Understanding Pain and Pain Treatment for Veterans: Responding to the Federal Pain Research Strategy

Ketamine in the effective management of chronic pain, depression, and posttraumatic stress disorder for Veterans: A meta-analysis and systematic review

Introduction

Ketamine has emerged as a promising treatment alternative for the management of chronic pain. Despite encouraging findings in civilian populations, and favourable results from trials examining its efficacy in military populations, there is still a dearth of information pointing to optimal specifications related to ketamine administration for pain, depression, and posttraumatic stress disorder (PTSD) in military populations. This meta-analysis and systematic review synthesised available evidence on the effectiveness, tolerability, and feasibility of ketamine in the management of chronic pain and mental health conditions in military populations.

Methods

This review followed the Cochrane's Guide for systematic reviews of interventions and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) as frameworks for data collection and synthesis.

Results

A total of 11 studies and 22 independent samples were retained for data analyses. Across samples, improvements in pain, depression, and PTSD outcomes were evident, with the use of ketamine leading to significant reductions, g = 1.76, SE = 0.19, 95% CI (1.39, 2.13), Z = 9.26, p <.001. These effect sizes were robust with moderate-to-large effects. In addition, the reductions in symptoms were observed in both active-duty and Veteran groups, and for different routes of ketamine administration, frequencies of ketamine administration, duration of ketamine treatments, dosage, study design, and allowance for concurrent treatments.

Discussion

This review provides a preliminary synthesis of available evidence which suggests that ketamine may be a potential option for the treatment of depression, PTSD, and chronic pain in military populations. The viability of ketamine as an alternative treatment may be particularly impactful for those who are treatment resistant, experience chronic symptoms, and/or have exhausted conventional treatments. More research is warranted in order verify the findings presented in this review.

The association of the localized pain sensitivity in the residual limb and prosthesis use in male veterans with transtibial amputation

The association of localized pain sensitivity in the residual limb and prosthesis use has clinical implications, however, rarely been assessed. This study aimed to investigate pain sensitivity and explore its range, variability, and association with prosthesis use alongside other demographic and clinical characteristics of veterans with transtibial amputation. Pain sensitivity was determined as pressure pain threshold (PPT) and pressure tolerance (PT) in 19 male veterans with a mean age of 49.5 years using pressure algometry at 12 anatomical locations on‎ the residual limb. A comparison of pain sensitivity at each location, and among anatomical locations and participants was explored using independent t-test, analysis of variance, and Kruskal-Wallis tests, respectively. Pain sensitivity range (PSR), the difference between PT and PPT, was significantly different (p < 0.05) at mid-patellar tendon, medial tibial flare, and the distal end of the tibia. The lowest PPT and PT (20.5 and 33 Ncm-2, p = 0.13) were recorded at the distal end of the residual limb, and the highest PPT and PT (73.4 and 94.3 Ncm-2, p = 0.03) were recorded at the mid-patellar tendon. Pain sensitivity was significantly different among anatomical locations and participants. The correlation tests (Pearson and partial eta squared) showed non-significant associations of pain sensitivity with participants' demographic and clinical characteristics except for daily prosthesis use. The mid-patellar tendon, medial tibial flare, and distal end of the tibia revealed the lowest pain hypersensitivity ‎due to higher PSR. Longer daily prosthesis use was associated with increased pain sensitivity.

Trends in Cannabis Use Disorder Diagnoses in the U.S. Veterans Health Administration, 2005-2019

OBJECTIVE

In the United States, adult cannabis use has increased over time, but less information is available on time trends in cannabis use disorder. The authors used Veterans Health Administration (VHA) data to examine change over time in cannabis use disorder diagnoses among veterans, an important population subgroup, and whether such trends differ by age group (<35 years, 35-64 years, ≥65 years), sex, or race/ethnicity.

METHODS

VHA electronic health records from 2005 to 2019 (range of Ns per year, 4,403,027-5,797,240) were used to identify the percentage of VHA patients seen each year with a cannabis use disorder diagnosis (ICD-9-CM, January 1, 2005-September 30, 2015; ICD-10-CM, October 1, 2015-December 31, 2019). Trends in cannabis use disorder diagnoses were examined by age and by race/ethnicity and sex within age groups. Given the transition in ICD coding, differences in trends were tested within two periods: 2005-2014 (ICD-9-CM) and 2016-2019 (ICD-10-CM).

RESULTS

In 2005, the percentages of VHA patients diagnosed with cannabis use disorder in the <35, 35-64, and ≥65 year age groups were 1.70%, 1.59%, and 0.03%, respectively; by 2019, the percentages had increased to 4.84%, 2.86%, and 0.74%, respectively. Although the prevalence of cannabis use disorder was consistently higher among males than females, between 2016 and 2019, the prevalence increased more among females than males in the <35 year group. Black patients had a consistently higher prevalence of cannabis use disorder than other racial/ethnic groups, and increases were greater among Black than White patients in the <35 year group in both periods.

CONCLUSIONS

Since 2005, diagnoses of cannabis use disorder have increased substantially among VHA patients, as they have in the general population and other patient populations. Possible explanations warranting investigation include decreasing perception of risk, changing laws, increasing cannabis potency, stressors related to growing socioeconomic inequality, and use of cannabis to self-treat pain. Clinicians and the public should be educated about the increases in cannabis use disorder in general in the United States, including among patients treated at the VHA.

Psychosocial factors correlate with fatigue among pregnant women in Jordan

PURPOSE

The study aimed to assess the correlation between fatigue and psychological factors, namely stress, social support, self-esteem, and depression among pregnant women in Jordan.

DESIGN AND METHODS

A cross-sectional design was suggested. Cluster stratified random sampling technique was adopted. Fatigue assessment scale, Rosenberg Self-Esteem Scale, Perceived Stress Scale, Multidimensional Social Support Scale, and Beck's Depression Inventory were used.

FINDINGS

A total of 580 pregnant women were included. Overall, 67.4% of the participants experienced fatigue, about 74.0% had moderate to high stress, 56.0% had moderate social support, around 89.0% had normal self-esteem, and 43.1% experienced moderate to extreme depression. Stress, self-esteem, and depression were correlated with fatigue.

PRACTICE IMPLICATIONS

This study can help develop proper psychosocial care and sustain mental health among women during pregnancy.