. The primary objective of this narrative review is to present a summarized guideline for the treatment of two types of pain that likely affect SMs, namely nociceptive somatic pain and neuropathic pain. This review focused on a stepwise approach starting with nonopioid interventions prior to opioid therapy. The secondary objective of this review is to elucidate the primary mechanisms of action and pathways associated with these two types of pain. METHODS We followed the Scale for Assessment of Narrative Review Articles when transcribing this narrative review article to enhance the quality and brevity of this review. This Scale has 0.77% an intra-class coefficient of correlation, 95% confidence interval and 0.88 inter-rater reliability. We searched PubMed, Google Scholar, WorldCAT, and the Cochrane Library for the primary and secondary articles that targeted mechanisms of action, pathways, and pharmacological modalities for nociceptive somatic and neuropathic pain that were published from 2011 to 2022. We excluded articles related to pediatric, some specific pain conditions such as cancer-related pain, palliative care, end-of-life care, and articles that were not written in English language. For pharmacologic selection, we adopted the guidelines from the Policy for Implementation of a Comprehensive Policy on Pain Management by the Military Health Care system for the Fiscal Year 2021; the Clinical Practice Guidance for Opioid Therapy for Chronic Pain by the Department of Defense/Veterans Health Administration (2022); the (2021) Implementation of a Comprehensive Policy on Pain Management by the Military Health Care System; and the (2022) Guideline for Prescribing Opioids for Chronic Painby the Centers for Disease Control. DISCUSSION From the knowledge of the mechanisms of action and pathways, we can be more likely to identify the causative origins of pain. As a result, we can correctly diagnose the type of pain, properly develop an efficient and personalized treatment plan, minimize adverse effects, and optimize clinical outcomes. The guideline, however, does not serve as a substitute for clinical judgment in patient-centered decision-making. Medication choices should be individualized judiciously based on the patient's comorbid conditions, available social and economic resources, and the patient's preferences to balance the benefits and risks associated with various pain medications and to achieve optimal pain relief and improve the patient's quality of life.
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Affiliation(s)
- Khan Thi Nguyen
- Interdisciplinary Pain Management Clinic, William Beaumont Army Medical Center, Fort Bliss, TX 79918, USA
| | - Daniel W Beauchamp
- Interdisciplinary Pain Management Clinic, William Beaumont Army Medical Center, Fort Bliss, TX 79918, USA
| | - Reginald B O'Hara
- Department of Clinical Investigation, William Beaumont Army Medical Center, Fort Bliss, TX 79918, USA
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2
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Rhon DI, George SZ, Greenlee TA, Farrokhi S, Lentz TA. General and Pain-Associated Psychological Distress Phenotypes Among Patients With Low Back Pain in the Military Health System. Arthritis Care Res (Hoboken) 2024; 76:943-952. [PMID: 38383982 DOI: 10.1002/acr.25315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 01/17/2024] [Accepted: 02/20/2024] [Indexed: 02/23/2024]
Abstract
OBJECTIVE The primary objective was to describe rates of general and pain-related psychological distress for individuals with low back pain (LBP) in the Military Health System (MHS). We identified common phenotypes defined by rates of general and pain-related psychological distress and compared phenotypes on their level of pain interference, physical function, anxiety, and depression. METHODS We created a cohort from two completed trials assessing nonpharmacological treatment for LBP in the MHS (n = 510 total). The Optimal Screening for Prediction of Referral and Outcome Yellow Flag assessment tool identified the presence of 11 different yellow flags. Latent class analysis (LCA) used yellow flag indicators to identify common psychological phenotypes. We then compared Patient-Reported Outcomes Measurement Information Systems measures of pain interference, physical function, sleep disturbance, depression, and anxiety across phenotypes. RESULTS LCA identified five phenotypes (percentage of the sample): low distress (32%), high distress (27%), poor pain coping and low self-efficacy (18%), low self-efficacy and acceptance (14%), and poor pain coping (10%). Highly distressed phenotypes reported higher levels of pain interference, sleep disturbance, depression, and anxiety than those with other phenotypes, whereas the low distress phenotype had significantly lower pain interference and higher physical function scores than those characterized by all other phenotypes. CONCLUSION These phenotypes provide opportunities for clinicians and researchers to develop novel LBP treatment pathways tailored to patients with different profiles of psychological distress. Future work is needed to validate their predictive capabilities for clinical outcomes.
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Affiliation(s)
- Daniel I Rhon
- Brooke Army Medical Center, Joint Base San Antonio, Fort Sam Houston, Texas, Uniformed Services University, Bethesda, Maryland, and The Geneva Foundation, Tacoma, Washington
| | | | - Tina A Greenlee
- Brooke Army Medical Center, Joint Base San Antonio, Fort Sam Houston, Texas, Uniformed Services University, Bethesda, Maryland, and The Geneva Foundation, Tacoma, Washington
| | - Shawn Farrokhi
- Extremity Trauma and Amputation Center of Excellence, San Diego, California
| | - Trevor A Lentz
- Duke Clinical Research Institute, Durham, North Carolina
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3
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Rupp TL, Amoako M, Johnson K, Rojas W, Highland KB. Massage Therapy Utilization in the Military Health System. Mil Med 2024:usae299. [PMID: 38861401 DOI: 10.1093/milmed/usae299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 05/06/2024] [Accepted: 05/23/2024] [Indexed: 06/13/2024] Open
Abstract
INTRODUCTION Massage therapy is an evidence-based approach for pain management. Information regarding its utilization in the Military Health System (MHS) is lacking. The goal of this study is to evaluate massage therapy utilization patterns across the MHS to include who receives (patient characteristics and diagnoses) and provides (e.g., massage therapists) massage therapy and where (e.g., clinic type). MATERIALS AND METHODS Medical record data of adult TRICARE Prime enrollees receiving outpatient massage therapy (Current Procedural Terminology codes: 97124 and 97140) from June 1, 2021, to May 31, 2023, were extracted from the MHS Data Repository. After identifying the index massage therapy visit, records for 6 months pre- and post-index were included. Descriptive statistics described massage therapy utilization patterns overall. Bivariate analysis compared patients who received massage therapy from massage therapists versus nonmassage therapist clinicians. RESULTS Of patients who received massage therapy (n = 179,215), the median number of visits was 2 (interquartile range 1 to 4), the median age was 32 years (interquartile range 25 to 40), they were mostly assigned male (72%), White (53%), Senior Enlisted (51%), with a musculoskeletal diagnosis (90%), and recent non-steroidal anti-inflammatory drug (NSAID) prescription (58%). Massage therapy was primarily delivered by physical therapists (49%) in physical therapy clinics (74%). Massage therapists provided 0.2% of massage therapy. Patients who received massage therapy from massage therapists versus nonmassage therapists significantly varied across several patient and care characteristics. CONCLUSIONS While massage therapy codes are documented frequently, massage therapists do not commonly provide massage therapy relative to nonmassage therapist providers. Access to massage therapists may be stymied by both lack of massage therapists and need for tertiary pain management referrals to access massage therapist-delivered care. Future research will leverage a health equity framework to (1) evaluate accessibility to massage therapy provided by massage therapists and (2) evaluate real-world evidence of massage therapy effectiveness.
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Affiliation(s)
- Tracy L Rupp
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Rockville, MD 20817, USA
| | - Maxwell Amoako
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Rockville, MD 20817, USA
- Enterprise Intelligence and Data Solutions (EIDS) program office, Program Executive Office, Defense Healthcare Management Systems (PEO DHMS), Arlington, VA 22209, USA
| | - Kevin Johnson
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Rockville, MD 20817, USA
| | - Winifred Rojas
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Rockville, MD 20817, USA
| | - Krista B Highland
- Department of Anesthesiology, School of Medicine, Uniformed Services University, Bethesda, MD 20814, USA
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Wi D, Ransom JC, Flynn DM, Steffen AD, Park C, Burke LA, Doorenbos AZ. Role of Pain Catastrophizing in the Effects of Cognitive Behavioral Therapy for Chronic Pain in Different Subgroups: An Exploratory Secondary Data Analysis Using Finite Mixture Models. Mil Med 2024:usae288. [PMID: 38829170 DOI: 10.1093/milmed/usae288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 03/08/2024] [Accepted: 05/22/2024] [Indexed: 06/05/2024] Open
Abstract
INTRODUCTION Providing effective treatment for debilitating chronic pain is a challenge among many populations including military service members. Cognitive behavioral therapy for chronic pain (CBT-CP) is a leading psychological pain treatment. Pain catastrophizing is a pivotal mediator of pain-related outcomes. The purpose of this study was (1) to identify patient subgroups who differ in response to CBT-CP and (2) to explore the characteristics that define these patient subgroups. The overall goal was to obtain a better understanding of factors that may influence response to CBT-CP. MATERIALS AND METHODS This study was a secondary analysis of data from a clinical trial of 149 U.S. active duty service members with chronic pain. Participants underwent group-based CBT-CP for 6 weeks and completed pre- and posttreatment assessments. Finite mixture models were employed to identify subgroups in treatment response, with pain impact score as the primary outcome measure. RESULTS We identified two classes of nearly equal size with distinct pain impact responses. One class reported improved pain impact scores following CBT-CP. This improvement was significantly associated with lower (better) baseline depression scores and greater improvement in posttreatment pain catastrophizing. In contrast, the other class reported slightly worse mean pain impact scores following CBT-CP treatment; this response was not related to baseline depression or change in pain catastrophizing. CONCLUSIONS Our findings demonstrate that a sizable proportion of individuals with chronic pain may not respond to group-based CBT-CP and may require a more individualized treatment approach.
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Affiliation(s)
- Dahee Wi
- Department of Human Development Nursing Science, College of Nursing, University of Illinois Chicago, Chicago, IL 60612, USA
| | - Jeffrey C Ransom
- Physical Performance Service Line, Interdisciplinary Pain Management Center, Madigan Army Medical Center, Tacoma, WA 98431, USA
| | - Diane M Flynn
- Physical Performance Service Line, Interdisciplinary Pain Management Center, Madigan Army Medical Center, Tacoma, WA 98431, USA
| | - Alana D Steffen
- Department of Population Health Nursing Science, College of Nursing, University of Illinois, Chicago, IL 60612, USA
| | - Chang Park
- Department of Population Health Nursing Science, College of Nursing, University of Illinois, Chicago, IL 60612, USA
| | - Larisa A Burke
- Office of Research Facilitation, College of Nursing, University of Illinois, Chicago, IL 60612, USA
| | - Ardith Z Doorenbos
- Department of Biobehavioral Nursing Science, College of Nursing, University of Illinois, Chicago, IL 60612, USA
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA 98195, USA
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Kelber MS, Smolenski DJ, Belsher BE, O'Gallagher K, Issa F, Stewart LT, Evatt DP. The associations of opioid and benzodiazepine prescriptions with injuries among US military service members. Pain 2024:00006396-990000000-00586. [PMID: 38709494 DOI: 10.1097/j.pain.0000000000003264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 03/18/2024] [Indexed: 05/07/2024]
Abstract
ABSTRACT Given the high rates of physical trauma and pain among service members, opioid-prescribing practices and use patterns have significant implications for the well-being of service members and can affect military medicine and personnel readiness. This study measured the association between prescribed opioid and benzodiazepine medications and subsequently reported injuries (accidental, alcohol and drug related, self-inflicted, and violence related) among active duty military members. Participants were service members who entered the military between January 1, 2005, and June 30, 2010. In a nested case-control design, we compared individuals with injuries to individuals without injuries with respect to their opioid and benzodiazepine prescriptions in the 30 days before the injury of an index case. We used a multiintercept, logistic regression model to compare coefficient estimates by injury type. Overall, approximately 17% of individuals with an injury and 4% of individuals without an injury had a recorded opioid prescription. Individuals with an injury of any type had greater odds of prior exposure to opioid prescriptions than controls. Although a dose-response effect was observed for all injury types, it reached a plateau sooner for natural or environmental accidents and self-inflicted injuries relative to alcohol-related and drug-related injuries, violence-related injuries, vehicle accidents, accidental falls, and other accidents. Benzodiazepine prescriptions were found in 3.5% of individuals with an injury and 0.5% of individuals without an injury. The association between benzodiazepine prescriptions and injuries was strongest for natural and environmental accidents.
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Affiliation(s)
- Marija S Kelber
- Psychological Health Center of Excellence, Defense Health Agency
| | | | - Bradley E Belsher
- Psychological Health Center of Excellence, Defense Health Agency
- Carl T Hayden Veterans Medical Center, Phoenix VA Health Care System
| | | | - Fuad Issa
- Psychological Health Center of Excellence, Defense Health Agency
| | | | - Daniel P Evatt
- Psychological Health Center of Excellence, Defense Health Agency
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Snow T, Burke L, Sanford DC, Mathew A, Steffen AD, Flynn DM, Doorenbos AZ. Use of a treadmill, lift, and carry battery as a composite functional performance test: analysis of data from a pragmatic randomized controlled trial in a military population participating in a functional restoration program. Physiother Theory Pract 2024; 40:647-657. [PMID: 36282735 PMCID: PMC10126206 DOI: 10.1080/09593985.2022.2135149] [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: 12/24/2021] [Revised: 09/16/2022] [Accepted: 09/17/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND The treadmill, lift, and carry (TLC) battery is a composite functional performance test created to measure the effectiveness of a functional restoration (FR) program in a military population. PURPOSE To determine the validity, reliability, and minimal clinically important differences (MCIDs) of the individual tests and the composite TLC battery. METHODS We assessed the validity by mean differences, effect sizes, and standardized response means pre- and post-FR; and by correlations between the TLC battery and other established measures. We assessed reliability by correlating pre- and post-FR scores. We used principal component analysis (PCA) to create a composite measure. We determined MCIDs via distribution methods and receiver operator curve analysis. RESULTS There were significant (p < .001) mean changes and large effect sizes (0.6-0.8) pre- to post-FR. Pre- and posttest Spearman's correlations ranged from 0.5 to 0.6. Spearman's correlations between TLC battery scores and other measures were small (± 0.3-0.4) and significant (p < .001). PCA supported use of a single-component composite. MCIDs were treadmill time: 3 minutes; metabolic equivalent of task: 1.5 units; floor-to-waist lift: 15 lbs; waist-to-shoulder lift: 10 lbs; 40-foot carry: 10 lbs; and composite score: 6 units. CONCLUSION This secondary data analysis provides preliminary support for the validity and reliability of the TLC battery for use in military populations.
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Affiliation(s)
- Tyler Snow
- Department of Rehabilitative Medicine, Madigan Army Medical Center, 9040 Jackson Ave. Tacoma, WA, 98431 USA
| | - Larisa Burke
- College of Nursing, University of Illinois Chicago, 845 S. Damen Ave. Chicago, IL, 60612 USA
| | - Dana C. Sanford
- Department of Rehabilitative Medicine, Madigan Army Medical Center, 9040 Jackson Ave. Tacoma, WA, 98431 USA
| | - Asha Mathew
- College of Nursing, University of Illinois Chicago, 845 S. Damen Ave. Chicago, IL, 60612 USA
| | - Alana D. Steffen
- College of Nursing, University of Illinois Chicago, 845 S. Damen Ave. Chicago, IL, 60612 USA
| | - Diane M. Flynn
- Department of Rehabilitative Medicine, Madigan Army Medical Center, 9040 Jackson Ave. Tacoma, WA, 98431 USA
| | - Ardith Z. Doorenbos
- College of Nursing, University of Illinois Chicago, 845 S. Damen Ave. Chicago, IL, 60612 USA
- Department of Anesthesiology and Pain Medicine, University of Washington, 1959 NE Pacific St. Seattle, WA, USA
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7
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Wi D, Park C, Ransom JC, Flynn DM, Doorenbos AZ. A network analysis of pain intensity and pain-related measures of physical, emotional, and social functioning in US military service members with chronic pain. PAIN MEDICINE (MALDEN, MASS.) 2024; 25:231-238. [PMID: 37944054 PMCID: PMC10906708 DOI: 10.1093/pm/pnad148] [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: 05/08/2023] [Revised: 10/20/2023] [Accepted: 10/26/2023] [Indexed: 11/12/2023]
Abstract
OBJECTIVE The purpose of this study was to apply network analysis methodology to better understand the relationships between pain-related measures among people with chronic pain. METHODS We analyzed data from a cross-sectional sample of 4614 active duty service members with chronic pain referred to 1 military interdisciplinary pain management center between 2014 and 2021. Using a combination of Patient-Reported Outcomes Measurement Information System measures and other pain-related measures, we applied the "EBICglasso" algorithm to create regularized partial correlation networks that would identify the most influential measures. RESULTS Pain interference, depression, and anxiety had the highest strength in these networks. Pain catastrophizing played an important role in the association between pain and other pain-related health measures. Bootstrap analyses showed that the networks were very stable and the edge weights accurately estimated in 2 analyses (with and without pain catastrophizing). CONCLUSIONS Our findings offer new insights into the relationships between symptoms using network analysis. Important findings highlight the strength of association between pain interference, depression and anxiety, which suggests that if pain is to be treated depression and anxiety must also be addressed. What was of specific importance was the role that pain catastrophizing had in the relationship between pain and other symptoms suggesting that pain catastrophizing is a key symptom on which to focus for treatment of chronic pain.
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Affiliation(s)
- Dahee Wi
- Department of Biobehavioral Nursing Science, College of Nursing, University of Illinois Chicago, Chicago, IL 60612, United States
| | - Chang Park
- Department of Population Health Nursing Science, College of Nursing, University of Illinois Chicago, Chicago, IL 60612, United States
| | - Jeffrey C Ransom
- Physical Performance Service Line, Madigan Army Medical Center, Interdisciplinary Pain Management Center, Joint Base Lewis-McChord, WA 98431, United States
| | - Diane M Flynn
- Physical Performance Service Line, Madigan Army Medical Center, Interdisciplinary Pain Management Center, Joint Base Lewis-McChord, WA 98431, United States
| | - Ardith Z Doorenbos
- Department of Biobehavioral Nursing Science, College of Nursing, University of Illinois Chicago, Chicago, IL 60612, United States
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA 98195, United States
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Ullman CJ, Hengst D, Rolfson O, Myers S, Robinson Y. Systematic Review of Injuries and Chronic Musculoskeletal Pain Among High-speed Boat Operators. Mil Med 2024; 189:e573-e580. [PMID: 37837204 PMCID: PMC10898931 DOI: 10.1093/milmed/usad377] [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: 05/22/2023] [Revised: 09/11/2023] [Accepted: 09/19/2023] [Indexed: 10/15/2023] Open
Abstract
INTRODUCTION High-speed boat operators constitute a population at risk of work-related injuries and disabilities. This review aimed to summarize the available knowledge on workplace-related injuries and chronic musculoskeletal pain among high-speed boat operators. MATERIALS AND METHODS In this systematic review, we searched Medline, Embase, Scopus, and the Cochrane Library Database for studies, published from 1980 to 2022, on occupational health and hazards onboard high-speed boats. Studies and reports were eligible for inclusion if they evaluated, compared, used, or described harms associated with impact exposure onboard high-speed boats. Studies focusing on recreational injuries and operators of non-planing boats were excluded. The primary outcome of interest was the incidence of acute injuries. The secondary outcome measures comprised the presence of chronic musculoskeletal disorders, pain medication use, and days off work. RESULTS Of the 163 search results, 5 (2 prospective longitudinal and 3 cross-sectional cohort studies) were included in this systematic review. A total of 804 cases with 3,312 injuries sustained during 3,467 person-years onboard high-speed boats were included in the synthesis of the results. The pooled incidence rate was 1.0 per person-year. The most common injuries were related to the lower back (26%), followed by neck (16%) and head (12%) injuries. The pooled prevalence of chronic pain was 74% (95% CI: 73-75%) and 60% (95% CI: 59-62%) of the cohort consumed analgesics. CONCLUSIONS Despite very limited data, this review found evidence that high-speed boat operators have a higher rate of injuries and a higher prevalence of chronic pain than other naval service operators and the general workforce. Given the low certainty of these findings, further prospective research is required to verify the injury incidence and chronic pain prevalence among high-speed boat operators.
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Affiliation(s)
- Cpt Johan Ullman
- Centre for Disaster Medicine, University of Gothenburg, Box 426, Göteborg 413 45, Sweden
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Göteborgsvägen 31, Mölndal 431 80, Sweden
- Centre for Defence Medicine, Swedish Armed Forces, Göta Älvsgatan 20, Västra Frölunda 426 05, Sweden
| | - David Hengst
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Göteborgsvägen 31, Mölndal 431 80, Sweden
- Department of Orthopaedics, Sahlgrenska University Hospital, Länsmansgatan 28, Mölndal 431 30, Sweden
| | - Ola Rolfson
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Göteborgsvägen 31, Mölndal 431 80, Sweden
- Department of Orthopaedics, Sahlgrenska University Hospital, Länsmansgatan 28, Mölndal 431 30, Sweden
| | - Stephen Myers
- Occupational Performance Research Group, Institute of Applied Sciences, University of Chichester, College Lane, Chichester, West Sussex PO19 6PE, Great Britain
| | - Yohan Robinson
- Centre for Disaster Medicine, University of Gothenburg, Box 426, Göteborg 413 45, Sweden
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Göteborgsvägen 31, Mölndal 431 80, Sweden
- Centre for Defence Medicine, Swedish Armed Forces, Göta Älvsgatan 20, Västra Frölunda 426 05, Sweden
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Gray JC, Larson MJ, Moresco N, Dufour S, Ritter GA, DeLeon PD, Milliken CS, Vest N, Adams RS. Healthcare utilization and readiness outcomes among soldiers with post-deployment at-risk drinking, by multimorbidity class. Alcohol 2024; 114:31-39. [PMID: 37619959 PMCID: PMC10881892 DOI: 10.1016/j.alcohol.2023.08.008] [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: 05/22/2023] [Revised: 08/08/2023] [Accepted: 08/20/2023] [Indexed: 08/26/2023]
Abstract
Although alcohol use disorder (AUD) regularly co-occurs with other conditions, there has not been investigation of specific multimorbidity classes among military members with at-risk alcohol use. We used latent class analysis (LCA) to cluster 138,929 soldiers with post-deployment at-risk drinking based on their co-occurring psychological and physical health conditions and indicators of alcohol severity. We examined the association of these multimorbidity classes with healthcare utilization and military readiness outcomes. Latent class analysis was conducted on 31 dichotomous indicators capturing alcohol use severity, mental health screens, psychological and physical health diagnoses, and tobacco use. Longitudinal survival analysis was used to examine the relative hazards of class membership regarding healthcare utilization (e.g., emergency department visit, inpatient stay) and readiness outcomes (e.g., early separation for misconduct). Latent class analysis identified five classes: Class 1 -Relatively Healthy (51.6 %); Class 2 - Pain/Tobacco (17.3 %); Class 3 - Heavy Drinking/Pain/Tobacco (13.1 %); Class 4 - Mental Health/Pain/Tobacco (12.7 %); and Class 5 - Heavy Drinking/Mental Health/Pain/Tobacco (5.4 %). Musculoskeletal pain and tobacco use were prevalent in all classes, though highest in Classes 2, 4, and 5. Classes 4 and 5 had the highest hazards of all outcomes. Class 5 generally exhibited slightly higher hazards of all outcomes than Class 4, demonstrating the exacerbation of risk among those with heavy drinking/AUD in combination with mental health conditions and other multimorbidity. This study provides new information about the most common multimorbidity presentations of at-risk drinkers in the military so that targeted, individualized care may be employed. Future research is needed to determine whether tailored prevention and treatment approaches for soldiers in different multimorbidity classes is associated with improved outcomes.
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Affiliation(s)
- Joshua C Gray
- Uniformed Services University of the Health Sciences, Department of Medical and Clinical Psychology, Bethesda, MD 20814, United States.
| | - Mary Jo Larson
- Brandeis University, Heller School for Social Policy and Management, Institute for Behavioral Health, Waltham, MA 02453, United States
| | - Natalie Moresco
- Brandeis University, Heller School for Social Policy and Management, Institute for Behavioral Health, Waltham, MA 02453, United States
| | - Steven Dufour
- Uniformed Services University of the Health Sciences, Department of Medical and Clinical Psychology, Bethesda, MD 20814, United States; Naval Medical Center Portsmouth, Portsmouth, VA 23708, United States
| | - Grant A Ritter
- Brandeis University, Heller School for Social Policy and Management, Institute for Behavioral Health, Waltham, MA 02453, United States
| | - Patrick D DeLeon
- Walter Reed National Military Medical Center, Bethesda, MD 20814, United States
| | - Charles S Milliken
- Army's Substance Use Disorder Clinical Care, Office of the Army Surgeon General, Defense Health Headquarters, 7700 Arlington Blvd., Falls Church, VA 22042, United States
| | - Noel Vest
- Boston University School of Public Health, Department of Community Health Sciences, Boston, MA 02118, United States
| | - Rachel Sayko Adams
- Brandeis University, Heller School for Social Policy and Management, Institute for Behavioral Health, Waltham, MA 02453, United States; Boston University School of Public Health, Department of Health Law, Policy & Management, Boston, MA 02118, United States; Veterans Health Administration, Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, CO 80045, United States
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10
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Bounds CL, Coppieters MW, Thomson HW, Larsen B, Evans K. Efficacy of Conservative Interventions for Musculoskeletal Conditions on Pain and Disability in Active Serving Military Personnel-A Systematic Review. Mil Med 2024; 189:e66-e75. [PMID: 36722165 PMCID: PMC10824481 DOI: 10.1093/milmed/usac409] [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: 05/25/2022] [Revised: 08/21/2022] [Accepted: 12/12/2022] [Indexed: 02/02/2023] Open
Abstract
INTRODUCTION Musculoskeletal (MSK) injuries and associated pain disorders are one of the leading causes for soldiers not being medically fit for deployment, impacting force capability and readiness. Musculoskeletal pain continues to be a leading cause of disability within military services and is associated with a substantial financial burden. A better understanding of the effectiveness of MSK pain management strategies is required. This review was designed to determine the efficacy of nonsurgical interventions, such as physiotherapy, exercise, pharmacology, and multidisciplinary programs, to manage MSK conditions in active serving military populations. MATERIALS AND METHODS MEDLINE, Embase, CINAHL, and SPORTDiscus were searched to identify relevant randomized clinical trials. Recommended methods were used for article identification, selection, and data extraction. The Cochrane Risk of Bias tool and the Grade of Recommendation, Assessment, Development, and Evaluation were used to appraise the studies. Where possible, meta-analyses were performed. The review was conducted according to the PRISMA guidelines. RESULTS Nineteen articles (1,408 participants) met the eligibility criteria. Low back pain (LBP) was the most frequently investigated condition, followed by knee pain, neck pain, and shoulder pain. Early physiotherapy, exercise and adjunct chiropractic manipulation (for LBP), and multidisciplinary pain programs (physiotherapy, occupational therapy, and psychology) (for chronic MSK pain) improved pain (standardized mean difference ranged from -0.39 to -1.34; low strength of evidence). Participation in multidisciplinary pain programs, adjunct chiropractic manipulation, and early physiotherapy improved disability (for LBP) (standardized mean difference ranged from -0.45 to -0.86; low to very low strength of evidence). No studies evaluated pain medication. Dietary supplements (glucosamine, chondroitin sulfate, and manganese ascorbate), electrotherapy, isolated lumbar muscle exercises, home cervical traction, or training in virtual reality showed no benefit. The studies had a high risk of bias, were typically underpowered, and demonstrated high clinical heterogeneity. CONCLUSIONS Currently available randomized clinical trials do not provide sufficient evidence to guide military organizations or health care professionals in making appropriate treatment decisions to manage MSK pain in active serving military personnel. Future research is essential to enable evidence-based recommendations for the effective management of MSK pain conditions in this unique population.
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Affiliation(s)
- Courtney L Bounds
- Menzies Health Institute Queensland, Griffith University, Brisbane (Nathan), QLD 4111, Australia
| | - Michel W Coppieters
- Menzies Health Institute Queensland, Griffith University, Brisbane (Nathan), QLD 4111, Australia
- Amsterdam Movement Sciences-Program Musculoskeletal Health, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam 1081 BT, The Netherlands
| | - Hayley W Thomson
- Menzies Health Institute Queensland, Griffith University, Brisbane (Nathan), QLD 4111, Australia
- Gold Coast University Hospital, Gold Coast Hospital and Health Service, Southport, QLD 4125, Australia
- Griffith Sports Physiology and Performance, Griffith University, Southport QLD 4222, Australia
- Healthia Limited, Brisbane, QLD 4006, Australia
| | - Brianna Larsen
- School of Health and Medical Sciences, University of Southern Queensland, Ipswich, QLD 4305, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2006, Australia
| | - Kerrie Evans
- Griffith Sports Physiology and Performance, Griffith University, Southport QLD 4222, Australia
- Healthia Limited, Brisbane, QLD 4006, Australia
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11
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Dufour S, Banaag A, Schoenfeld AJ, Adams RS, Koehlmoos TP, Gray JC. Diagnostic profiles associated with long-term opioid therapy in active duty servicemembers. PM R 2024; 16:14-24. [PMID: 37162022 PMCID: PMC10786620 DOI: 10.1002/pmrj.12994] [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: 12/23/2022] [Revised: 03/20/2023] [Accepted: 04/26/2023] [Indexed: 05/11/2023]
Abstract
INTRODUCTION Over-prescription of opioids has diminished in recent years; however, certain populations remain at high risk. There is a dearth of research evaluating prescription rates using specific multimorbidity patterns. OBJECTIVE To identify distinct clinical profiles associated with opioid prescription and evaluate their relative odds of receiving long-term opioid therapy. DESIGN Retrospective analysis of the complete military electronic health record. We assessed demographics and 26 physiological, psychological, and pain conditions present during initial opioid prescription. Latent class analysis (LCA) identified unique clinical profiles using diagnostic data. Logistic regression measured the odds of these classes receiving long-term opioid therapy. SETTING All electronic health data under the TRICARE network. PARTICIPANTS All servicemembers on active duty during fiscal years 2016 through 2019 who filled at least one opioid prescription. MAIN OUTCOME MEASURES Number and qualitative characteristics of LCA classes; odds ratios (ORs) from logistic regression. We hypothesized that LCA classes characterized by high-risk contraindications would have significantly higher odds of long-term opioid therapy. RESULTS A total of N = 714,446 active duty servicemembers were prescribed an opioid during the study window, with 12,940 (1.8%) receiving long-term opioid therapy. LCA identified five classes: Relatively Healthy (82%); Musculoskeletal Acute Pain and Substance Use Disorders (6%); High Pain, Low Mental Health Burden (9%); Low Pain, High Mental Health Burden (2%), and Multisystem Multimorbid (1%). Logistic regression found that, compared to the Relatively Healthy reference, the Multisystem Multimorbid class, characterized by multiple opioid contraindications, had the highest odds of receiving long-term opioid therapy (OR = 9.24; p < .001; 95% confidence interval [CI]: 8.56, 9.98). CONCLUSION Analyses demonstrated that classes with greater multimorbidity at the time of prescription, particularly co-occurring psychiatric and pain disorders, had higher likelihood of long-term opioid therapy. Overall, this study helps identify patients most at risk for long-term opioid therapy and has implications for health care policy and patient care.
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Affiliation(s)
- Steven Dufour
- Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, MD
- Naval Medical Center Portsmouth, Portsmouth, VA
| | - Amanda Banaag
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD
| | - Andrew J. Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Rachel Sayko Adams
- Boston University School of Public Health, Department of Health Law, Policy and Management, Boston, MA
- Veterans Health Administration, Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, CO
| | - Tracey Perez Koehlmoos
- Center for Health Services Research, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Joshua C. Gray
- Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, MD
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12
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Hepner KA, Sousa JL, Roth CP, Huilgol SS, Jean C, Schulson LB, Gandhi P, Malika N, Engel CC. Improving Pain Care for Service Members: Administrator, Provider, and Patient Perspectives on Treatment, Policies, and Opportunities for Change. RAND HEALTH QUARTERLY 2023; 11:3. [PMID: 38264313 PMCID: PMC10732241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
Acute and chronic pain are common among service members, with musculoskeletal pain and injuries being the leading cause of nondeployability among active-duty service members. Given the significant implications for individual health and force readiness, providing high-quality pain care to service members is a priority of the Military Health System (MHS). Prior RAND research used administrative data to assess the quality and safety of pain care and opioid prescribing in the MHS, generated a set of quality measures that the MHS could adopt going forward, and identified strengths and opportunities for improvement in care provided to service members with pain conditions. In this study, authors document findings from interviews with MHS administrators, providers, and patients, providing valuable detail and context for those findings, along with on-the-ground perspectives on MHS pain care policies and guidance in practice. Staff and patients recommended prioritizing increases in treatment access and availability to improve pain care, and patients emphasized effective treatment and patient-centered care as the most important facilitators of high-quality pain care.
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13
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Schaaf S, Flynn DM, Steffen AD, Ransom J, Doorenbos A. Pain Catastrophizing and Its Association with Military Medical Disability Among US Active Duty Service Members with Chronic Predominately Musculoskeletal Pain: A Retrospective Cohort Analysis. J Pain Res 2023; 16:3837-3852. [PMID: 37965277 PMCID: PMC10642487 DOI: 10.2147/jpr.s400313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 07/06/2023] [Indexed: 11/16/2023] Open
Abstract
Context Pain catastrophizing is characterized by negative emotional and cognitive responses to pain and is a predictor of work-related disability. Its association with military medical disability has not been studied. Objective To (1) identify the pain catastrophizing scale (PCS) score cut point most strongly associated with military medical disability, (2) measure the difference in rate of disability between service members with baseline PCS scores above versus below the cut point, and (3) determine if improvement in PCS score during pain specialty care is associated with decreased likelihood of disability. Methods This was a retrospective cohort analysis comparing PCS scores collected from US Army active duty service members at time of initial visit to an interdisciplinary pain management center and periodically during pain treatment. Outcome was determination during the following year of a military service-disqualifying disability. Results Receiver operating characteristic (ROC) curves determined that a PCS score of 20 was the single cut point most closely associated with subsequent disability. Kaplan-Meier curves showed significantly higher disability rate during the following year among those with baseline PCS scores ≥20 (52%) compared to those with lower scores (26%). Scheffe-adjusted contrasts showed that service members with PCS scores ≥20 whose scores improved to <20 at follow-up were significantly less likely to have a medical disability (42.6%; 95% CI, 0.07-0.58) than those whose PCS score remained ≥20 (76.3%; 95% CI, 68.0%-84.7%). Conclusion A PCS score cut point of 20 distinguishes between high versus low likelihood of disability among service members. Those with high baseline PCS score had twice the likelihood of disability than those with low scores. Service members who decreased their PCS score from high to low during pain specialty care had lower likelihood of disability. Prospective research is needed to determine if treatments that lower pain catastrophizing yield reduced likelihood of subsequent disability.
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Affiliation(s)
- Sherrill Schaaf
- School of Health Sciences, A.T. Still University, Mesa, AZ, USA
| | - Diane M Flynn
- Interdisciplinary Pain Management Center, Madigan Army Medical Center, Tacoma, WA, USA
| | - Alana D Steffen
- College of Nursing, University of Illinois Chicago, Chicago, IL, USA
| | - Jeffrey Ransom
- Interdisciplinary Pain Management Center, Madigan Army Medical Center, Tacoma, WA, USA
| | - Ardith Doorenbos
- College of Nursing, University of Illinois Chicago, Chicago, IL, USA
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA, USA
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14
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Ee JS, Culp PA, Bevis ZJ, Dogbey GY, Agnello RN, Chang MH. Chronic Pain and Childhood Adversity Experiences Among U.S. Military Personnel. Mil Med 2023; 188:561-566. [PMID: 37948239 DOI: 10.1093/milmed/usad244] [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: 11/24/2022] [Revised: 04/14/2023] [Accepted: 06/25/2023] [Indexed: 11/12/2023] Open
Abstract
INTRODUCTION Chronic pain in a military population is prevalent, is costly, and can limit daily activities and affect soldier readiness. It has been associated with childhood adversity (CA) within the veteran, adult, and pediatric populations. Given the need to maximize soldier resiliency, an examination of the link between CA and chronic pain in an active duty population for a better understanding that informs treatment options is warranted. MATERIALS AND METHODS The analytic sample comprised 32 men and 8 women drawn from a retrospective review of 203 intake assessments at an interdisciplinary pain management center. We identified a group (CA) of 20 patients who reported a history of pre-adolescent sexual abuse or living in an "abusive" childhood home and compared it with a control group (no-CA) of 20 patients, matched for age, gender, pain history duration, and pain problem. Validated measures were used to assess pain intensity, interference in functioning and well-being, emotional sequelae of pain as reflected in symptoms of depression and anxiety, and pain-related catastrophic thinking. Data were analyzed using descriptive statistics and independent samples t-test analyses. RESULTS Differences in current, worst, and average pain ratings were non-significant between groups. The CA group reported significantly greater effect of pain on mood (mean: 6.20 versus 4.25, P < .02) and showed a trend toward higher pain interference in functioning (mean: 17.70 versus 15.05, P = .053). The CA patients had significantly more serious depression (mean: 12.65 versus 4.50, P < .001) and anxiety symptoms (mean: 10.60 versus 2.35, P < .001) and significantly higher pain catastrophizing tendency (mean: 30.05 versus 20.50, P < .03). CONCLUSIONS Overall, the findings suggest that childhood trauma should be considered by providers when treating depression and anxiety in soldiers with chronic pain. Being mindful of trauma-informed care may have implications, perhaps, for cases perceived as treatment resistant.
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Affiliation(s)
- Juliana S Ee
- Department of Family Medicine, Womack Army Medical Center, Fort Liberty, NC 28310, USA
| | - Phillip A Culp
- Department of Family Medicine, Dwight D. Eisenhower Army Medical Center, Fort Gordon, GA 30905, USA
| | - Zachary J Bevis
- Department of Family Medicine, Womack Army Medical Center, Fort Liberty, NC 28310, USA
| | - Godwin Y Dogbey
- Department of Research and Medical Education, Campbell University, Jerry M. Wallace School of Osteopathic Medicine, Lillington, NC 27546, USA
| | - Robert N Agnello
- Department of Family Medicine, Campbell University, Jerry M. Wallace School of Osteopathic Medicine, Lillington, NC 27546, USA
| | - Min Ho Chang
- Department of Medicine, Womack Army Medical Center, Fort Liberty, NC 28310, USA
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15
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Kegel JL, Kazman JB, Clifton DR, Emanuele P, Nelson DA, Deuster PA. The combined effects of coping and pain interference on army readiness. FRONTIERS IN PAIN RESEARCH 2023; 4:1175574. [PMID: 37654909 PMCID: PMC10465792 DOI: 10.3389/fpain.2023.1175574] [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: 03/07/2023] [Accepted: 08/01/2023] [Indexed: 09/02/2023] Open
Abstract
Introduction Chronic pain and associated interference with daily activities are common in the military and impact Force readiness. Chronic pain affects one-third of service members and is a leading cause of medical non-readiness (MNR) in the military. Research suggests that underlying psychological mechanisms related to trait coping styles and pain interference (PI) affect functional outcomes, but little research exists examining this relationship within an Army population. The purpose of this study was to examine the combined effects of PI and coping on U.S. Army soldier readiness by using annual well-being data from the Global Assessment Tool (GAT) and medical non-readiness (MNR) based on duty restriction records. Methods The sample comprised 866,379 soldiers who completed the GAT between 2014 and 2017 with no duty restrictions at the time of baseline GAT completion; subjects were observed through 2018 for duty restrictions. Parametric survival regression models with a Weibull distribution predicted demographic-adjusted hazards of MNR by dichotomized PI (no PI/PI) and beneficial/non-beneficial use of GAT coping components (good coping, bad coping, catastrophizing-flexibility, and catastrophizing-hopelessness). Incident MNR was evaluated for all duty restrictions, and stratified by selected body systems (upper extremity, lower extremity, psychiatric). Results Among soldiers with PI, hazards were higher in those reporting non-beneficial coping styles (bad coping, hopelessness) and lower in those reporting beneficial coping styles (good coping, flexibility). Across all coping styles, PI/coping interactions were particularly strong for catastrophizing-hopelessness and when examining MNR from psychiatric conditions. Discussion These findings suggest some synergistic associations between pain and coping that may impact pain-related occupational disability. Coping skills may be an effective interventional target for chronic pain reduction/prevention within military programs, such as the Master Resilience Training Course offered to soldiers in the Army. Further research should assess whether early coping style interventions can reduce pain-related outcomes.
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Affiliation(s)
- Jessica L. Kegel
- Consortium for Health and Military Performance, Department of Military and Emergency Medicine, F. Edward Hébert School of Medicine, Uniformed Services University, Bethesda, MD, United States
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, United States
| | - Josh B. Kazman
- Consortium for Health and Military Performance, Department of Military and Emergency Medicine, F. Edward Hébert School of Medicine, Uniformed Services University, Bethesda, MD, United States
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, United States
| | - Daniel R. Clifton
- Consortium for Health and Military Performance, Department of Military and Emergency Medicine, F. Edward Hébert School of Medicine, Uniformed Services University, Bethesda, MD, United States
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, United States
| | - Peter Emanuele
- Consortium for Health and Military Performance, Department of Military and Emergency Medicine, F. Edward Hébert School of Medicine, Uniformed Services University, Bethesda, MD, United States
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, United States
| | - D. Alan Nelson
- Consortium for Health and Military Performance, Department of Military and Emergency Medicine, F. Edward Hébert School of Medicine, Uniformed Services University, Bethesda, MD, United States
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, United States
| | - Patricia A. Deuster
- Consortium for Health and Military Performance, Department of Military and Emergency Medicine, F. Edward Hébert School of Medicine, Uniformed Services University, Bethesda, MD, United States
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16
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Moore BA, Vincent SR, Schlenk MA, McNamara CL. Opioid use disorder in the active service: Implications for intervention. Am J Addict 2023; 32:415-418. [PMID: 36960793 DOI: 10.1111/ajad.13415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 02/22/2023] [Accepted: 03/22/2023] [Indexed: 03/25/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Military service members experience occupational-specific injuries that may result in chronic pain and comorbid behavioral health concerns. METHODS Data from the Defense Medical Epidemiology Database was used to examine opioid use disorder (OUD) diagnoses between 2016 and 2021. Statistical analysis calculated incidence rates and diagnostic variability by demographic density. RESULTS The average incidence rate of OUD was 6.1 (per 10,000) and declined by 34% between 2016 and 2021. Diagnoses were most frequently made in service members classified as male, married, white, aged 30-39, junior enlisted, and serving in the Army. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE To our knowledge, this is the first study to examine the incidence rates of OUD among active duty personnel.
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Affiliation(s)
- Brian A Moore
- Department of Psychological Science, Kennesaw State University, Kennesaw, Georgia, USA
- Center for the Advancement of Military and Emergency Services (AMES) Research, Kennesaw, Georgia, USA
| | - Sophie R Vincent
- Center for the Advancement of Military and Emergency Services (AMES) Research, Kennesaw, Georgia, USA
- Department of Molecular and Cellular Biology, Kennesaw State University, Kennesaw, Georgia, USA
| | - Michael A Schlenk
- Center for the Advancement of Military and Emergency Services (AMES) Research, Kennesaw, Georgia, USA
| | - Corinne L McNamara
- Department of Psychological Science, Kennesaw State University, Kennesaw, Georgia, USA
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17
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Ransom JC, Brosz-Hardin S, Calero P, DeFord N, Burkard JF. Examining the effects of chronic pain on work performance in the military. J Am Assoc Nurse Pract 2022; 34:827-834. [PMID: 35439215 DOI: 10.1097/jxx.0000000000000711] [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: 11/16/2021] [Accepted: 02/25/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Effectively managing pain is a unique challenge for the U.S. military. Chronic pain has a tremendous detrimental impact on mission readiness throughout the Armed Forces. Examining the effects of chronic pain on readiness is critical to understanding and addressing these challenges. PURPOSE The purpose of this study was to examine the associations of chronic pain and sleep disruption in the context of work performance among active duty military service members. METHODOLOGICAL ORIENTATION The study design was a cross-sectional observational study that examined associations between patients with chronic pain and sleep disruption, in the context of work performance. RESULTS One hundred forty-five participants completed the study. Age, depression, sleep, and pain severity were consistently strong predictors of work performance. CONCLUSIONS Patients performed better with age, whereas those with depression, sleep disruption, and increased pain severity performed poorly. IMPLICATIONS FOR PRACTICE Research focused on the differences in work performance among age groups may provide a better understanding of coping strategies. Focused depression research can lead to a greater understanding of how mental health affects pain, sleep, and work. The findings of this study open the door to explore multiple approaches that could lead to treatments and preventions for military members living with chronic pain.
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Affiliation(s)
- Jeffrey C Ransom
- Center for Nursing Science & Clinical Inquiry, Madigan Army Medical Center, Joint Base Lewis-McChord, Washington
- Naval Medical Center San Diego, San Diego, California
- Hahn School of Nursing and Health Science, University of San Diego, San Diego, California
| | - Sally Brosz-Hardin
- Hahn School of Nursing and Health Science, University of San Diego, San Diego, California
| | - Patricia Calero
- Hahn School of Nursing and Health Science, University of San Diego, San Diego, California
| | - Nicole DeFord
- Naval Medical Center San Diego, San Diego, California
| | - Joseph F Burkard
- Hahn School of Nursing and Health Science, University of San Diego, San Diego, California
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Jacob L, López-Sánchez GF, Oh H, Grabovac I, Stefanac S, Shin JI, Tully MA, López-Bueno R, Koyanagi A, Barnett Y, Haro JM, Smith L. Association between back and neck pain and workplace absenteeism in the USA: the role played by walking, standing, and sitting difficulties. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2022; 31:926-934. [PMID: 35034162 DOI: 10.1007/s00586-021-07084-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 08/23/2021] [Accepted: 11/30/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE There is a paucity of literature identifying factors that influence the back and neck pain (BNP)-workplace absenteeism relationship. Therefore, this study aimed to investigate the association between BNP and workplace absenteeism and potential mediating variables in a large sample of the US population. METHODS Nationally representative data collected in 2019 from the RAND American Life Panel (ALP) were used for this retrospective study. Workplace absenteeism was defined as the number of days of absence in the past 12 months for health-related reasons (count variable), while BNP corresponded to the presence of back pain due to spinal stenosis, back pain due to other causes, or neck pain (dichotomous variable). Control variables included sex, age, ethnicity, marital status, education, occupation, annual family income, health insurance, obesity, and diabetes. There were eight influential variables (depression, anxiety, sleep disorder, alcohol dependence, opioid dependence, walking difficulty, standing difficulty, and sitting difficulty). The association between BNP and workplace absenteeism was analyzed using a negative binomial regression model. RESULTS There were 1,471 adults aged 22-83 years included in this study (52.9% of men; mean [standard deviation] age 44.5 [13.0] years). After adjusting for control variables, BNP was positively and significantly associated with workplace absenteeism (incidence rate ratio = 1.40, 95% confidence interval: 1.07-1.83). Walking, standing, and sitting difficulties individually explained between 24 and 43% of this association. CONCLUSIONS Workplace interventions focusing on the management of BNP and overcoming difficulties in walking, standing, and sitting, potentially utilizing exercise, therapy, and ergonomic interventions, may prevent absenteeism.
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Affiliation(s)
- Louis Jacob
- Research and Development Unit, Parc Sanitari Sant Joan de Déu, Dr. Antoni Pujadas, 42, 08830, Sant Boi de Llobregat, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain
- Faculty of Medicine, University of Versailles Saint-Quentin-en-Yvelines, 78180, Montigny-le-Bretonneux, France
| | - Guillermo F López-Sánchez
- Faculty of Health, Education, Medicine and Social Care, School of Medicine, Vision and Eye Research Institute, Anglia Ruskin University-Cambridge Campus, Cambridge, UK.
| | - Hans Oh
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, CA, 90015, USA
| | - Igor Grabovac
- Department of Social and Preventive Medicine, Centre for Public Health, Medical University of Vienna, Vienna, Austria
| | - Sinisa Stefanac
- Centre for Medical Statistics, Informatics and Intelligent Systems, Institute for Outcomes Research, Medical University of Vienna, Vienna, Austria
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Mark A Tully
- School of Health Sciences, Institute of Mental Health Sciences, Ulster University, Newtownabbey, Antrim, UK
| | - Rubén López-Bueno
- Department of Physical Medicine and Nursing, University of Zaragoza, 50009, Zaragoza, Spain
| | - Ai Koyanagi
- Research and Development Unit, Parc Sanitari Sant Joan de Déu, Dr. Antoni Pujadas, 42, 08830, Sant Boi de Llobregat, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain
- ICREA, Pg. Lluis Companys 23, 08010, Barcelona, Spain
| | - Yvonne Barnett
- Faculty of Science and Engineering, Anglia Ruskin University, Cambridge, CB1 1PT, UK
| | - Josep Maria Haro
- Research and Development Unit, Parc Sanitari Sant Joan de Déu, Dr. Antoni Pujadas, 42, 08830, Sant Boi de Llobregat, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain
| | - Lee Smith
- The Cambridge Centre for Sport and Exercise Sciences, Anglia Ruskin University, Cambridge, UK
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Meerwijk EL, Adams RS, Larson MJ, Highland KB, Harris AHS. Dose of Exercise Therapy Among Active Duty Soldiers With Chronic Pain Is Associated With Lower Risk of Long-Term Adverse Outcomes After Linking to the Veterans Health Administration. Mil Med 2022; 188:usac074. [PMID: 35311994 PMCID: PMC10363012 DOI: 10.1093/milmed/usac074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 02/09/2022] [Accepted: 03/04/2022] [Indexed: 07/25/2023] Open
Abstract
INTRODUCTION Research in soldiers who had been deployed to Iraq or Afghanistan suggests that nonpharmacological treatments may be protective against adverse outcomes. However, the degree to which exercise therapy received in the U.S. Military Health System (MHS) among soldiers with chronic pain is associated with adverse outcomes after soldiers transition to the Veterans Health Administration (VHA) is unclear. The objective of this study was to determine if exercise therapy received in the MHS among soldiers with chronic pain is associated with long-term adverse outcomes after military separation and enrollment into the VHA and whether this association is moderated by prescription opioid use before starting exercise therapy. MATERIALS AND METHODS We conducted a longitudinal cohort study of electronic medical records of active duty Army soldiers with documented chronic pain after an index deployment to Iraq or Afghanistan (years 2008-2014) who subsequently enrolled in the VHA (N = 93,967). Coarsened exact matching matched 37,310 soldiers who received exercise therapy and 28,947 soldiers who did not receive exercise therapy in the MHS. Weighted multivariable Cox proportional hazard models tested for differences in adverse outcomes between groups with different exercise therapy exposure vs. no exercise therapy.Exercise therapy was identified by procedure codes on ambulatory records in the MHS and expressed as the number of exercise therapy visits in 1 year after the first diagnosis with a chronic pain condition. The number of visits was then stratified into seven dose groups.The primary outcomes were weighted proportional hazards for: (1) alcohol and drug disorders, (2) suicide ideation, (3) intentional self-injury, and (4) all-cause mortality. Outcomes were determined based on ICD-9 and ICD-10 diagnoses recorded in VHA healthcare records from enrollment till September 30, 2020. RESULTS Our main analysis indicated significantly lower hazard ratios (HRs) for all adverse outcomes except intentional self-injury, for soldiers with at least eight visits for exercise therapy, compared to soldiers who received no exercise therapy. In the proportional hazard model for any adverse outcome, the HR was 0.91 (95% CI 0.84-0.99) for soldiers with eight or nine exercise therapy visits and 0.91 (95% CI 0.86-0.96) for soldiers with more than nine visits. Significant exercise therapy × prior opioid prescription interactions were observed. In the group that was prescribed opioids before starting exercise therapy, significantly lower HRs were observed for soldiers with more than nine exercise therapy visits, compared to soldiers who received no exercise therapy, for alcohol and drug disorders (HR = 0.85, 95% CI 0.77-0.92), suicide ideation (HR = 0.77, 95% CI 0.66-0.91), and for self-injury (HR = 0.58, 95% CI 0.41-0.83). CONCLUSIONS Exercise therapy should be considered in the multimodal treatment of chronic pain, especially when pain is being managed with opioids, as it may lower the risk of serious adverse outcomes associated with chronic pain and opioid use. Our findings may generalize only to those active duty soldiers with chronic pain who enroll into VHA after separating from the military.
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Affiliation(s)
- Esther L Meerwijk
- VA Health Services Research & Development, Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA 94025, USA
| | - Rachel Sayko Adams
- Heller School for Social Policy and Management, Institute for Behavioral Health, Brandeis University, Waltham, MA 02453, USA
- Rocky Mountain Mental Illness Research Education and Clinical Center, Veterans Health Administration, Aurora, CO 80045, USA
| | - Mary Jo Larson
- Heller School for Social Policy and Management, Institute for Behavioral Health, Brandeis University, Waltham, MA 02453, USA
| | - Krista B Highland
- Department of Anesthesiology, Uniformed Services University, Bethe-sda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine Inc., Bethesda, MD 20817, USA
| | - Alex H S Harris
- VA Health Services Research & Development, Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA 94025, USA
- Department of Surgery, Stanford University, Stanford, CA 94305, USA
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Flynn DM, McQuinn H, Burke L, Steffen A, Fairchok A, Snow T, Doorenbos AZ. Use of Complementary and Integrative Health Therapies Prior to Intensive Functional Restoration in Active Duty Service Members with Chronic Pain. PAIN MEDICINE 2021; 23:844-856. [PMID: 34791423 DOI: 10.1093/pm/pnab326] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 10/09/2021] [Accepted: 10/24/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Psychosocial factors are known to predict chronic pain, and the use of complementary and integrative health (CIH) therapies to address pain is emerging among military population. However, conflicting results on pain outcomes warrant additional research. This study aimed to (1) evaluate the benefit of adding a CIH pain management program to standard rehabilitative care (SRC), as compared to SRC alone, as precursor to an intensive functional restoration (FR) program; (2) identify factors that predict improvement in pain outcomes following treatment; and (3) determine the proportion of participants who experience clinically meaningful response. DESIGN Pragmatic randomized controlled clinical trial. Participants were randomized to a 3-week course of either SRC alone or SRC+CIH (stage 1), followed by a 3- to 6-week course of FR (stage 2). SETTING AND SUBJECTS Active duty service members with chronic pain. METHODS Participants completed either SRC alone or SRC+CIH (stage 1), followed by a course of FR (stage 2). Patient-reported and provider-determined outcomes were collected at baseline, after stage 1, and after stage 2. A covariance pattern model with unstructured residual covariance matrix was used to compare treatment arms while accounting for dependency due to repeated measurements. RESULTS A total of 210 service members participated. Most were Army (82%) and male (84%). Participants randomized to the SRC+CIH intervention had greater improvement in the pain impact score than those in the SRC alone group. Predictors of outcomes were baseline impact score, anger, depression, and educational status. CONCLUSIONS This study found that military service members with the highest pain impact benefit the most from interdisciplinary pain care.
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Affiliation(s)
| | | | - Larisa Burke
- College of Nursing, University of Illinois, Chicago, USA
| | - Alana Steffen
- College of Nursing, University of Illinois, Chicago, USA
| | | | - Tyler Snow
- Madigan Army Medical Center, Washington, USA
| | - Ardith Z Doorenbos
- College of Nursing, University of Illinois, Chicago, USA.,Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, USA
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21
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Bauer MR, Larson MJ, Moresco N, Huntington N, Walker R, Richard P. Association between 1-year patient outcomes and opioid-prescribing group of emergency department clinicians: A cohort study with Army active-duty soldiers. Acad Emerg Med 2021; 28:1251-1261. [PMID: 34245641 PMCID: PMC10393064 DOI: 10.1111/acem.14331] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 06/07/2021] [Accepted: 06/23/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective was to examine the association between clinicians' opioid prescribing group and patients' outcomes among patients treated in the emergency department (ED). METHODS This was a retrospective cohort study. The setting was the EDs of the U.S. Military Health System (MHS). Patients were 181,557 Army active-duty opioid-naïve (no fill in past 180 days) patients with an index encounter to the ED between October 2010 and September 2016. Exposure was patients classified by opioid prescribing tier of the treating ED clinician: top, middle, or bottom third relative to the clinician's peers in the same ED. Follow-up measurement was from 31 to 365 days after the index encounter. The primary outcome was long-term opioid prescriptions (LTOPs) defined as 180 (or more) days' supply within the follow-up window. We also computed the total morphine milligram equivalents (MME) and total opioid days' supply. Secondary measures were any repeat ED encounter, any hospitalization, any sick leave, and any military-duty restriction. RESULTS We found a 2.5-fold variation in opioid prescribing rates among clinicians in the same MHS ED. Controlling for sample demographics, reason for encounter, and military background, in multivariate analyses the odds of receiving a 180-day opioid supply during follow-up were 1.19 (95% confidence interval [CI] = 1.01 to 1.40, p < 0.05) for the top opioid exposure group and 1.37 (95% CI = 1.19 to 1.57, p < 0.001) for the middle opioid exposure group compared to the bottom exposure group, and there were significant increases in total opioid days' supply and total MME. There were no differences in secondary outcome measures. CONCLUSION In a relatively healthy sample of Army soldiers, variation in opioid exposure defined by clinician's prescribing history was associated with increased odds of LTOP and increase in opioid volume, but not in functional outcomes.
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Affiliation(s)
- Mark R. Bauer
- Institute for Behavioral Health The Heller School for Social Policy and Management Brandeis University Waltham MA USA
| | - Mary Jo Larson
- Institute for Behavioral Health The Heller School for Social Policy and Management Brandeis University Waltham MA USA
| | - Natalie Moresco
- Institute for Behavioral Health The Heller School for Social Policy and Management Brandeis University Waltham MA USA
| | - Nick Huntington
- Institute for Behavioral Health The Heller School for Social Policy and Management Brandeis University Waltham MA USA
| | - Regine Walker
- Uniformed Services University of the Health Sciences Bethesda MD USA
| | - Patrick Richard
- Uniformed Services University of the Health Sciences Bethesda MD USA
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22
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Mullinax LRA, Grunwald L, Banaag A, Olsen C, Koehlmoos TP. A Longitudinal Study of Prevalence Ratios for Musculoskeletal Back Injury Among U.S. Navy and Marine Corps Personnel, 2009-2015. Mil Med 2021; 188:e1094-e1101. [PMID: 34718700 DOI: 10.1093/milmed/usab432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 08/30/2021] [Accepted: 10/13/2021] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Medical readiness to deploy is an increasingly important issue within the military. Musculoskeletal back pain is one of the most common medical problems that affects service members. This study demonstrates the associations between risk factors and the prevalence of musculoskeletal back pain among active duty sailors and Marines within the Department of the Navy (DoN). MATERIALS AND METHODS Utilizing the Military Health System Data Repository, we conducted a retrospective cross-sectional review of administrative healthcare claim data for all active duty DoN personnel with at least one medical encounter during fiscal years 2009-2015. For each fiscal year, we identified all claims with an ICD-9 code for back pain and calculated prevalence. We compared those with and without back pain across all variables (age, gender, rank, race, body mass index, tobacco use, occupation, and branch of service) using chi-square analysis. Unadjusted and adjusted log-binomial regressions were used to calculate prevalence ratios and examine associated risk factors for back pain. RESULTS The number of active duty subjects per fiscal year ranged from 424,460 to 437,053. The prevalence of back pain showed an upward trend, ranging from 9.99% in 2009 to 12.09% in 2015. Personnel aged 35 years and older had the strongest adjusted prevalence ration (APR) for back pain (APR 2.59; 95% CI, 2.53-2.66). There were also strong associations with obese body mass index (APR 1.76; 95% CI, 1.66-1.86), overweight body mass index (APR 1.29; 95% CI, 1.27-1.32), and tobacco use (APR 1.39; 95% CI, 1.36-1.42). Females were more likely to have back pain than males (APR 1.43; 95% CI, 1.40-1.47) and Marines more likely than sailors (APR 1.39; 95% CI, 1.36-1.42). The occupation with the highest prevalence ratio was healthcare (APR 1.34; 95% CI, 1.29-1.40) when compared to the reference group of combat specialists. CONCLUSIONS There was an increasing prevalence of back pain across the DoN from 2009 to 2015. Different occupational categories demonstrate different prevalence of back pain. Surprisingly, combat occupations and aviators were among the groups with the lowest prevalence. Lifestyle factors such as excess body weight and use of tobacco products are clearly associated with increased prevalence. These results could inform military leaders with regard to setting policies that could increase medical readiness.
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Affiliation(s)
- Lcdr Ross A Mullinax
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Lindsay Grunwald
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - Amanda Banaag
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - Cara Olsen
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Tracey P Koehlmoos
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
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Kim H, Markert R, Burtson K. Battlefield acupuncture appears to be an effective therapy for pain management. Acupunct Med 2021; 40:43-49. [PMID: 34625003 DOI: 10.1177/09645284211050648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION The Department of Defense has been training primary care providers in battlefield acupuncture (BFA), a subtype of auricular acupuncture, as an adjunct therapy for pain management. METHODS The objective of this study was to evaluate the effectiveness and safety of BFA for pain management in an outpatient Internal Medicine clinic staffed by resident physicians. The target population for this single-center prospective cohort study were military beneficiaries at a medical treatment facility located at the Wright-Patterson Air Force Base. Participants who met inclusion criteria were treated with BFA in addition to routine standard care for pain (n = 69). The control group was composed of participants who received routine standard care only without BFA (n = 27). Pain was assessed by a self-reported pain scale (0-10) at the time of encounter, immediately after BFA (for the intervention group), then at 24 and 48 h afterwards. RESULTS Mean pain for the intervention group decreased from 5.45 before BFA to 3.29 immediately following BFA to 2.21 at 24 h and to 2.10 at 48 h (p < 0.001). Thus, at all three post-treatment time points, mean decrease in pain surpassed a two-point reduction, deemed to be a clinically important difference. The BFA group had a greater reduction in pain compared to the no intervention group at 24 h (3.14 vs 0.59, p < 0.001) and at 48 h (3.26 vs 0.96, p < 0.001). Four intervention group participants (6%) reported an adverse reaction (three with pain at the insertion site) or complication (one with superficial infection). CONCLUSION BFA provided by Internal Medicine residents appears to be a safe and effective adjunct therapy for pain management in an outpatient setting, but requires further validation by randomized controlled trials.
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Affiliation(s)
- Hyaehwan Kim
- United States Air Force, Osan Air Base, Pyeongtaek, South Korea
| | - Ronald Markert
- Department of Internal Medicine and Neurology, Boonshoft School of Medicine, Wright State University, Dayton, OH, USA
| | - Kathryn Burtson
- Department of Internal Medicine and Neurology, Boonshoft School of Medicine, Wright State University, Dayton, OH, USA
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24
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Hughey S, Spevak C, Stedje-Larsen E. Military Pain Medicine: Sustaining the Fighting Force. Mil Med 2021; 187:84-87. [PMID: 34611703 DOI: 10.1093/milmed/usab419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 08/24/2021] [Accepted: 09/27/2021] [Indexed: 11/15/2022] Open
Abstract
Active duty military service members (ADSMs) suffer disproportionately from chronic pain. In the USA, military pain physicians serve an important role in the treatment of pain conditions in addition to the maintenance of the fighting force. Expanding roles for pain physicians, including novel therapies, consulting roles for opioid policy, and usefulness in a deployed setting create enormous value for military pain physicians. Ongoing force structure changes, including proposed reduction in the U.S. Military's healthcare workforce may significantly impact pain care and the health of the fighting forces. Military pain physicians support a variety of different roles in the military healthcare system. Ultimately, maintaining a robust faculty of pain physicians allows for both preservation of the fighting forces and a ready medical force.
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Affiliation(s)
- Scott Hughey
- Department of Anesthesiology and Pain Medicine, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA.,Naval Biotechnology Group, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA
| | - Christopher Spevak
- Department of Anesthesiology and Pain Medicine, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
| | - Eric Stedje-Larsen
- Department of Anesthesiology and Pain Medicine, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA.,Naval Biotechnology Group, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA
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25
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Karasel S, Cebesi D. Comparison the Effects of Physical Therapy on Chronic Pain in Active or Sedentary Military Personnel. Mater Sociomed 2021; 33:199-205. [PMID: 34759778 PMCID: PMC8563037 DOI: 10.5455/msm.2021.33.199-205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 09/18/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Chronic pain (CP) is a debilitating condition in which pain persists for months or years beyond the expected duration seen in normal healing processes. Because of the social and economic burden of CP in military personnel, it is important to ascertain pain-related physical, mental and psychological conditions to improve pain management. OBJECTIVE The aim of the study was to evaluate the effectiveness of the physical therapy in active military personnel (AMP) with CP through self-reported questionnaires. METHODS Sixty male AMP outpatients suffering from CP were included and divided into two groups according to their exercise levels in daily life (30 patients exercised regularly, while the remaining 30 had a sedentary lifestyle). All participants completed the following forms and questionnaires: Oswestry Disability Index (ODI), Visual Analogue Scale (VAS) for pain, Neck Disability Index (NDI), Neck Bournemouth Questionnaire (NBQ), International Physical Activity Questionnaire (IPAQ), Hospital Anxiety-Depression Index (HADS), 36-item Short Form Survey (SF-36), Automatic Thoughts Questionnaire (ATQ), and Pain Belief Questionnaire (PBQ). Patients were given 10 sessions of a standardized physical therapy program, including hot pack applications, TENS, ultrasound therapy and also home-based physical exercise. RESULTS The median age of patients was 22 (min-max: 20-42) years. The HADS and PBQ-psychological scores were high and ATQ scores were low in both groups. After the treatment, ODI and VAS scores decreased in both groups; however, the group comprised of patients that exercised regularly at baseline also demonstrated a significant decrease in NBQ and NDI values. CONCLUSION We showed that three components of pain (physical, cognitive and emotional) are indeed effective on pain intensity and levels of disability. Our study showed that scales related with pain could improve by physical therapy in AMP, and that patients who normally exercised benefitted from physical therapy at a relatively higher degree. Chronic pain needs to be managed in the context of the patient's biological, psychological, social and also occupational characteristics; thus, individualized, patient-specific and multi-factorial treatments should be considered whenever possible.
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Affiliation(s)
| | - Dua Cebesi
- Famagusta State Hospital, Famagusta, Cyprus
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26
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Adams RS, Meerwijk EL, Larson MJ, Harris AHS. Predictors of Veterans Health Administration utilization and pain persistence among soldiers treated for postdeployment chronic pain in the Military Health System. BMC Health Serv Res 2021; 21:494. [PMID: 34030684 PMCID: PMC8145830 DOI: 10.1186/s12913-021-06536-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 05/17/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chronic pain presents a significant burden for both federal health care systems designed to serve combat Veterans in the United States (i.e., the Military Health System [MHS] and Veterans Health Administration [VHA]), yet there have been few studies of Veterans with chronic pain that have integrated data from both systems of care. This study examined 1) health care utilization in VHA as an enrollee (i.e., linkage to VHA) after military separation among soldiers with postdeployment chronic pain identified in the MHS, and predictors of linkage, and 2) persistence of chronic pain among those utilizing the VHA. METHODS Observational, longitudinal study of soldiers returning from a deployment in support of the Afghanistan/Iraq conflicts in fiscal years 2008-2014. The analytic sample included 138,206 active duty soldiers for whom linkage to VHA was determined through FY2019. A Cox proportional hazards model was estimated to examine the effects of demographic characteristics, military history, and MHS clinical characteristics on time to linkage to VHA after separation from the military. Among the subpopulation of soldiers who linked to VHA, we described whether they met criteria for chronic pain in the VHA and pain management treatments received during the first year in VHA. RESULTS The majority (79%) of soldiers within the chronic pain cohort linked to VHA after military separation. Significant predictors of VHA linkage included: VHA utilization as a non-enrollee prior to military separation, separating for disability, mental health comorbidities, and being non-Hispanic Black or Hispanic. Soldiers that separated because of misconduct were less likely to link than other soldiers. Soldiers who received nonpharmacological treatments, opioids/tramadol, or mental health treatment in the MHS linked earlier to VHA than soldiers who did not receive these treatments. Among those who enrolled in VHA, during the first year after linking to the VHA, 49.7% of soldiers met criteria for persistent chronic pain in VHA. CONCLUSIONS The vast majority of soldiers identified with chronic pain in the MHS utilized care within VHA after military separation. Careful coordination of pain management approaches across the MHS and VHA is required to optimize care for soldiers with chronic pain.
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Affiliation(s)
- Rachel Sayko Adams
- Heller School for Social Policy & Management, Institute for Behavioral Health, Brandeis University, 415 South Street MS 035, Waltham, MA, 02453, USA.
- Rocky Mountain Mental Illness Research Education and Clinical Center, Veterans Health Administration, 1700 N. Wheeling Street, Aurora, CO, 80045, USA.
| | - Esther L Meerwijk
- VA Health Services Research & Development, Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, 94025, USA
| | - Mary Jo Larson
- Heller School for Social Policy & Management, Institute for Behavioral Health, Brandeis University, 415 South Street MS 035, Waltham, MA, 02453, USA
| | - Alex H S Harris
- VA Health Services Research & Development, Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, 94025, USA
- Department of Surgery, Stanford University, Stanford, CA, 94305, USA
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27
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Downs JW, Cumpston KL. "Road Rash" and Dizziness: A Case of Hemodynamically Significant Topical Clonidine Toxicity. Mil Med 2021; 186:e451-e453. [PMID: 33005940 DOI: 10.1093/milmed/usaa284] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 07/09/2020] [Accepted: 08/08/2020] [Indexed: 11/14/2022] Open
Abstract
Clonidine is a central alpha-2 agonist well known to produce a syndrome of bradycardia and hypotension in overdose. However, few examples of overt clinical clonidine toxicity secondary to cutaneous absorption have been reported. We report a case of unintentional systemic clonidine toxicity in an adult because of a compounded preparation of clonidine applied to a degraded skin barrier. A 35-year-old male suffered a motorcycle accident 48 hours before presentation resulting in an abrasion to his distal left leg. On the day of presentation, he self-treated the wound by repeated application of a family member's pain-relieving cream. Later he was found confused and unable to stand by a family member. The family member recognized the thick visible coat of cream as the likely cause and decontaminated the patient while calling 911. Prehospital vitals were notable for a blood pressure of 80/30 mm Hg and heart rate of 38 beats per minute. In the emergency department, the patient was resuscitated with intravenous fluids with resultant normalization of blood pressure. Upon later review, the cream was determined to have been created by a local compounding pharmacy for the use in neuropathic pain and was labeled to contain clonidine, lidocaine, ketamine, and gabapentin. Cutaneous absorption of the pain cream was greatly increased because of loss of skin integrity. Military physicians and compounding pharmacies should ensure that patients are aware of the proper application of compounded creams and the potential risk for systemic toxicity with overuse or degraded skin.
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Affiliation(s)
- John W Downs
- Division of Clinical Toxicology, Department of Emergency Medicine, Virginia Commonwealth University Health Sys tem, Richmond, VA, 23219, USA
| | - Kirk L Cumpston
- Division of Clinical Toxicology, Department of Emergency Medicine, Virginia Commonwealth University Health Sys tem, Richmond, VA, 23219, USA
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Benedict TM, Keenan PG, Nitz AJ, Moeller-Bertram T. Post-Traumatic Stress Disorder Symptoms Contribute to Worse Pain and Health Outcomes in Veterans With PTSD Compared to Those Without: A Systematic Review With Meta-Analysis. Mil Med 2021; 185:e1481-e1491. [PMID: 32248229 DOI: 10.1093/milmed/usaa052] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 03/03/2020] [Accepted: 03/05/2020] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Post-traumatic stress disorder (PTSD) and chronic pain are frequently co-morbid conditions in the U.S. veteran population. Although several theories about the cause of increased pain prevalence in individuals with PTSD have been presented, no synthesis of primary data informing the impact of co-morbid PTSD and pain has been completed. The purpose of this study was to systematically review the literature and quantify disability, function, and pain-related beliefs and outcomes in veterans with PTSD compared to veterans without PTSD. MATERIALS AND METHODS A systematic search of three electronic databases was conducted. Inclusion criteria required pain-related comparison of veterans with PTSD to those without PTSD. Primary outcome measures and standardized mean differences (SMDs) were assessed for pain, function, disability, pain beliefs, and healthcare utilization using a random effects model. RESULTS 20 original research studies met inclusion criteria and were assessed for quality and outcomes of interest. The majority of studies were cross-sectional. Veterans with PTSD and pain demonstrated higher pain (SMD = 0.58, 95% CI 0.28-0.89), disability (SMD = 0.52, 95%CI 0.33-0.71), depression (SMD = 1.40, 95%CI 1.2-1.6), catastrophizing beliefs (SMD = 0.95, 95% CI 0.69-1.2), sleep disturbance (SMD = 0.80, 95% CI 0.57-1.02), and healthcare utilization; they had lower function (SMD = 0.41, 95% CI 0.25-0.56) and pain self-efficacy (SMD = 0.77, 95% CI 0.55-0.99) compared to veterans without PTSD. CONCLUSION In veterans with chronic pain, PTSD symptomology has a large effect for many negative health-related outcomes. This review supports the need for clinicians to screen and understand the effects of PTSD symptoms on patients with pain. Clinicians should recognize that veterans with PTSD and pain likely have elevated pain catastrophizing beliefs and decreased self-efficacy that should be targeted for intervention.
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Affiliation(s)
- Timothy M Benedict
- Department of Rehabilitation Sciences, University of Kentucky, 900 S. Limestone Ave Lexington, Lexington, KY 40536-0200
| | - Patrick G Keenan
- Office of the Chief, Specialist Corps, 3630 Stanley Road, Fort Sam Houston, San Antonio, TX 78234
| | - Arthur J Nitz
- Department of Rehabilitation Sciences, University of Kentucky, 900 S. Limestone Ave Lexington, Lexington, KY 40536-0200
| | - Tobias Moeller-Bertram
- Department of Medicine at UC Riverside, Desert Clinic Pain Institute, 36101 Bob Hope Drive, Rancho Mirage, CA 92270
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Saadoun M, Bauer MR, Adams RS, Highland KB, Larson MJ. Opioid and Nonpharmacologic Treatments Among Soldiers With Chronic Pain and Posttraumatic Stress Disorder. Psychiatr Serv 2021; 72:264-272. [PMID: 33467870 PMCID: PMC8127998 DOI: 10.1176/appi.ps.201900303] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE This study examined the prevalence of chronic pain alone, posttraumatic stress disorder (PTSD) alone, and both chronic pain and PTSD among U.S. Army soldiers during the postdeployment year. METHODS The sample was 576,425 active duty soldiers returning from deployment in Afghanistan or Iraq between October 1, 2008, and September 30, 2014. Bivariate statistics were used to compare health care utilization among subgroups. Multivariate logistic regression with additional covariates was used to identify predictors of receiving an opioid days' supply of >30 days in the postdeployment year among soldiers with chronic pain, focusing on the effect of PTSD alone and on an interaction of PTSD with nonpharmacologic treatments (including therapeutic exercise, chiropractic treatment, acupuncture, and biofeedback). RESULTS In total, 12.2% of the soldiers received a chronic pain diagnosis, 5.1% a PTSD diagnosis, and 1.8% had both. Among soldiers with both conditions, 80.3% received nonpharmacologic treatment, and 31.4% received an opioid days' supply of >30 days. Among soldiers with chronic pain, comorbid PTSD and lack of nonpharmacologic treatment was associated with increased odds of receiving an opioid days' supply of >30 days (odds ratio [OR]=1.4, 95% confidence interval [CI]=1.3-1.6). PTSD combined with specific nonpharmacologic treatment modalities had a variable relationship with opioid receipt, and only PTSD with acupuncture or biofeedback was associated with reduced odds (OR=0.8, 95% CI=0.7-0.9). CONCLUSIONS Soldiers having both chronic pain and PTSD have significant health care needs. Although these soldiers accessed mental health care and received nonpharmacologic treatment, additional interventions are needed to mitigate protracted opioid utilization.
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Affiliation(s)
- Mayada Saadoun
- Schneider Institutes for Health Policy and Research, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts (Saadoun, Bauer, Adams, Larson); Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, and the Henry M. Jackson Foundation, Bethesda, Maryland (Highland)
| | - Mark R Bauer
- Schneider Institutes for Health Policy and Research, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts (Saadoun, Bauer, Adams, Larson); Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, and the Henry M. Jackson Foundation, Bethesda, Maryland (Highland)
| | - Rachel Sayko Adams
- Schneider Institutes for Health Policy and Research, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts (Saadoun, Bauer, Adams, Larson); Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, and the Henry M. Jackson Foundation, Bethesda, Maryland (Highland)
| | - Krista Beth Highland
- Schneider Institutes for Health Policy and Research, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts (Saadoun, Bauer, Adams, Larson); Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, and the Henry M. Jackson Foundation, Bethesda, Maryland (Highland)
| | - Mary Jo Larson
- Schneider Institutes for Health Policy and Research, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts (Saadoun, Bauer, Adams, Larson); Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, and the Henry M. Jackson Foundation, Bethesda, Maryland (Highland)
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Flynn D, Doorenbos AZ, Steffen A, McQuinn H, Langford DJ. Pain Management Telementoring, Long-term Opioid Prescribing, and Patient-Reported Outcomes. PAIN MEDICINE 2021; 21:266-273. [PMID: 31876948 DOI: 10.1093/pm/pnz338] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Benefits of primary care provider (PCP) participation in pain management telementoring have been reported; however, no studies have examined within-patient changes in dose or discontinuation of long-term opioid therapy (LOT). The objectives of this nonrandomized study were to evaluate the relationship between telementoring participation and 1) LOT dose reduction and 2) LOT discontinuation and to 3) explore the relationship between LOT dose changes and patient-reported outcomes. METHODS PCPs were recruited from a US Army medical center. Intervention group PCPs (N = 12) attended telementoring sessions; control group providers (N = 13) did not. Morphine equivalent daily doses (MEDD) for patients of study providers (N = 396) were extracted from the study site's opioid database. The intervention group was subdivided based on number of sessions attended (i.e., active and low participation). Intent-to-treat and as-treated analyses were conducted using generalized estimating equations. Separate analyses evaluated the association between within-patient changes in MEDD and pain impact, depression, and anxiety (N = 40). RESULTS Intent-to-treat analysis revealed no significant difference in MEDD reduction; however, a higher proportion of patients of intervention PCPs discontinued LOT (25% ± 3.6%) compared with control PCPs (16% ± 3.6%, P < 0.05). As-treated analyses revealed differences in MEDD reduction between active (13.2 ± 3.0) and low-participating (2.6 ± 3.0) PCPs (P < 0.01). Further, a higher proportion of patients of actively participating PCPs discontinued LOT (29% ± 4.9%) compared with control PCPs (16% ± 3.6%, P = 0.01). We found no evidence that decreased MEDD was associated with poorer self-reported outcomes within patients. CONCLUSIONS Pain management telementoring supports PCPs' efforts to reduce reliance on LOT for chronic pain management and highlights the need for actively engaged PCP pain champions.
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Affiliation(s)
- Diane Flynn
- Madigan Army Medical Center, Tacoma, Washington
| | | | - Alana Steffen
- Health Systems Science, College of Nursing, University of Illinois at Chicago, Chicago, Illinois
| | | | - Dale J Langford
- Department of Anesthesiology & Pain Medicine, School of Medicine, University of Washington, Seattle, Washington, USA
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Adams RS, Larson MJ, Meerwijk EL, Williams TV, Harris AHS. Postdeployment Polytrauma Diagnoses Among Soldiers and Veterans Using the Veterans Health Affairs Polytrauma System of Care and Receipt of Opioids, Nonpharmacologic, and Mental Health Treatments. J Head Trauma Rehabil 2020; 34:167-175. [PMID: 31058759 PMCID: PMC6546163 DOI: 10.1097/htr.0000000000000481] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To determine the proportion of Army soldiers who utilized care in the Veterans Health Administration (VHA) Polytrauma System of Care (PSC) within the postdeployment year and to describe prevalence of polytrauma diagnoses, and receipt of opioids, nonpharmacologic treatments (NPTs), and mental health treatments in the VHA during the year following first PSC utilization. SETTING VHA's 4-tiered integrated PSC network of specialized rehabilitation services for military members and veterans with polytrauma. PARTICIPANTS Soldiers and veterans who used the PSC during the postdeployment year after an Afghanistan or Iraq deployment ending in fiscal years 2008-2011. DESIGN Population-based cohort study. MAIN MEASURES Prevalence of polytrauma diagnoses (ie, traumatic brain injury [TBI], posttraumatic stress disorder [PTSD], and chronic pain [CP]), VHA utilization rates of opioid prescriptions, NPT, and specialty mental health treatment within 1 year of PSC utilization. RESULTS In total, 2.6% of the sample (n = 16 590) used the PSC during the postdeployment year. Among PSC users, CP (76.5%), PTSD (53.1%), and TBI (48.6%) were common and more frequently found together than in isolation; 26.6% filled an opioid prescription, 35.5% received at least 1 NPT, and 83.8% received specialty mental health treatment in the VHA within 1 year of PSC utilization. CONCLUSION CP was the most common polytrauma condition among PSC users, highlighting the importance of incorporating interdisciplinary pain management approaches within the PSC, with an effort to reduce reliance on long-term opioid therapy and improve rehabilitation.
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Affiliation(s)
- Rachel Sayko Adams
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts (Drs Adams and Larson); Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California (Drs Meerwijk and Harris); and NORC at the University of Chicago, Bethesda, Maryland (Dr Williams)
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Meerwijk EL, Larson MJ, Schmidt EM, Adams RS, Bauer MR, Ritter GA, Buckenmaier C, Harris AHS. Nonpharmacological Treatment of Army Service Members with Chronic Pain Is Associated with Fewer Adverse Outcomes After Transition to the Veterans Health Administration. J Gen Intern Med 2020; 35:775-783. [PMID: 31659663 PMCID: PMC7080907 DOI: 10.1007/s11606-019-05450-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 09/26/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Potential protective effects of nonpharmacological treatments (NPT) against long-term pain-related adverse outcomes have not been examined. OBJECTIVE To compare active duty U.S. Army service members with chronic pain who did/did not receive NPT in the Military Health System (MHS) and describe the association between receiving NPT and adverse outcomes after transitioning to the Veterans Health Administration (VHA). DESIGN AND PARTICIPANTS A longitudinal cohort study of active duty Army service members whose MHS healthcare records indicated presence of chronic pain after an index deployment to Iraq or Afghanistan in the years 2008-2014 (N = 142,539). Propensity score-weighted multivariable Cox proportional hazard models tested for differences in adverse outcomes between the NPT group and No-NPT group. EXPOSURES NPT received in the MHS included acupuncture/dry needling, biofeedback, chiropractic care, massage, exercise therapy, cold laser therapy, osteopathic spinal manipulation, transcutaneous electrical nerve stimulation and other electrical manipulation, ultrasonography, superficial heat treatment, traction, and lumbar supports. MAIN MEASURES Primary outcomes were propensity score-weighted proportional hazards for the following adverse outcomes: (a) diagnoses of alcohol and/or drug disorders; (b) poisoning with opioids, related narcotics, barbiturates, or sedatives; (c) suicide ideation; and (d) self-inflicted injuries including suicide attempts. Outcomes were determined based on ICD-9 and ICD-10 diagnoses recorded in VHA healthcare records from the start of utilization until fiscal year 2018. KEY RESULTS The propensity score-weighted proportional hazards for the NPT group compared to the No-NPT group were 0.92 (95% CI 0.90-0.94, P < 0.001) for alcohol and/or drug use disorders; 0.65 (95% CI 0.51-0.83, P < 0.001) for accidental poisoning with opioids, related narcotics, barbiturates, or sedatives; 0.88 (95% CI 0.84-0.91, P < 0.001) for suicide ideation; and 0.83 (95% CI 0.77-0.90, P < 0.001) for self-inflicted injuries including suicide attempts. CONCLUSIONS NPT provided in the MHS to service members with chronic pain may reduce risk of long-term adverse outcomes.
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Affiliation(s)
- Esther L Meerwijk
- VA Health Services Research & Development, Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA.
| | - Mary Jo Larson
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA
| | - Eric M Schmidt
- Program Evaluation and Resource Center, VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - Rachel Sayko Adams
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA
| | - Mark R Bauer
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA
| | - Grant A Ritter
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA
| | - Chester Buckenmaier
- Defense and Veterans Center for Integrative Pain Management, Uniformed Services University, Rockville, MD, USA
| | - Alex H S Harris
- VA Health Services Research & Development, Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA
- Department of Surgery, Stanford University, Stanford, CA, USA
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Sosanya NM, Kumar R, Clifford JL, Chavez R, Dimitrov G, Srinivasan S, Gautam A, Trevino AV, Williams M, Hammamieh R, Cheppudira BP, Christy RJ, Crimmins SL. Identifying Plasma Derived Extracellular Vesicle (EV) Contained Biomarkers in the Development of Chronic Neuropathic Pain. THE JOURNAL OF PAIN 2020; 21:82-96. [DOI: 10.1016/j.jpain.2019.05.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 05/09/2019] [Accepted: 05/24/2019] [Indexed: 12/29/2022]
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Reif S, Adams RS, Ritter GA, Larson MJ. Exploration of the association of selected pain diagnoses with risky alcohol use among active duty soldiers. Subst Abus 2019; 41:456-462. [PMID: 31638881 DOI: 10.1080/08897077.2019.1671944] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Pain and its consequences remain of concern, particularly in high-risk occupations such as the military. Alcohol is a legal and accessible means of self-medication, and risky alcohol use is associated with potentially serious consequences. This exploratory analysis aimed to better understand the association of selected pain diagnoses with risky alcohol use among soldiers returning from deployment. Methods: Analysis of data from active duty soldiers returning from Afghanistan or Iraq deployments in fiscal years 2008-2011 who completed Department of Defense health questionnaires after deployment (n = 267,100). Each questionnaire included self-reported alcohol consumption and items yielding AUDIT-C screening scores. Military Health System data were used to identify diagnoses of pain-related conditions. Results: About 70% of soldiers had none of the selected pain diagnoses either pre- or post-deployment. 10% had incident pain diagnoses (only post-deployment), 7% had persistent pain diagnoses (both pre- and post-deployment), and 13% had remitted pain diagnoses (only pre-deployment). On the AUDIT-C, 39% screened positive for at-risk drinking and 6% were likely to have severe alcohol problems. Half of the respondents reported any binge drinking; 20% at least monthly binge drinking. Logistic regression analyses found reduced odds of risky alcohol use post-deployment in association with incident and persistent pain diagnoses, compared to no pain diagnoses pre- or post-deployment. Conclusions: Pain diagnoses, binge drinking, and risky alcohol use were prevalent among this sample of Army soldiers. An inverse relationship was found between pain diagnosis (incident, persistent) and risky alcohol use post-deployment. Attention should continue to be paid to risky alcohol use in this population, yet these exploratory findings do not suggest that soldiers with the pain diagnoses used in this study are at greater risk. Combat exposure, traumatic brain injury, and psychological health were more important predictors, and should continue to warrant enhanced alcohol screening.
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Affiliation(s)
- Sharon Reif
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts, USA
| | - Rachel Sayko Adams
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts, USA
| | - Grant A Ritter
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts, USA
| | - Mary Jo Larson
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts, USA
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Adams RS, Thomas CP, Ritter GA, Lee S, Saadoun M, Williams TV, Larson MJ. Predictors of Postdeployment Prescription Opioid Receipt and Long-term Prescription Opioid Utilization Among Army Active Duty Soldiers. Mil Med 2019; 184:e101-e109. [PMID: 30007291 DOI: 10.1093/milmed/usy162] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 06/10/2018] [Indexed: 12/12/2022] Open
Abstract
Introduction Little is known about long-term prescription opioid utilization in the Military Health System. The objectives of this study were to examine predictors of any prescription opioid receipt, and predictors of long-term opioid utilization among active duty soldiers in the year following deployment. Materials and Methods The analytic sample consisted of Army active duty soldiers returning from deployment to Operation Enduring Freedom, Operation Iraqi Freedom, or Operation New Dawn in fiscal years 2008-2014 (N = 540,738). The Heckman probit procedure was used to jointly examine predictors of any opioid prescription receipt and long-term opioid utilization (i.e., an episode of 90 days or longer where days-supply covered at least two-thirds of days) in the postdeployment year. Predictors were based on diagnoses and characteristics of opioid prescriptions. Results More than one-third of soldiers (34.8%, n = 188,211) had opioid receipt, and among those soldiers, 3.3% had long-term opioid utilization (or 1.1% of the cohort, n = 6,188). The largest magnitude predictors of long-term opioid utilization were receiving a long-acting opioid within the first 30 days of the episode, diagnoses of chronic pain (no specified source), back/neck pain, or peripheral/central nervous system pain, and severe pain score in vital records. Conclusions Soldiers returning from deployment were more likely to receive an opioid prescription than the overall active duty population, and 1.1% initiated a long-term opioid episode. We report a declining rate of opioid receipt and long-term opioid utilization among Army members from fiscal years 2008-2014. This study demonstrates that the most important predictors of opioid receipt were not demographic factors, but generally clinical indicators of acute pain or physical trauma.
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Affiliation(s)
- Rachel Sayko Adams
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA
| | - Cindy Parks Thomas
- Schneider Institute for Health Policy, Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA
| | - Grant A Ritter
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA
| | - Sue Lee
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA
| | - Mayada Saadoun
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA
| | | | - Mary Jo Larson
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA
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Flynn DM, McQuinn H, Fairchok A, Eaton LH, Langford DJ, Snow T, Doorenbos AZ. Enhancing the success of functional restoration using complementary and integrative therapies: Protocol and challenges of a comparative effectiveness study in active duty service members with chronic pain. Contemp Clin Trials Commun 2018; 13:100311. [PMID: 30582069 PMCID: PMC6297112 DOI: 10.1016/j.conctc.2018.100311] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 11/12/2018] [Accepted: 11/28/2018] [Indexed: 12/22/2022] Open
Abstract
Chronic pain significantly impairs physical, psychological and social functioning. Among military populations, pain due to injuries sustained both on and off the battlefield is a leading cause of short and long-term disability. Improving the quality of pain care for active duty service members is a major priority of the Department of Defense. This article describes an ongoing comparative effectiveness study which aims to (1) evaluate the benefit of a multimodal complementary and integrative health (CIH) pain management program when added to standard rehabilitative care (SRC) prior to an intensive functional restoration (FR) program compared to SRC alone, and (2) identify factors that predict improvement in pain impact following treatment completion. Using a randomized controlled trial design, active duty service members with pain related to musculoskeletal injury are assigned to a 3-week course of either SRC or SRC combined with CIH therapies prior to beginning a 3-week course of FR. Outcomes are collected at baseline, at the end of stage 1 treatment, post-FR, and at 3- and 6-months post-FR. Outcome measures include provider-measured functional assessments and patient-reported assessment through the Pain Assessment Screening Tool and Outcomes Registry (PASTOR). The military health system provides a supportive environment for implementation of this research protocol. Challenges to conducting the study have included new technology systems at the study site, slower than projected enrollment, and program delivery issues. These challenges have been successfully managed and have not significantly impacted study participant enrollment and completion of study treatments.
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Affiliation(s)
- Diane M Flynn
- Madigan Army Medical Center, 9040 Jackson Ave, Tacoma, WA, 98431, USA
| | - Honor McQuinn
- Madigan Army Medical Center, 9040 Jackson Ave, Tacoma, WA, 98431, USA
| | | | - Linda H Eaton
- School of Nursing & Health Studies, University of Washington Bothell, Box 357266, Seattle, WA, 98195, USA
| | - Dale J Langford
- School of Medicine, University of Washington, Box 356340, Seattle, WA, 98195, USA
| | - Tyler Snow
- Madigan Army Medical Center, 9040 Jackson Ave, Tacoma, WA, 98431, USA
| | - Ardith Z Doorenbos
- School of Medicine, University of Washington, Box 356340, Seattle, WA, 98195, USA.,College of Nursing, University of Illinois Chicago, 845 S. Damen, Chicago, IL, 60612, USA
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