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The Emerging Role of Virtual Reality as an Adjunct to Procedural Sedation and Anesthesia: A Narrative Review. J Clin Med 2023; 12:jcm12030843. [PMID: 36769490 PMCID: PMC9917582 DOI: 10.3390/jcm12030843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/03/2023] [Accepted: 01/08/2023] [Indexed: 01/24/2023] Open
Abstract
Over the past 20 years, there has been a significant reduction in the incidence of adverse events associated with sedation outside of the operating room. Non-pharmacologic techniques are increasingly being used as peri-operative adjuncts to facilitate and promote anxiolysis, analgesia and sedation, and to reduce adverse events. This narrative review will briefly explore the emerging role of immersive reality in the peri-procedural care of surgical patients. Immersive virtual reality (VR) is intended to distract patients with the illusion of "being present" inside the computer-generated world, drawing attention away from their anxiety, pain, and discomfort. VR has been described for a variety of procedures that include colonoscopies, venipuncture, dental procedures, and burn wound care. As VR technology develops and the production costs decrease, the role and application of VR in clinical practice will expand. It is important for medical professionals to understand that VR is now available for prime-time use and to be aware of the growing body in the literature that supports VR.
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Lee M, Bastian LA, LaRowe L, DeRycke EC, Relyea M, Becker WC, Ditre JW. Perceived pain and smoking interrelations among veterans with chronic pain enrolled in a smoking cessation trial. PAIN MEDICINE 2022; 23:1820-1827. [PMID: 35639969 DOI: 10.1093/pm/pnac082] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 04/22/2022] [Accepted: 05/12/2022] [Indexed: 11/14/2022]
Abstract
INTRODUCTION The Pain and Smoking Inventory (PSI) measures patients' perceived interrelations of their pain and smoking behavior, and comprises three conceptually-distinct domains: smoking to cope with pain (PSI-Cope), pain as a motivator of smoking (PSI-Motivate), and pain as a barrier to cessation (PSI-Barrier). Associations between PSI scores and pain interference and self-efficacy to quit smoking, two measures that can affect cessation outcomes, remain unclear. METHODS Secondary analysis of baseline data from 371 Veterans with chronic pain (88% male, M age = 60) enrolled in a randomized smoking cessation trial. We used sequential multivariate regression models to examine associations between the three PSI domains and pain interference/self-efficacy. RESULTS Of 371 Veterans who completed baseline surveys, 88% were male with median age 60 years. PSI-Motivate scores were positively associated with pain interference (B: 0.18, 95% CI: 0.02, 0.34). PSI-Barrier sub-scores were negatively associated with self-efficacy (B: -0.23, 95% CI:-0.36, -0.10). CONCLUSION Findings suggest that individuals who hold maladaptive perceptions of pain-smoking interrelations may be more likely to endorse higher pain interference and lower self-efficacy-two established predictors of cessation outcomes. Moreover, each PSI subscale demonstrated unique relationships with the dependent variables, and our results provided support for a three-factor structure. These findings further demonstrate that the PSI comprises three conceptually and empirically distinct domains; future research should evaluate the clinical utility of assessing each domain in relation to cessation outcomes.
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Affiliation(s)
- Megan Lee
- Yale School of Medicine, New Haven, Connecticut, United States
| | - Lori A Bastian
- Yale School of Medicine, New Haven, Connecticut, United States.,Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System West Haven, Connecticut, United States
| | - Lisa LaRowe
- Department of Behavioral and Social Sciences, School of Public Health, Brown University
| | - Eric C DeRycke
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System West Haven, Connecticut, United States
| | - Mark Relyea
- Yale School of Medicine, New Haven, Connecticut, United States.,Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System West Haven, Connecticut, United States
| | - William C Becker
- Yale School of Medicine, New Haven, Connecticut, United States.,Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System West Haven, Connecticut, United States
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3
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Bastian LA, Driscoll M, DeRycke E, Edmond S, Mattocks K, Goulet J, Kerns RD, Lawless M, Quon C, Selander K, Snow J, Casares J, Lee M, Brandt C, Ditre J, Becker W. Pain and smoking study (PASS): A comparative effectiveness trial of smoking cessation counseling for veterans with chronic pain. Contemp Clin Trials Commun 2021; 23:100839. [PMID: 34485755 PMCID: PMC8391053 DOI: 10.1016/j.conctc.2021.100839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 08/11/2021] [Accepted: 08/18/2021] [Indexed: 11/08/2022] Open
Abstract
Introduction Smoking is associated with greater pain intensity and pain-related functional interference in people with chronic pain. Interventions that teach smokers with chronic pain how to apply adaptive coping strategies to promote both smoking cessation and pain self-management may be effective. Methods The Pain and Smoking Study (PASS) is a randomized clinical trial of a telephone-delivered, cognitive behavioral intervention among Veterans with chronic pain who smoke cigarettes. PASS participants are randomized to a standard telephone counseling intervention that includes five sessions focusing on motivational interviewing, craving and relapse management, rewards, and nicotine replacement therapy versus the same components with the addition of a cognitive behavioral intervention for pain management. Participants are assessed at baseline, 6, and 12 months. The primary outcome is smoking cessation. Results The 371 participants are 88% male, a median age of 60 years old (range 24–82), and smoke a median of 15 cigarettes per day. Participants are mainly white (61%), unemployed (70%), 33% had a high school degree or less, and report their overall health as “Fair” (40%) to “Poor” (11%). Overall, pain was moderately high (mean pain intensity in past week = 5.2 (Standard Deviation (SD) = 1.6) and mean pain interference = 5.5 (SD = 2.2)). Pain-related anxiety was high (mean = 47.0 (SD = 22.2)) and self-efficacy was low (mean = 3.8 (SD = 1.6)). Conclusions PASS utilizes an innovative smoking and pain intervention to promote smoking cessation among Veterans with chronic pain. Baseline characteristics reflect a socioeconomically vulnerable population with a high burden of mental health comorbidities.
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Affiliation(s)
- Lori A Bastian
- Pain Research, Informatics, Multimorbidities, Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, United States.,Yale University School of Medicine, New Haven, CT, United States
| | - Mary Driscoll
- Pain Research, Informatics, Multimorbidities, Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, United States.,Yale University School of Medicine, New Haven, CT, United States
| | - Eric DeRycke
- Pain Research, Informatics, Multimorbidities, Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, United States
| | - Sara Edmond
- Pain Research, Informatics, Multimorbidities, Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, United States.,Yale University School of Medicine, New Haven, CT, United States
| | - Kristin Mattocks
- University of Massachusetts Medical School, Worcester, MA, United States.,VA Central Western Massachusetts Healthcare System, Leeds, MA, United States
| | - Joe Goulet
- Pain Research, Informatics, Multimorbidities, Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, United States.,Yale University School of Medicine, New Haven, CT, United States
| | - Robert D Kerns
- Pain Research, Informatics, Multimorbidities, Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, United States.,Yale University School of Medicine, New Haven, CT, United States
| | - Mark Lawless
- Pain Research, Informatics, Multimorbidities, Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, United States
| | - Caroline Quon
- Pain Research, Informatics, Multimorbidities, Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, United States
| | - Kim Selander
- Pain Research, Informatics, Multimorbidities, Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, United States
| | - Jennifer Snow
- Pain Research, Informatics, Multimorbidities, Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, United States
| | - Jose Casares
- VA Central Western Massachusetts Healthcare System, Leeds, MA, United States
| | - Megan Lee
- Yale University School of Medicine, New Haven, CT, United States
| | - Cynthia Brandt
- Pain Research, Informatics, Multimorbidities, Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, United States.,Yale University School of Medicine, New Haven, CT, United States
| | - Joseph Ditre
- Department of Psychology, Syracuse University, Syracuse, NY, United States
| | - William Becker
- Pain Research, Informatics, Multimorbidities, Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, United States.,Yale University School of Medicine, New Haven, CT, United States
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4
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Husebo BS, Kerns RD, Han L, Skanderson M, Gnjidic D, Allore HG. Pain, Complex Chronic Conditions and Potential Inappropriate Medication in People with Dementia. Lessons Learnt for Pain Treatment Plans Utilizing Data from the Veteran Health Administration. Brain Sci 2021; 11:86. [PMID: 33440668 PMCID: PMC7827274 DOI: 10.3390/brainsci11010086] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/05/2021] [Accepted: 01/07/2021] [Indexed: 12/21/2022] Open
Abstract
Alzheimer's disease and related dementias (ADRD), pain and chronic complex conditions (CCC) often co-occur leading to polypharmacy and with potential inappropriate medications (PIMs) use, are important risk factors for adverse drug reactions and hospitalizations in older adults. Many US veterans are at high risk for persistent pain due to age, injury or medical illness. Concerns about inadequate treatment of pain-accompanied by evidence about the analgesic efficacy of opioids-has led to an increase in the use of opioid medications to treat chronic pain in the Veterans Health Administration (VHA) and other healthcare systems. This study aims to investigate the relationship between receipt of pain medications and centrally (CNS) acting PIMs among veterans diagnosed with dementia, pain intensity, and CCC 90-days prior to hospitalization. The final analytic sample included 96,224 (81.7%) eligible older veterans from outpatient visits between October 2012-30 September 2013. We hypothesized that veterans with ADRD, and severe pain intensity may receive inappropriate pain management and CNS-acting PIMs. Seventy percent of the veterans, and especially people with ADRD, reported severe pain intensity. One in three veterans with ADRD and severe pain intensity have an increased likelihood for CNS-acting PIMs, and/or opioids. Regular assessment and re-assessment of pain among older persons with CCC, patient-centered tapering or discontinuation of opioids, alternatives to CNS-acting PIMs, and use of non-pharmacological approaches should be considered.
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Affiliation(s)
- Bettina S. Husebo
- Centre for Elderly and Nursing Home Medicine, Department of Global Public Health and Primary Care, University of Bergen, 5020 Bergen, Norway
- Municipality of Bergen, 5020 Bergen, Norway
| | - Robert D. Kerns
- Departments of Psychiatry, Neurology and Psychology, Yale University, New Haven, CT 06511, USA;
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT 06516, USA;
| | - Ling Han
- Section of Geriatrics, Department of Internal Medicine, School of Medicine, Yale University, New Haven, CT 06511, USA; (L.H.); (H.G.A.)
| | - Melissa Skanderson
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT 06516, USA;
| | - Danijela Gnjidic
- Charles Perkins Centre, Faculty of Medicine and Health, School of Pharmacy, University of Sydney, Sydney 2006 NSW, Australia;
| | - Heather G. Allore
- Section of Geriatrics, Department of Internal Medicine, School of Medicine, Yale University, New Haven, CT 06511, USA; (L.H.); (H.G.A.)
- Department of Biostatistics, School of Public Health, Yale University, New Haven, CT 06511, USA
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Fritz JM, Rhon DI, Teyhen DS, Kean J, Vanneman ME, Garland EL, Lee IE, Thorp RE, Greene TH. A Sequential Multiple-Assignment Randomized Trial (SMART) for Stepped Care Management of Low Back Pain in the Military Health System: A Trial Protocol. PAIN MEDICINE 2020; 21:S73-S82. [PMID: 33313724 DOI: 10.1093/pm/pnaa338] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND The Defense Health Agency has prioritized system-level pain management initiatives within the Military Health System (MHS), with low back pain as one of the key focus areas. A stepped care model focused on nonpharmacologic treatment to promote self-management is recommended. Implementation of stepped care is complicated by lack of information on the most effective nonpharmacologic strategies and how to sequence and tailor the various available options. The Sequential Multiple-Assignment Randomization Trial for Low Back Pain (SMART LBP) is a multisite pragmatic trial using a SMART design to assess the effectiveness of nonpharmacologic treatments for chronic low back pain. DESIGN This SMART trial has two treatment phases. Participants from three military treatment facilities are randomized to 6 weeks of phase I treatment, receiving either physical therapy (PT) or Army Medicine's holistic Move2Health (M2H) program in a package specific to low back pain. Nonresponders to treatment in phase I are again randomized to phase II treatment of combined M2H + PT or mindfulness-based treatment using the Mindfulness-Oriented Recovery Enhancement (MORE) program. The primary outcome is the Patient-Reported Outcomes Measurement Information System pain interference computer-adapted test score. SUMMARY This trial is part of an initiative funded by the National Institutes of Health, Veterans Affairs, and the Department of Defense to establish a national infrastructure for effective system-level management of chronic pain with a focus on nonpharmacologic treatments. The results of this study will provide important information on nonpharmacologic care for chronic LBP in the MHS embedded within a stepped care framework.
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Affiliation(s)
| | - Daniel I Rhon
- Brooke Army Medical Center, San Antonio, Texas.,Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Deydre S Teyhen
- Walter Reed Army Institute of Research, Silvers Spring, Maryland
| | - Jacob Kean
- University of Utah, Salt Lake City, Utah
| | | | | | - Ian E Lee
- Defense Health Management Systems, Falls Church, Virginia
| | - Richard E Thorp
- Directorate of Program Analysis and Evaluation, Office of the Army Surgeon General, Joint Base San Antonio Fort Sam Houston, San Antonio, Texas, USA
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Kroenke K, Krebs EE, Turk D, Von Korff M, Bair MJ, Allen KD, Sandbrink F, Cheville AL, DeBar L, Lorenz KA, Kerns RD. Core Outcome Measures for Chronic Musculoskeletal Pain Research: Recommendations from a Veterans Health Administration Work Group. PAIN MEDICINE 2020; 20:1500-1508. [PMID: 30615172 DOI: 10.1093/pm/pny279] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Chronic musculoskeletal pain (CMSP) disorders are among the most prevalent and disabling conditions worldwide. It would be advantageous to have common outcome measures when comparing results across different CMSP research studies. METHODS The Veterans Health Administration appointed a work group to recommend core outcome measures for assessing pain intensity and interference as well as important secondary domains in clinical research. The work group used three streams of data to inform their recommendations: 1) literature synthesis augmented by three recently completed trials; 2) review and comparison of measures recommended by other expert groups; 3) two Delphi surveys of work group members. RESULTS The single-item numerical rating scale and seven-item Brief Pain Inventory interference scale emerged as the recommended measures for assessing pain intensity and interference, respectively. The secondary domains ranked most important included physical functioning and depression, followed by sleep, anxiety, and patient-reported global impression of change (PGIC). For these domains, the work group recommended the Patient-Reported Outcome Information System four-item physical function and sleep scales, the Patient Health Questionnaire two-item depression scale, the Generalized Anxiety Disorder two-item anxiety scale, and the single-item PGIC. Finally, a single-item National Health Interview Survey item was favored for defining chronic pain. CONCLUSIONS Two scales comprising eight items are recommended as core outcome measures for pain intensity and interference in all studies of chronic musculoskeletal pain, and brief scales comprising 13 additional items can be added when possible to assess important secondary domains.
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Affiliation(s)
- Kurt Kroenke
- Indiana University and Roudebush VAMC, Indianapolis, Indiana
| | - Erin E Krebs
- University of Minnesota and Minneapolis VAMC, Minneapolis, Minnesota
| | - Dennis Turk
- University of Washington, Seattle, Washington
| | - Michael Von Korff
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Matthew J Bair
- Indiana University and Roudebush VAMC, Indianapolis, Indiana
| | - Kelli D Allen
- University of North Carolina and Durham VAMC, Chapel Hill, North Carolina
| | - Friedhelm Sandbrink
- George Washington University and Washington DC VAMC, Washington, District of Columbia
| | | | - Lynn DeBar
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Karl A Lorenz
- Stanford University and Palo Alto VAMC, Palo Alto, California
| | - Robert D Kerns
- Yale University and West Haven VAMC, West Haven, Connecticut, USA
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7
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Wandner LD, Fenton BT, Goulet JL, Carroll CM, Heapy A, Higgins DM, Bair MJ, Sandbrink F, Kerns RD. Treatment of a Large Cohort of Veterans Experiencing Musculoskeletal Disorders with Spinal Cord Stimulation in the Veterans Health Administration: Veteran Characteristics and Outcomes. J Pain Res 2020; 13:1687-1697. [PMID: 32753944 PMCID: PMC7354010 DOI: 10.2147/jpr.s241567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 05/07/2020] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE Spinal cord stimulator (SCS) implantation is used to treat chronic pain, including painful musculoskeletal disorders (MSDs). This study examined the characteristics and outcomes of veterans receiving SCSs in Veterans Health Administration (VHA) facilities. METHODS The sample was drawn from the MSD Cohort and limited to three MSDs with the highest number of implants (N=815,475). There were 1490 veterans with these conditions who received SCS implants from 2000 to 2012, of which 95% (n=1414) had pain intensity numeric rating scale (NRS) data both pre- and post-implant. RESULTS Veterans who were 35-44 years old, White, and married reported higher pain NRS ratings, had comorbid inclusion diagnoses, had no medical comorbidities, had a BMI 25-29.9, or had a depressive disorder diagnosis were more likely to receive an SCS. Veterans 55+ years old or with an alcohol or substance use disorder were less likely to receive an SCS. Over 90% of those receiving an SCS were prescribed opioids in the year prior to implant. Veterans who had a presurgical pain score ≥4 had a clinically meaningful decrease in their pain score in the year following their 90-day recovery period (Day 91-456) greater than expected by chance alone. Similarly, there was a significant decrease in the percent of veterans receiving opioid therapy (92.4% vs 86.6%, p<0.0001) and a significant overall decrease in opioid dose [morphine equivalent dose per day (MEDD) =26.48 vs MEDD=22.59, p<0.0003]. CONCLUSION Results offer evidence of benefit for some veterans with the examined conditions. Given known risks of opioid therapy, the reduction is an important potential benefit of SCS implants.
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Affiliation(s)
- Laura D Wandner
- National Institute of Neurological Disorders and Stroke (NINDS), National Institutes of Health (NIH), Bethesda, MD, USA
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Brenda T Fenton
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, USA
| | - Joseph L Goulet
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | | | - Alicia Heapy
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Diana M Higgins
- VA Boston Healthcare System, Boston, MA, USA
- Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA
| | - Matthew J Bair
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, IN, USA
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Regenstrief Institute, Indianapolis, IN, USA
| | - Friedhelm Sandbrink
- Department of Neurology, VA Medical Center, Washington, DC, USA
- Department of Neurology, Georgetown University, Washington, DC, USA
| | - Robert D Kerns
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
- Department of Psychology, Yale University, New Haven, CT, USA
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Lynch SM, Wilson SM, DeRycke EC, Driscoll MA, Becker WC, Goulet JL, Kerns RD, Mattocks KM, Brandt CA, Bathulapalli H, Skanderson M, Haskell SG, Bastian LA. Impact of Cigarette Smoking Status on Pain Intensity Among Veterans With and Without Hepatitis C. PAIN MEDICINE 2019; 19:S5-S11. [PMID: 30203017 DOI: 10.1093/pm/pny146] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Objective Chronic pain is a significant problem in patients living with hepatitis C virus (HCV). Tobacco smoking is an independent risk factor for high pain intensity among veterans. This study aims to examine the independent associations with smoking and HCV on pain intensity, as well as the interaction of smoking and HCV on the association with pain intensity. Design/Particpants Cross-sectional analysis of a cohort study of veterans of Operations Enduring Freedom/Iraqi Freedom/New Dawn (OEF/OIF/OND) who had at least one visit to a Veterans Health Administration (VHA) primary care clinic between 2001 and 2014. Methods HCV was identified using ICD-9 codes from electronic medical records (EMRs). Pain intensity, reported on a 0-10 numeric rating scale, was categorized as none/mild (0-3) and moderate/severe (4-10). Results Among 654,841 OEF/OIF/OND veterans (median age [interquartile range] = 26 [23-36] years), 2,942 (0.4%) were diagnosed with HCV. Overall, moderate/severe pain intensity was reported in 36% of veterans, and 37% were current smokers. The adjusted odds of reporting moderate/severe pain intensity were 1.23 times higher (95% confidence interval [CI] = 1.14-1.33) for those with HCV and 1.26 times higher (95% CI = 1.25-1.28) for current smokers. In the interaction model, there was a significant Smoking Status × HCV interaction (P = 0.03). Among veterans with HCV, smoking had a significantly larger association with moderate/severe pain (adjusted odds ratio [OR] = 1.50, P < 0.001) than among veterans without HCV (adjusted OR = 1.26, P < 0.001). Conclusions We found that current smoking is more strongly linked to pain intensity among veterans with HCV. Further investigations are needed to explore the impact of smoking status on pain and to promote smoking cessation and pain management in veterans with HCV.
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Affiliation(s)
- Shaina M Lynch
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Sarah M Wilson
- Center for Health Services Research in Primary Care, Durham VA Health Care System, Durham, North Carolina.,Duke University School of Medicine, Durham, North Carolina
| | - Eric C DeRycke
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System West Haven, Connecticut
| | - Mary A Driscoll
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System West Haven, Connecticut.,Department of Psychiatry
| | - William C Becker
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System West Haven, Connecticut.,Department of Internal Medicine
| | - Joseph L Goulet
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System West Haven, Connecticut.,Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
| | | | - Kristin M Mattocks
- VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts.,University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Cynthia A Brandt
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System West Haven, Connecticut.,Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Harini Bathulapalli
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System West Haven, Connecticut
| | - Melissa Skanderson
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System West Haven, Connecticut
| | - Sally G Haskell
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System West Haven, Connecticut.,Department of Internal Medicine
| | - Lori A Bastian
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System West Haven, Connecticut.,Department of Internal Medicine
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9
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Edmond SN, Moore BA, Dorflinger LM, Goulet JL, Becker WC, Heapy AA, Sellinger JJ, Lee AW, Levin FL, Ruser CB, Kerns RD. Project STEP: Implementing the Veterans Health Administration's Stepped Care Model of Pain Management. PAIN MEDICINE 2019; 19:S30-S37. [PMID: 30203015 DOI: 10.1093/pm/pny094] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Objective The "stepped care model of pain management" (SCM-PM) prioritizes the role of primary care providers in optimizing pharmacological management and timely and equitable access to patient-centered, evidence-based nonpharmacological approaches, when indicated. Over the past several years, the Veterans Health Administration (VHA) has supported implementation of SCM-PM, but few data exist regarding changes in pain care resulting from implementation. We examined trends in prescribing and referral practices of primary care providers with hypotheses of decreased opioid prescribing, increased nonopioid prescribing, and increased referrals to specialty care for nonpharmacological services. Design An initiative was designed to foster implementation and systematic evaluation of the SCM-PM over a five-year period at the VA Connecticut Healthcare System (VACHS) while fostering collaborative, partnered initiatives to promote organizational improvements in the delivery of pain care. Subjects Participants were veterans receiving care at VACHS with at least one pain intensity rating ≥4/10 over the course of the study period (7/2008-6/2013). Methods We used electronic health record data to examine changes in indicators of pain care including pharmacy and health care utilization data. Results We observed hypothesized changes in long-term opioid and nonopioid analgesic prescribing and increased utilization of nonpharmacological treatments such as physical therapy, occupational therapy, and clinical health psychology. Conclusions Through a multifaceted comprehensive implementation approach, primary care providers demonstrated increases in guideline-concordant pain care practices. Findings suggest that engagement of interdisciplinary teams and partnerships to promote organizational improvements is a useful strategy to increase the use of integrated, multimodal pain care for veterans, consistent with VHA's SCM-PM.
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Affiliation(s)
- Sara N Edmond
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut.,Department of Psychiatry
| | - Brent A Moore
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut.,Department of Psychiatry
| | - Lindsey M Dorflinger
- Health Psychology Service, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Joseph L Goulet
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut.,Department of Emergency Medicine
| | - William C Becker
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut.,Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Alicia A Heapy
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut.,Department of Psychiatry
| | - John J Sellinger
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut.,Department of Psychiatry
| | - Allison W Lee
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Forrest L Levin
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Christopher B Ruser
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Robert D Kerns
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut.,Department of Psychiatry.,Departments of Neurology and Psychology, Yale University, New Haven, Connecticut, USA
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10
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Price C, de C Williams AC, Smith BH, Bottle A. The National Pain Audit for specialist pain services in England and Wales 2010-2014. Br J Pain 2018; 13:185-193. [PMID: 31308943 DOI: 10.1177/2049463718814277] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Introduction Numerous reports highlight variations in pain clinic provision between services, particularly in the provision of multidisciplinary services and length of waiting times. A National Audit aims to identify and quantify these variations, to facilitate raising standards of care in identified areas of need. This article describes a Quality Improvement Programme cycle covering England and Wales that used such an approach to remedy the paucity of data on the current state of UK pain clinics. Methods Clinics were audited over a 4-year period using standards developed by the Faculty of Pain Medicine of The Royal College of Anaesthetists. Reporting was according to guidance from a recent systematic review of national surveys of pain clinics. A range of quality improvement measures was introduced via a series of roadshows led by the British Pain Society. Results 94% of clinics responded to the first audit and 83% responded to the second. Per annum, 0.4% of the total national population was estimated to attend a specialist pain service. A significant improvement in multidisciplinary staffing was found (35-56%, p < 0.001) over the 4-year audit programme, although this still requires improvement. Very few clinics achieved recommended evidence-based waiting times, although only 2.5% fell outside government targets; this did not improve. Safety standards were generally met. Clinicians often failed to code diagnoses. Conclusion A National Audit found that while generally safe many specialist pain services in England and Wales fell below recommended standards of care. Waiting times and staffing require improvement if patients are to get effective and timely care. Diagnostic coding also requires improvement.
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Affiliation(s)
| | - Amanda C de C Williams
- Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Blair H Smith
- Department of Population Health Sciences, University of Dundee, Dundee, UK
| | - Alex Bottle
- Dr Foster Unit, Imperial College London, London, UK
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11
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Kannampallil TG, McNutt R, Falck S, Galanter WL, Patterson D, Darabi H, Sharabiani A, Schiff G, Odwazny R, Vaida AJ, Wilkie DJ, Lambert BL. Learning optimal opioid prescribing and monitoring: a simulation study of medical residents. JAMIA Open 2018; 1:246-254. [PMID: 31984336 PMCID: PMC6951957 DOI: 10.1093/jamiaopen/ooy026] [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: 02/16/2018] [Revised: 05/21/2018] [Accepted: 06/05/2018] [Indexed: 12/23/2022] Open
Abstract
Objective Hospitalized patients often receive opioids. There is a lack of consensus regarding evidence-based guidelines or training programs for effective management of pain in the hospital. We investigated the viability of using an Internet-based opioid dosing simulator to teach residents appropriate use of opioids to treat and manage acute pain. Materials and methods We used a prospective, longitudinal design to evaluate the effects of simulator training. In face-to-face didactic sessions, we taught 120 (108 internal medicine and 12 family medicine) residents principles of pain management and how to use the simulator. Each trainee completed 10 training and, subsequently, 5 testing trials on the simulator. For each trial, we collected medications, doses, routes and times of administration, pain scores, and a summary score. We used mixed-effects regression models to assess the impact of simulation training on simulation performance scores, variability in pain score trajectories, appropriate use of short- and long-acting opioids, and use of naloxone. Results Trainees completed 1582 simulation trials (M = 13.2, SD = 6.8), with sustained improvements in their simulated pain management practices. Over time, trainees improved their overall simulated pain management scores (b = 0.05, P < .01), generated lower pain score trajectories with less variability (b = −0.02, P < .01), switched more rapidly from short-acting to long-acting agents (b = −0.50, P < .01), and used naloxone less often (b = −0.10, P < .01). Discussion and conclusions Trainees translated their understanding of didactically presented principles of pain management to their performance on simulated patient cases. Simulation-based training presents an opportunity for improving opioid-based inpatient acute pain management.
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Affiliation(s)
- Thomas G Kannampallil
- Department of Family Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Robert McNutt
- Department of Medicine, College of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Suzanne Falck
- Department of Medicine, College of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - William L Galanter
- Department of Medicine, College of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA.,Departments of Pharmacy Practice and Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Dave Patterson
- Discerning Systems Inc., Burnaby, British Columbia, Canada
| | - Houshang Darabi
- Department of Mechanical & Industrial Engineering, College of Engineering, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Ashkan Sharabiani
- Department of Mechanical & Industrial Engineering, College of Engineering, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Gordon Schiff
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Allen J Vaida
- Institute for Safe Medication Practices, Horsham, Pennsylvania, USA
| | - Diana J Wilkie
- Center for Palliative Care Research and Education, College of Nursing, University of Florida, Gainesville, Florida
| | - Bruce L Lambert
- Center for Communication and Health, Department of Communication Studies, Northwestern University, Chicago, Illinois, USA
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12
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Feingold D, Goor-Aryeh I, Bril S, Delayahu Y, Lev-Ran S. Problematic Use of Prescription Opioids and Medicinal Cannabis Among Patients Suffering from Chronic Pain. PAIN MEDICINE 2018; 18:294-306. [PMID: 28204792 DOI: 10.1093/pm/pnw134] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objective To assess prevalence rates and correlates of problematic use of prescription opioids and medicinal cannabis (MC) among patients receiving treatment for chronic pain. Design Cross-sectional study. Setting Two leading pain clinics in Israel. Subjects Our sample included 888 individuals receiving treatment for chronic pain, of whom 99.4% received treatment with prescription opioids or MC. Methods Problematic use of prescription opioids and MC was assessed using DSM-IV criteria, Portenoy’s Criteria (PC), and the Current Opioid Misuse Measure (COMM) questionnaire. Additional sociodemographic and clinical correlates of problematic use were also assessed. Results Among individuals treated with prescription opioids, prevalence of problematic use of opioids according to DSM-IV, PC, and COMM was 52.6%, 17.1%, and 28.7%, respectively. Among those treated with MC, prevalence of problematic use of cannabis according to DSM-IV and PC was 21.2% and 10.6%, respectively. Problematic use of opioids and cannabis was more common in individuals using medications for longer periods of time, reporting higher levels of depression and anxiety, and using alcohol or drugs. Problematic use of opioids was associated with higher self-reported levels of pain, and problematic use of cannabis was more common among individuals using larger amounts of MC. Conclusions Problematic use of opioids is common among chronic pain patients treated with prescription opioids and is more prevalent than problematic use of cannabis among those receiving MC. Pain patients should be screened for risk factors for problematic use before initiating long-term treatment for pain-control.
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Affiliation(s)
- Daniel Feingold
- Dual Diagnosis Clinic, Lev-Hasharon Medical Center, Pardesiya, Israel
| | | | - Silviu Bril
- Pain Center, Sourasky Medical Center, Tel Aviv, Israel
| | - Yael Delayahu
- Department of Dual Diagnosis, Abarbanel Mental Health Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shaul Lev-Ran
- Dual Diagnosis Clinic, Lev-Hasharon Medical Center, Pardesiya, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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13
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Green KT, Wilson SM, Dennis PA, Runnals JJ, Williams RA, Bastian LA, Beckham JC, Dedert EA, Kudler HS, Straits-Tröster K, Gierisch JM, Calhoun PS. Cigarette Smoking and Musculoskeletal Pain Severity Among Male and Female Afghanistan/Iraq Era Veterans. PAIN MEDICINE 2018; 18:1795-1804. [PMID: 28340108 DOI: 10.1093/pm/pnw339] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Objective Cigarette smoking and musculoskeletal pain are prevalent among Department of Veterans Affairs (VA) health care system users. These conditions frequently co-occur; however, there is limited empirical information specific to Afghanistan/Iraq era veterans. The present study sought to examine gender differences in the association between cigarette smoking and moderate to severe musculoskeletal pain in US veterans with Afghanistan/Iraq era service. Methods A random sample of 5,000 veterans with service after November 11, 2001, participated in a survey assessing health care needs and barriers to care. One thousand ninety veterans completed the survey assessing post-traumatic stress disorder (PTSD) symptoms, depressive symptoms, and current pain severity. Multivariate logistic regression was used to examine the association between gender, cigarette smoking status, and current moderate to severe musculoskeletal pain. Results Findings indicated a significant gender by smoking interaction on moderate/severe musculoskeletal pain, adjusting for age, self-reported race/ethnicity and weight status, combat exposure, probable PTSD, depressive symptoms, service-connected injury during deployment, and VA health care service utilization. Deconstruction of the interaction indicated that female veteran smokers, relative to female nonsmokers, had increased odds of endorsing moderate to severe musculoskeletal pain (odds ratio [OR] = 2.73, 95% confidence interval [CI] = 1.16-6.41), whereas this difference was nonsignificant for male veterans (OR = 1.03, 95% CI = 0.69-1.56). Conclusions Survey data from Operation Enduring Freedom/Operation Iraqi Freedom veterans suggest an association between current smoking, gender, and moderate to severe musculoskeletal pain. The stronger relationship between smoking and pain in women supports the need for interventional and longitudinal research that can inform gender-based risk factors for pain in veteran cigarette smokers.
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Affiliation(s)
- Kimberly T Green
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Sarah M Wilson
- VA Mid-Atlantic Region Mental Illness Research, Education and Clinical Center (MIRECC), Durham, NC, USA.,Durham VA Medical Center, Durham, NC, USA.,Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Paul A Dennis
- Durham VA Medical Center, Durham, NC, USA.,Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Jennifer J Runnals
- VA Mid-Atlantic Region Mental Illness Research, Education and Clinical Center (MIRECC), Durham, NC, USA.,Durham VA Medical Center, Durham, NC, USA.,Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Rebecca A Williams
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Lori A Bastian
- Department of Internal Medicine, Yale University, New Haven, CT, USA.,Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven Campus, West Haven, CT, USA
| | - Jean C Beckham
- VA Mid-Atlantic Region Mental Illness Research, Education and Clinical Center (MIRECC), Durham, NC, USA.,Durham VA Medical Center, Durham, NC, USA.,Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Eric A Dedert
- Durham VA Medical Center, Durham, NC, USA.,Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Harold S Kudler
- VA Mid-Atlantic Region Mental Illness Research, Education and Clinical Center (MIRECC), Durham, NC, USA.,Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Kristy Straits-Tröster
- VA Mid-Atlantic Region Mental Illness Research, Education and Clinical Center (MIRECC), Durham, NC, USA.,Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA.,Phoenix VA Healthcare System, 650 E. Indian School Road, Phoenix, AZ, USA8
| | - Jennifer M Gierisch
- Center for Health Services Research in Primary Care, Durham VA Medical Center, NC, USA.,Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Patrick S Calhoun
- VA Mid-Atlantic Region Mental Illness Research, Education and Clinical Center (MIRECC), Durham, NC, USA.,Durham VA Medical Center, Durham, NC, USA.,Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA.,Center for Health Services Research in Primary Care, Durham VA Medical Center, NC, USA
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14
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Characterizing the pain score trajectories of hospitalized adult medical and surgical patients: a retrospective cohort study. Pain 2017; 157:2739-2746. [PMID: 27548045 PMCID: PMC5113285 DOI: 10.1097/j.pain.0000000000000693] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Pain care for hospitalized patients is often suboptimal. Representing pain scores as a graphical trajectory may provide insights into the understanding and treatment of pain. We describe a 1-year, retrospective, observational study to characterize pain trajectories of hospitalized adults during the first 48 hours after admission at an urban academic medical center. Using a subgroup of patients who presented with significant pain (pain score >4; n = 7762 encounters), we characterized pain trajectories and measured area under the curve, slope of the trajectory for the first 2 hours after admission, and pain intensity at plateau. We used mixed-effects regression to assess the association between pain score and sociodemographics (age, race, and gender), pain medication orders (opioids, nonopioids, and no medications), and medical service (obstetrics, psychiatry, surgery, sickle cell, intensive care unit, and medicine). K-means clustering was used to identify patient subgroups with similar trajectories. Trajectories showed differences based on race, gender, service, and initial pain score. Patients presumed to have dissimilar pain experiences (eg, sickle vs obstetrical) had markedly different pain trajectories. Patients with higher initial pain had a more rapid reduction during their first 2 hours of treatment. Pain reduction achieved in the 48 hours after admission was approximately 50% of the initial pain, regardless of the initial pain. Most patients' pain failed to fully resolve, plateauing at a pain score of 4 or greater. Visualizing pain scores as graphical trajectories illustrates the dynamic variability in pain, highlighting pain responses over a period of observation, and may yield new insights for quality improvement and research.
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15
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Combat exposure and pain in male and female Afghanistan and Iraq veterans: The role of mediators and moderators. Psychiatry Res 2017; 257:7-13. [PMID: 28709118 DOI: 10.1016/j.psychres.2017.07.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 05/26/2017] [Accepted: 07/01/2017] [Indexed: 11/21/2022]
Abstract
Veterans experience physical health problems associated with disability and poor quality of life following combat exposure (CE). Understanding the CE-physical health relationship, specifically pain intensity and somatic pain, may inform etiological models and interventions. This study examined the CE-pain relationship, associated mediators, and gender as a moderator. 2381 veterans at the VA San Diego Healthcare System completed paper or electronic self-report measures of pain intensity and somatic pain. Analyses examined associations of pain with CE and posttraumatic stress disorder (PTSD), depression, and resilience as mediators of the CE-pain association. Moderated mediation models explored gender as a moderator of significant mediated pathways. Controlling for age, veterans with CE had significantly higher pain intensity and somatic pain, and PTSD and depression scores significantly mediated the CE-pain relationships. Gender significantly moderated the CE-pain intensity association through depression scores such that the indirect effect was stronger for female veterans relative to male veterans. CE is associated with pain intensity and somatic pain, with greater levels of PTSD and depression mediating the CE-pain link and gender moderating the depression mediated CE-pain association. Future studies should examine gender differences and mediators in the CE-pain relationships using longitudinal designs to inform etiological models and targeted pain interventions.
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16
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Abstract
Study design Narrative review. Method Eight bibliographic databases were searched for studies published in the (last five years up until Feb 2017). For the two database searches (Cochrane and DARE), the time frame was unlimited. The review involved keyword searches of the term 'Amputation' AND 'chronic pain'. Studies selected were interrogated for any association between peri-operative factors and the occurrence of chronic post amputation pain (CPAP). Results Heterogeneity of study populations and outcome measures prevented a systematic review and hence a narrative synthesis of results was undertaken. The presence of variation in two gene alleles (GCH1 and KCNS1) may be relevant for development of CPAP. There was little evidence to draw conclusions on the association between age, gender and CPAP. Pre-operative anxiety and depression influenced pain intensity post operatively and long-term post amputation pain (CPAP). The presence of pre-amputation pain is correlated to the development of acute and chronic post amputation pain while evidence for the association of post-operative pain with CPAP is modest. Regional anaesthesia and peri-neural catheters improve acute postoperative pain relief but evidence on their efficacy to prevent CPAP is limited. A suggested whole system pathway based on current evidence to optimize peri-operative amputation pain is described. Conclusion The current evidence suggests that optimized peri-operative analgesia reduces the incidence of acute peri-operative pain but no firm conclusion can be drawn on reducing risk for CPAP.
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Affiliation(s)
- Devjit Srivastava
- Department of Anaesthesia, Raigmore Hospital, Inverness, Scotland, United Kingdom, IV2 3UJ
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17
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Patel B, Hacker E, Murks C, Ryan C. Interdisciplinary Pain Education: Moving From Discipline-Specific to Collaborative Practice. Clin J Oncol Nurs 2016; 20:636-643. [DOI: 10.1188/16.cjon.636-643] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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18
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Dobscha SK, Lovejoy TI, Morasco BJ, Kovas AE, Peters DM, Hart K, Williams JL, McFarland BH. Predictors of Improvements in Pain Intensity in a National Cohort of Older Veterans With Chronic Pain. THE JOURNAL OF PAIN 2016; 17:824-35. [PMID: 27058162 DOI: 10.1016/j.jpain.2016.03.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Revised: 03/21/2016] [Accepted: 03/24/2016] [Indexed: 12/25/2022]
Abstract
UNLABELLED Little is known about the factors associated with pain-related outcomes in older adults. In this observational study, we sought to identify patient factors associated with improvements in pain intensity in a national cohort of older veterans with chronic pain. We included 12,924 veterans receiving treatment from the Veterans Health Administration with persistently elevated numeric rating scale scores in 2010 who had not been prescribed opioids in the previous 12 months. We examined: 1) percentage decrease over 12 months in average pain intensity scores relative to average baseline pain intensity score; and 2) time to sustained improvement in average pain intensity scores, defined as a 30% reduction in 3-month scores compared with baseline. Average relative improvement in pain intensity scores from baseline ranged from 25% to 29%; almost two-thirds met criteria for sustained improvement during the 12-month follow-up period. In models, higher baseline pain intensity and older age were associated with greater likelihood of improvement in pain intensity, whereas Veterans Affairs service-connected disability, mental health, and certain pain-related diagnoses were associated with lower likelihood of improvement. Opioid prescription initiation during follow-up was associated with lower likelihood of sustained improvement. The findings call for further characterization of heterogeneity in pain outcomes in older adults as well as further analysis of the relationship between prescription opioids and treatment outcomes. PERSPECTIVE This study identified factors associated with improvements in pain intensity in a national cohort of older veterans with chronic pain. We found that older veterans frequently show improvements in pain intensity over time, and that opioid prescriptions, mental health, and certain pain diagnoses are associated with lower likelihood of improvement.
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Affiliation(s)
- Steven K Dobscha
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon; Department of Psychiatry, Oregon Health and Science University, Portland, Oregon.
| | - Travis I Lovejoy
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon; Department of Psychiatry, Oregon Health and Science University, Portland, Oregon
| | - Benjamin J Morasco
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon; Department of Psychiatry, Oregon Health and Science University, Portland, Oregon
| | - Anne E Kovas
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon
| | - Dawn M Peters
- Department of Public Health and Preventive Medicine, Oregon Health and Science University, Portland, Oregon
| | - Kyle Hart
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon
| | - J Lucas Williams
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon
| | - Bentson H McFarland
- Department of Psychiatry, Oregon Health and Science University, Portland, Oregon; Department of Public Health and Preventive Medicine, Oregon Health and Science University, Portland, Oregon
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19
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Moore BA, Anderson D, Dorflinger L, Zlateva I, Lee A, Gilliam W, Tian T, Khatri K, Ruser CB, Kerns RD. Stepped care model of pain management and quality of pain care in long-term opioid therapy. ACTA ACUST UNITED AC 2016; 53:137-46. [PMID: 27006068 DOI: 10.1682/jrrd.2014.10.0254] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Revised: 09/11/2015] [Indexed: 11/05/2022]
Abstract
Successful organizational improvement processes depend on application of reliable metrics to establish targets and to monitor progress. This study examined the utility of the Pain Care Quality (PCQ) extraction tool in evaluating implementation of the Stepped Care Model for Pain Management at one Veterans Health Administration (VHA) healthcare system over 4 yr and in a non-VHA Federally qualified health center (FQHC) over 2 yr. Two hundred progress notes per year from VHA and 150 notes per year from FQHC primary care prescribers of long-term opioid therapy (>90 consecutive days) were randomly sampled. Each note was coded for the presence or absence of key dimensions of PCQ (i.e., pain assessment, treatment plans, pain reassessment/outcomes, patient education). General estimating equations controlling for provider and facility were used to examine changes in PCQ items over time. Improvements in the VHA were noted in pain reassessment and patient education, with trends in positive directions for all dimensions. Results suggest that the PCQ extraction tool is feasible and may be responsive to efforts to promote organizational improvements in pain care. Future research is indicated to improve the reliability of the PCQ extraction tool and enhance its usability.
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Affiliation(s)
- Brent A Moore
- Pain Research, Informatics, Multimorbidities and Education Center, Department of Veterans Affairs (VA) Connecticut Healthcare System, West Haven, CT, and Yale School of Medicine, New Haven, CT
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20
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Burgess DJ, Gravely AA, Nelson DB, Bair MJ, Kerns RD, Higgins DM, Farmer MM, Partin MR. Association between pain outcomes and race and opioid treatment: Retrospective cohort study of Veterans. ACTA ACUST UNITED AC 2016; 53:13-24. [DOI: 10.1682/jrrd.2014.10.0252] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Revised: 09/11/2015] [Indexed: 11/05/2022]
Affiliation(s)
- Diana J. Burgess
- Center for Chronic Disease Outcomes Research, Minneapolis Department of Veterans Affairs (VA) Health Care System, Minneapolis, MN
| | - Amy A. Gravely
- Center for Chronic Disease Outcomes Research, Minneapolis Department of Veterans Affairs (VA) Health Care System, Minneapolis, MN
| | - David B. Nelson
- Center for Chronic Disease Outcomes Research, Minneapolis Department of Veterans Affairs (VA) Health Care System, Minneapolis, MN
| | - Matthew J. Bair
- Center for Health Information and Communication, VA Health Services Research and Development, Richard L. Roudebush VA Medical Center, Indianapolis, IN; Indiana University School of Medicine, Indianapolis, IN; and Regenstrief Institute Inc, Indianapolis, IN
| | - Robert D. Kerns
- VA Connecticut Healthcare System, West Haven, CT; and Yale School of Medicine, New Haven, CT
| | - Diana M. Higgins
- VA Connecticut Healthcare System, West Haven, CT; and Yale School of Medicine, New Haven, CT
| | - Melissa M. Farmer
- VA Health Services Research and Development Service, Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Sepulveda, CA
| | - Melissa R. Partin
- Center for Chronic Disease Outcomes Research, Minneapolis Department of Veterans Affairs (VA) Health Care System, Minneapolis, MN
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21
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Vallerand AH, Cosler P, Henningfield JE, Galassini P. Pain management strategies and lessons from the military: A narrative review. Pain Res Manag 2015; 20:261-8. [PMID: 26448972 PMCID: PMC4596634 DOI: 10.1155/2015/196025] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Wounded soldiers often experience substantial pain, which must be addressed before returning to active duty or civilian life. The United States (US) military has instituted several guidelines and initiatives aimed at improving pain management by providing rapid access to medical care, and developing interdisciplinary multimodal pain management strategies based on outcomes observed both in combat and hospital settings. OBJECTIVE To provide a narrative review regarding US military pain management guidelines and initiatives, which may guide improvements in pain management, particularly chronic pain management and prevention, for the general population. METHODS A literature review of US military pain management guidelines and initiatives was conducted, with a particular focus on the potential of these guidelines to address shortcomings in chronic pain management in the general population. DISCUSSION The application of US military pain management guidelines has been shown to improve pain monitoring, education and relief. In addition, the US military has instituted the development of programs and guidelines to ensure proper use and discourage aberrant behaviours with regard to opioid use, because opioids are regarded as a critical part of acute and chronic pain management schemes. Inadequate pain management, particularly inadequate chronic pain management, remains a major problem for the general population in the US. Application of military strategies for pain management to the general US population may lead to more effective pain management and improved long-term patient outcomes.
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Affiliation(s)
| | | | - Jack E Henningfield
- Pinney Associates, Bethesda and The Johns Hopkins University School of Medicine, Baltimore, Maryland
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22
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Volkman JE, DeRycke EC, Driscoll MA, Becker WC, Brandt CA, Mattocks KM, Haskell SG, Bathulapalli H, Goulet JL, Bastian LA. Smoking Status and Pain Intensity Among OEF/OIF/OND Veterans. PAIN MEDICINE 2015; 16:1690-6. [PMID: 25917639 DOI: 10.1111/pme.12753] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 02/27/2015] [Accepted: 03/04/2015] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Pain and smoking are highly prevalent among Veterans. Studies in non-Veteran populations have reported higher pain intensity among current smokers compared with nonsmokers and former smokers. We examined the association of smoking status with reported pain intensity among Veterans of Operations Enduring Freedom, Iraqi Freedom, and New Dawn (OEF/OIF/OND). DESIGN The sample consisted of OEF/OIF/OND Veterans who had at least one visit to Veterans Affairs (2001-2012) with information in the electronic medical record for concurrent smoking status and pain intensity. The primary outcome measure was current pain intensity, categorized as none to mild (0-3); moderate (4-6); or severe (≥7); based on a self-reported 11-point pain numerical rating scale. Multivariable logistic regression analyses were used to assess the association of current smoking status with moderate to severe (≥4) pain intensity, controlling for potential confounders. RESULTS Overall, 50,988 women and 355,966 men Veterans were examined. The sample mean age was 30 years; 66.3% reported none to mild pain; 19.8% moderate pain; and 13.9% severe pain; 37% were current smokers and 16% former smokers. Results indicated that current smoking [odds ratio (OR) = 1.29 (95% confidence intervals (CI) = 1.27-1.31)] and former smoking [OR = 1.02 (95% CI = 1.01-1.05)] were associated with moderate to severe pain intensity, controlling for age, service-connected disability, gender, obesity, substance abuse, mood disorders, and Post Traumatic Stress Disorder. CONCLUSIONS We found an association between current smoking and pain intensity. This effect was attenuated in former smokers. Our study highlights the importance of understanding reported pain intensity in OEF/OIF/OND Veterans who continue to smoke.
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Affiliation(s)
| | - Eric C DeRycke
- VA Connecticut Healthcare System, West Haven, Connecticut
| | | | - William C Becker
- VA Connecticut Healthcare System, West Haven, Connecticut.,Yale University School of Medicine, New Haven, Connecticut
| | - Cynthia A Brandt
- VA Connecticut Healthcare System, West Haven, Connecticut.,Yale University School of Medicine, New Haven, Connecticut
| | - Kristin M Mattocks
- VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts.,University of Massachusetts Medical School, Worcester, Massachusetts
| | - Sally G Haskell
- VA Connecticut Healthcare System, West Haven, Connecticut.,Yale University School of Medicine, New Haven, Connecticut
| | | | - Joseph L Goulet
- VA Connecticut Healthcare System, West Haven, Connecticut.,Yale University School of Medicine, New Haven, Connecticut
| | - Lori A Bastian
- VA Connecticut Healthcare System, West Haven, Connecticut.,University of Connecticut Health Center, Farmington, Connecticut
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23
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Dobscha SK, Morasco BJ, Kovas AE, Peters DM, Hart K, McFarland BH. Short-term variability in outpatient pain intensity scores in a national sample of older veterans with chronic pain. PAIN MEDICINE 2014; 16:855-65. [PMID: 25545398 DOI: 10.1111/pme.12643] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The Department of Veterans Affairs (VA) uses the 11-point pain numeric rating scale (NRS) to gather pain intensity information from veterans at outpatient appointments. Yet, little is known about how NRS scores may vary over time within individuals; NRS variability may have important ramifications for treatment planning. Our main objective was to describe variability in NRS scores within a 1-month timeframe, as obtained during routine outpatient care in older patients with chronic pain treated in VA hospitals. A secondary objective was to explore for patient characteristics associated with within-month NRS score variability. DESIGN Retrospective cohort study. SUBJECTS National sample of veterans 65 years or older seen in VA in 2010 who had multiple elevated NRS scores indicating chronic pain. METHODS VA datasets were used to identify the sample and demographic and clinical variables including NRS scores. For the main analysis, we identified subjects with two or more NRS scores obtained in each of two or more months in a 12-month period; we examined ranges in NRS scores across the first two qualifying months. RESULTS Among 4,336 individuals in the main analysis cohort, the mean and median of the average NRS score range across the 2 months were 2.7 and 2.5, respectively. In multivariable models, main significant predictors of within-month NRS score variability were baseline pain intensity, overall medical comorbidity, and being divorced/separated. CONCLUSIONS The majority of patients in the sample had clinically meaningful variation in pain scores within a given month. This finding highlights the need for clinicians and their patients to consider multiple NRS scores when making chronic pain treatment decisions.
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Affiliation(s)
- Steven K Dobscha
- Center to Improve Veteran Involvement in Care, Portland Veterans Affairs Medical Center, Portland, Oregon, USA.,Department of Psychiatry, Oregon Health & Science University, Portland, Oregon, USA
| | - Benjamin J Morasco
- Center to Improve Veteran Involvement in Care, Portland Veterans Affairs Medical Center, Portland, Oregon, USA.,Department of Psychiatry, Oregon Health & Science University, Portland, Oregon, USA
| | - Anne E Kovas
- Center to Improve Veteran Involvement in Care, Portland Veterans Affairs Medical Center, Portland, Oregon, USA
| | - Dawn M Peters
- Department of Public Health & Preventive Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Kyle Hart
- Center to Improve Veteran Involvement in Care, Portland Veterans Affairs Medical Center, Portland, Oregon, USA
| | - Bentson H McFarland
- Department of Psychiatry, Oregon Health & Science University, Portland, Oregon, USA.,Department of Public Health & Preventive Medicine, Oregon Health & Science University, Portland, Oregon, USA
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Dorflinger LM, Gilliam WP, Lee AW, Kerns RD. Development and application of an electronic health record information extraction tool to assess quality of pain management in primary care. Transl Behav Med 2014; 4:184-9. [PMID: 24904702 DOI: 10.1007/s13142-014-0260-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Chronic pain is one of the most common presenting problems in primary care. Standards and guidelines have been developed for managing chronic pain, but it is unclear whether primary care providers routinely engage in guideline-concordant care. The purpose of this study is to develop a tool for extracting information about the quality of pain care in the primary care setting. Quality indicators were developed through review of the literature, input from an interdisciplinary panel of pain experts, and pilot testing. A comprehensive coding manual was developed, and inter-rater reliability was established. The final tool consists of 12 dichotomously scored indicators assessing quality and documentation of pain care in three domains: assessment, treatment, and reassessment. Presence of indicators varied widely. The tool is reliable and can be utilized to gather valuable information about pain management in the primary care setting.
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Affiliation(s)
| | - Wesley P Gilliam
- New Mexico VA Healthcare System, 1501 San Pedro Drive Southeast, Albuquerque, NM USA
| | - Allison W Lee
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT USA
| | - Robert D Kerns
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT USA
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Higgins DM, Kerns RD, Brandt CA, Haskell SG, Bathulapalli H, Gilliam W, Goulet JL. Persistent Pain and Comorbidity Among Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn Veterans. PAIN MEDICINE 2014; 15:782-90. [DOI: 10.1111/pme.12388] [Citation(s) in RCA: 118] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Burgess DJ, Nelson DB, Gravely AA, Bair MJ, Kerns RD, Higgins DM, van Ryn M, Farmer M, Partin MR. Racial Differences in Prescription of Opioid Analgesics for Chronic Noncancer Pain in a National Sample of Veterans. THE JOURNAL OF PAIN 2014; 15:447-55. [DOI: 10.1016/j.jpain.2013.12.010] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Revised: 12/19/2013] [Accepted: 12/23/2013] [Indexed: 01/02/2023]
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Zeitoun AA, Dimassi HI, Chami BA, Chamoun NR. Acute pain management and assessment: are guidelines being implemented in developing countries (Lebanon). J Eval Clin Pract 2013; 19:833-9. [PMID: 22639904 DOI: 10.1111/j.1365-2753.2012.01860.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
RATIONALE Pain assessment and treatment is influenced by subjective perception of pain. Despite the international efforts to implement guidelines and protocols for pain management, pain continues to be regarded as a complication rather than a primary problem. The literature pertaining to the adequacy of pain management in the Middle East is frail. This study focuses on revealing the implemented practices of initial pain assessment, follow-up and re-evaluation of pain treatment in Lebanese hospitals. AIM AND OBJECTIVES The objective of this study is to evaluate the presence and effectiveness of acute pain management and its impact on the quality of life in hospitals throughout Lebanon, in both cancer and non-cancer populations. METHODS A Lebanese multi-centre, prospective, chart review study was conducted over a period of 3 months. Data on demographics, pain medication, dose, route, duration and adjunct pain management were collected. Appropriateness of pain management was determined as per World Health Organization guidelines. Institutional Review Board approvals were obtained from each hospital. RESULTS Results from 582 participants revealed that 50% of initial pain assessment intensity scores were based on the assumptions of health care professionals. Furthermore, as pain severity scores increased, the adequacy of pain management decreased. Only 22% of the patients had a daily follow-up, and the majority of those continued to receive inappropriate therapy. CONCLUSION This study reflects the lack of a well-structured system for pain management in Lebanese hospitals. It underlines the need for pain research in the region. It also highlights the need for implementing the recommendations discussed to minimize risk and optimize pain management.
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Affiliation(s)
- Abeer A Zeitoun
- Clinical Assistant Professor, Pharmacy Practice Department, Lebanese American University, School of Pharmacy, Byblos, Lebanon Assistant Professor, Basic Science Department, Lebanese American University, School of Pharmacy, Byblos, Lebanon Student, Lebanese American University, School of Pharmacy, Byblos, Lebanon
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Evaluation of the psychometric properties of the revised short-form McGill Pain Questionnaire. THE JOURNAL OF PAIN 2013. [PMID: 23182230 DOI: 10.1016/j.jpain.2012.09.011] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
UNLABELLED The recently revised version of the Short-Form McGill Pain Questionnaire (SF-MPQ-2) was created to assess both neuropathic and non-neuropathic pain. The current study extends prior research by testing the reliability and validity of the SF-MPQ-2 in a sample of U.S. veteran patients with a range of chronic pain diagnoses. Participants (N = 186) completed the SF-MPQ-2, a sociodemographic questionnaire, the Structured Clinical Interview for the DSM-IV, and self-report pain and psychiatric measures. Pain diagnoses were extracted from the electronic medical record. The SF-MPQ-2 total and scale scores demonstrated good-to-excellent internal consistency. Convergent and discriminant validity were supported, and SF-MPQ-2 total and scale scores increased with number of pain diagnoses and pain severity. Confirmatory factor analyses indicated that a 4-factor model fit the data better than a single-factor model. However, high intercorrelations among the 4 latent constructs were observed, and a second-order global pain construct also emerged. Overall, the SF-MPQ-2 demonstrated excellent reliability and validity in a sample of U.S. veteran patients with chronic neuropathic and non-neuropathic pain. Future psychometric studies of the SF-MPQ-2 should employ longitudinal data to evaluate the ability of scale scores to uniquely predict clinical and health service outcomes. PERSPECTIVE This article presents the psychometric properties of a revised version of the SF-MPQ-2. This measure may have great utility as a screening tool in clinical practice and as an outcome measure in clinical trials.
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Weimer MB, Macey TA, Nicolaidis C, Dobscha SK, Duckart JP, Morasco BJ. Sex differences in the medical care of VA patients with chronic non-cancer pain. PAIN MEDICINE 2013; 14:1839-47. [PMID: 23802846 DOI: 10.1111/pme.12177] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Despite a growing number of women seeking medical care in the veterans affairs (VA) system, little is known about the characteristics of their chronic pain or the pain care they receive. This study sought to determine if sex differences are present in the medical care veterans received for chronic pain. DESIGN Retrospective cohort study using VA administrative data. SUBJECTS The subjects were 17,583 veteran patients with moderate to severe chronic non-cancer pain treated in the Pacific Northwest during 2008. METHODS Multivariate logistic regression assessed for sex differences in primary care utilization, prescription of chronic opioid therapy, visits to emergency departments for a pain-related diagnosis, and physical therapy referral. RESULTS Compared with male veterans, female veterans were more often diagnosed with two or more pain conditions, and had more of the following pain-related diagnoses: fibromyalgia, low back pain, inflammatory bowel disease, migraine headache, neck or joint pain, and arthritis. After adjustment for demographic characteristics, pain diagnoses, mental health diagnoses, substance use disorders, and medical comorbidity, women had lower odds of being prescribed chronic opioid therapy (adjusted OR [AOR] 0.67, 95% CI 0.58-0.78), greater odds of visiting an emergency department for a pain-related complaint (AOR 1.40, 95% CI 1.18-1.65), and greater odds of receiving physical therapy (AOR 1.19, 95% CI 1.05-1.33). Primary care utilization was not significantly different between sexes. CONCLUSIONS Sex differences are present in the care female veterans receive for chronic pain. Further research is necessary to understand the etiology of the observed differences and their associations with clinical outcomes.
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Affiliation(s)
- Melissa B Weimer
- Department of Medicine, Oregon Health & Science University, Portland, Oregon, USA
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Dobscha SK, Morasco BJ, Duckart JP, Macey T, Deyo RA. Correlates of prescription opioid initiation and long-term opioid use in veterans with persistent pain. Clin J Pain 2013; 29:102-8. [PMID: 23269280 PMCID: PMC3531630 DOI: 10.1097/ajp.0b013e3182490bdb] [Citation(s) in RCA: 106] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Little is known about how opioid prescriptions for chronic pain are initiated. We sought to describe patterns of prescription opioid initiation, identify correlates of opioid initiation, and examine correlates of receipt of chronic opioid therapy (COT) among veterans with persistent noncancer pain. METHODS Using Veterans Affairs administrative data, we identified 5961 veterans from the Pacific Northwest with persistent elevated pain intensity scores who had not been prescribed opioids in the prior 12 months. We compared veterans not prescribed opioids over the subsequent 12 months with those prescribed any opioid and to those prescribed COT (>90 consecutive days). RESULTS During the study year, 35% of the sample received an opioid prescription and 5% received COT. Most first opioid prescriptions were written by primary care clinicians. Veterans prescribed COT were younger, had greater pain intensity, and high rates of psychiatric and substance use disorders compared with veterans in the other 2 groups. Among patients receiving COT, 29% were prescribed long-acting opioids, 37% received 1 or more urine drug screens, and 24% were prescribed benzodiazepines. Adjusting for age, sex, and baseline pain intensity, major depression [odds ratio 1.24 (1.10-1.39); 1.48 (1.14-1.93)], and nicotine dependence [1.34 (1.17-1.53); 2.02 (1.53-2.67)] were associated with receiving any opioid prescription and with COT, respectively. DISCUSSION Opioid initiations are common among veterans with persistent pain, but most veterans are not prescribed opioids long-term. Psychiatric disorders and substance use disorders are associated with receiving COT. Many Veterans receiving COT are concurrently prescribed benzodiazepines and many do not receive urine drug screening; additional study regarding practices that optimize safety of COT in this population is indicated.
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Affiliation(s)
- Steven K Dobscha
- Mental Health and Clinical Neurosciences Division, Portland VA Medical Center, OR 97239, USA.
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Measuring sustainability within the Veterans Administration Mental Health System Redesign initiative. Qual Manag Health Care 2012; 20:263-79. [PMID: 21971024 DOI: 10.1097/qmh.0b013e3182314b20] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine how attributes affecting sustainability differ across Veterans Health Administration organizational components and by staff characteristics. SUBJECTS Surveys of 870 change team members and 50 staff interviews within the Veterans Affairs' Mental Health System Redesign initiative. METHODS A 1-way ANOVA with a Tukey post hoc test examined differences in sustainability by Veteran Integrated Service Networks, job classification, and tenure from staff survey data of the Sustainability Index. Qualitative interviews used an iterative process to identify "a priori" and "in vivo" themes. A simple stepwise linear regression explored predictors of sustainability. RESULTS Sustainability differed across Veteran Integrated Service Networks and staff tenure. Job classification differences existed for the following: (1) benefits and credibility of the change and (2) staff involvement and attitudes toward change. Sustainability barriers were staff and institutional resistance and nonsupportive leadership. Facilitators were commitment to veterans, strong leadership, and use of quality improvement tools. Sustainability predictors were outcomes tracking, regular reporting, and use of Plan, Do, Study, Adjust cycles. CONCLUSIONS Creating homogeneous implementation and sustainability processes across a national health system is difficult. Despite the Veterans Affairs' best evidence-based implementation efforts, there was significant variance. Locally tailored interventions might better support sustainability than "one-size-fits-all" approaches. Further research is needed to understand how participation in a quality improvement collaborative affects sustainability.
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Managing Clinical Risk and Measuring Participants’ Perceptions of the Clinical Research Process. PRINCIPLES AND PRACTICE OF CLINICAL RESEARCH 2012. [PMCID: PMC7271313 DOI: 10.1016/b978-0-12-382167-6.00039-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Kerns RD, Philip EJ, Lee AW, Rosenberger PH. Implementation of the veterans health administration national pain management strategy. Transl Behav Med 2011; 1:635-43. [PMID: 24073088 PMCID: PMC3717675 DOI: 10.1007/s13142-011-0094-3] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Since its introduction in 1998, the VHA National Pain Management Strategy has introduced and implemented a series of plans for promoting systems improvements in pain care. We present the milestones of VHA efforts in pain management as reflected by the work of the Strategy. This includes the development of the Strategy and its current structure as well as a review of important initiatives such as "pain as the fifth vital sign" and the stepped care model of pain management.
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Affiliation(s)
- Robert D Kerns
- />PRIME Center/11ACSLG, VA Connecticut Healthcare System, West Haven, CT 06516 USA
- />Department of Psychiatry, Yale University School of Medicine, New Haven, CT 06510 USA
| | - Errol J Philip
- />Memorial Sloan Kettering Cancer Center, New York, NY 10065 USA
| | - Allison W Lee
- />Department of Psychiatry, Yale University School of Medicine, New Haven, CT 06510 USA
| | - Patricia H Rosenberger
- />PRIME Center/11ACSLG, VA Connecticut Healthcare System, West Haven, CT 06516 USA
- />Department of Psychiatry, Yale University School of Medicine, New Haven, CT 06510 USA
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Macey TA, Morasco BJ, Duckart JP, Dobscha SK. Patterns and correlates of prescription opioid use in OEF/OIF veterans with chronic noncancer pain. PAIN MEDICINE 2011; 12:1502-9. [PMID: 21899715 DOI: 10.1111/j.1526-4637.2011.01226.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Little is known about the treatment Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans receive for chronic noncancer pain (CNCP). We sought to describe the prevalence of prescription opioid use, types, and doses of opioids received and to identify correlates of receiving prescription opioids for CNCP among OEF/OIF veterans. DESIGN Retrospective review of Veterans Affairs (VA) administrative data. SETTING Ambulatory clinics within a VA regional health care network. PATIENTS OEF/OIF veterans who had at least three elevated pain screening scores within a 12-month period in 2008. Within this group, those prescribed opioids (N = 485) over the next 12 months were compared with those not prescribed opioids (N = 277). In addition, patients receiving opioids short term (<90 days, N = 284) were compared with patients receiving them long term (≥90 consecutive days, N = 201). RESULTS Of 762 OEF/OIF veterans with CNCP, 64% were prescribed at least one opioid medication over the 12 months following their index dates. Of those prescribed an opioid, 59% were prescribed opioids short term and 41% were prescribed opioids long term. The average morphine-equivalent opioid dose for short-term users was 23.7 mg (standard deviation [SD] = 20.5) compared with 40.8 mg (SD = 36.1) for long-term users (P < 0.001). Fifty-one percent of long-term opioid users were prescribed short-acting opioids only, and one-third were also prescribed sedative hypnotics. In adjusted analyses, diagnoses of low back pain, migraine headache, posttraumatic stress disorder, and nicotine use disorder were associated with an increased likelihood of receiving an opioid prescription. CONCLUSION Prescription opioid use is common among OEF/OIF veterans with CNCP and is associated with several pain diagnoses and medical conditions.
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Affiliation(s)
- Tara A Macey
- Mental Health and Clinical Neurosciences Division, Portland VA Medical Center, Portland, Oregon 97239, USA
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Morasco BJ, Duckart JP, Dobscha SK. Adherence to clinical guidelines for opioid therapy for chronic pain in patients with substance use disorder. J Gen Intern Med 2011; 26:965-71. [PMID: 21562923 PMCID: PMC3157527 DOI: 10.1007/s11606-011-1734-5] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2010] [Revised: 03/23/2011] [Accepted: 04/19/2011] [Indexed: 12/01/2022]
Abstract
BACKGROUND Patients with chronic non-cancer pain (CNCP) have high rates of substance use disorders (SUD). SUD complicates pain treatment and may lead to worse outcomes. However, little information is available describing adherence to opioid treatment guidelines for CNCP generally, or guideline adherence for patients with comorbid SUD. OBJECTIVE Examine adherence to clinical guidelines for opioid therapy over 12 months, comparing patients with SUD diagnoses made during the prior year to patients without SUD. DESIGN Cohort study. PARTICIPANTS Administrative data were collected from veterans with CNCP receiving treatment within a Veterans Affairs regional healthcare network who were prescribed chronic opioid therapy in 2008 (n = 5814). KEY RESULTS Twenty percent of CNCP patients prescribed chronic opioid therapy had a prior-year diagnosis of SUD. Patients with SUD were more likely to have pain diagnoses and psychiatric comorbidities. In adjusted analyses, patients with SUD were more likely than those without SUD to have had a mental health appointment (29.7% versus 17.2%, OR = 1.49, 95% CI = 1.26-1.77) and a urine drug screen (UDS) (47.0% versus 18.2%, OR = 3.53, 95% CI = 3.06-4.06) over 12 months. There were no significant differences between groups on receiving more intensive treatment in primary care (63.4% versus 61.0%), long-acting opioids (26.9% versus 26.0%), prescriptions for antidepressants (88.2% versus 85.8%, among patients with depression), or participating in physical therapy (30.6% versus 28.6%). Only 35% of patients with SUD received substance abuse treatment. CONCLUSIONS CNCP patients with SUD were more likely to have mental health appointments and receive UDS monitoring, but not more likely to participate in other aspects of pain care compared to those without SUD. Given data suggesting patients with comorbid SUD may need more intensive treatment to achieve improvements in pain-related function, SUD patients may be at high risk for poor outcomes.
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Affiliation(s)
- Benjamin J Morasco
- Mental Health and Clinical Neurosciences Division, Portland VA Medical Center, Department of Psychiatry, Oregon Health & Science University, 3710 SW US Veterans Hospital Road, Portland, OR 97239, USA.
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White DE, Straus SE, Stelfox HT, Holroyd-Leduc JM, Bell CM, Jackson K, Norris JM, Flemons WW, Moffatt ME, Forster AJ. What is the value and impact of quality and safety teams? A scoping review. Implement Sci 2011; 6:97. [PMID: 21861911 PMCID: PMC3189393 DOI: 10.1186/1748-5908-6-97] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2010] [Accepted: 08/23/2011] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND The purpose of this study was to conduct a scoping review of the literature about the establishment and impact of quality and safety team initiatives in acute care. METHODS Studies were identified through electronic searches of Medline, Embase, CINAHL, PsycINFO, ABI Inform, Cochrane databases. Grey literature and bibliographies were also searched. Qualitative or quantitative studies that occurred in acute care, describing how quality and safety teams were established or implemented, the impact of teams, or the barriers and/or facilitators of teams were included. Two reviewers independently extracted data on study design, sample, interventions, and outcomes. Quality assessment of full text articles was done independently by two reviewers. Studies were categorized according to dimensions of quality. RESULTS Of 6,674 articles identified, 99 were included in the study. The heterogeneity of studies and results reported precluded quantitative data analyses. Findings revealed limited information about attributes of successful and unsuccessful team initiatives, barriers and facilitators to team initiatives, unique or combined contribution of selected interventions, or how to effectively establish these teams. CONCLUSIONS Not unlike systematic reviews of quality improvement collaboratives, this broad review revealed that while teams reported a number of positive results, there are many methodological issues. This study is unique in utilizing traditional quality assessment and more novel methods of quality assessment and reporting of results (SQUIRE) to appraise studies. Rigorous design, evaluation, and reporting of quality and safety team initiatives are required.
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Affiliation(s)
- Deborah E White
- Faculty of Nursing, University of Calgary, 2500 University Drive NW, Calgary, Alberta T2N 1N4, Canada
| | - Sharon E Straus
- Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada
| | - H Tom Stelfox
- Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Chaim M Bell
- Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada
| | - Karen Jackson
- Health Systems and Workforce Research Unit, Alberta Health Services, Calgary, Alberta, Canada
| | - Jill M Norris
- Faculty of Nursing, University of Calgary, 2500 University Drive NW, Calgary, Alberta T2N 1N4, Canada
| | - W Ward Flemons
- Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Michael E Moffatt
- Research and Applied Learning Division, Winnipeg Regional Health Authority, Winnipeg, Manitoba, Canada
| | - Alan J Forster
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Bentley TGK, Malin J, Longino S, Asch S, Dy S, Lorenz KA. Methods for improving efficiency in quality measurement: the example of pain screening. Int J Qual Health Care 2011; 23:657-63. [PMID: 21846733 DOI: 10.1093/intqhc/mzr054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Collecting unnecessary data when assessing quality of care wastes valuable resources. We evaluated three approaches for estimating quality-measure adherence and determined minimum visit data required to achieve accurate estimates. DESIGN We abstracted medical records for calculating physician-level pain screening rates as: visit-specific, using single-visit data for each patient; visit-level average, using data for all patients and visits; and patient-level average, using data from a subset of patients and visits. SETTING VA Greater Los Angeles Health-care System, 2006. PARTICIPANTS One hundred and six patients with Stage IV solid tumors. INTERVENTION Pain screening at every medical encounter, measured by a 0-10 numeric rating scale and reported to the national Medicare insurance program under a 'pay-for-reporting' program. MAIN OUTCOME MEASURES Amount of visit data needed to reach the smallest 95% confidence interval (CI) and stable pain screening estimates. RESULTS Pain screening occurred at 22% (23/106; 95% CI: 14-30%) of initial visits and 50% (8/16; 95% CI: 25-75%) of single visits. Across all visits, screening adherence averaged 34% when estimated at the visit-level precision and 30% at the patient level. Maximum patient-level precision was reached at visit 4 (95% CI: ± 8%) and visit level at visit 14 (95% CI: ± 6%). Using patient-level and visit-level approaches, estimates stabilized at visits 8 and 11, respectively, and reached within 1 percentage point of the steady-state value at visits 4 and 9. CONCLUSION To address low-pain screening among cancer patients, an oncology pain screening measure may be most efficiently evaluated with data from a sample of patients and visits. This approach may be valid for visit-level quality measures in other settings.
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Affiliation(s)
- T G K Bentley
- Partnership for Health Analytic Research, LLC, Beverly Hills, CA 90212, USA.
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Morasco BJ, Duckart JP, Carr TP, Deyo RA, Dobscha SK. Clinical characteristics of veterans prescribed high doses of opioid medications for chronic non-cancer pain. Pain 2011; 151:625-632. [PMID: 20801580 DOI: 10.1016/j.pain.2010.08.002] [Citation(s) in RCA: 145] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2010] [Revised: 07/07/2010] [Accepted: 08/02/2010] [Indexed: 11/26/2022]
Abstract
Little is known about patients prescribed high doses of opioids to treat chronic non-cancer pain, though these patients may be at higher risk for medication-related complications. We describe the prevalence of high-dose opioid use and associated demographic and clinical characteristics among veterans treated in a VA regional healthcare network. Veterans with chronic non-cancer pain prescribed high doses of opioids (≥ 180 mg/day morphine equivalent; n=478) for 90+ consecutive days were compared to two groups with chronic pain: Traditional-dose (5-179 mg/day; n=500) or no opioid (n=500). High-dose opioid use occurred in 2.4% of all chronic pain patients and in 8.2% of all chronic pain patients prescribed opioids long-term. The average dose in the high-dose group was 324.9 (SD=285.1)mg/day. The only significant demographic difference among groups was race (p=0.03) with black veterans less likely to receive high doses. High-dose patients were more likely to have four or more pain diagnoses and the highest rates of medical, psychiatric, and substance use disorders. After controlling for demographic factors and VA facility, neuropathy, low back pain, and nicotine dependence diagnoses were associated with increased likelihood of high-dose prescriptions. High-dose patients frequently did not receive care consistent with treatment guidelines: there was frequent use of short-acting opioids, urine drug screens were administered to only 25.7% of patients in the prior year, and 32.0% received concurrent benzodiazepine prescriptions, which may increase risk for overdose and death. Further study is needed to identify better predictors of high-dose usage, as well as the efficacy and safety of such dosing.
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Affiliation(s)
- Benjamin J Morasco
- Mental Health and Clinical Neurosciences Division, Portland VA Medical Center, Department of Psychiatry, Oregon Health & Science University, USA Portland Center for the Study of Chronic, Comorbid Mental and Physical Disorders, Portland VA Medical Center, USA Primary Care Division, Portland VA Medical Center, Department of Medicine, Division of General Medicine and Geriatrics, Oregon Health & Science University, USA Departments of Family Medicine and Internal Medicine, Oregon Health & Science University, USA
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Helfand M, Freeman M. Assessment and management of acute pain in adult medical inpatients: a systematic review. PAIN MEDICINE 2010; 10:1183-99. [PMID: 19818030 DOI: 10.1111/j.1526-4637.2009.00718.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To review the literature addressing effective care for acute pain in inpatients on medical wards. METHODS We searched Medline, PubMed Clinical Queries, and the Cochrane Database for systematic reviews published in 1996 through April 2007 on the assessment and management of acute pain in inpatients, including patients with impaired self-report or chemical dependencies. We conducted a focused search for studies on the timing and frequency of assessment, and on the use of patient-controlled analgesia (PCA) for nonsurgical pain. Two investigators performed a critical analysis of the literature and compiled narrative summaries to address the key questions. RESULTS We found no evidence that directly linked the timing, frequency, or method of pain assessment with outcomes or safety in medical inpatients. There is good evidence that treating abdominal pain does not compromise timely diagnosis and treatment of the surgical abdomen. Pain management teams and other systemwide interventions improve assessment and use of analgesics, but do not clearly affect pain outcomes. The safety and effectiveness of PCA in medical patients have not been studied. There is weak evidence that most cognitively impaired individuals can understand at least one self-assessment measure. Almost no evidence is available to guide management of pain in delirium. Evidence for managing pain in patients with substance abuse disorders or chronic opioid use is weak, being derived from case reports, retrospective studies, and expert opinion. CONCLUSIONS Pain is a prevalent problem for medical inpatients. Clinical research is needed to guide the assessment and management of pain in this setting.
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Affiliation(s)
- Mark Helfand
- Evidence-Based Synthesis Program, Portland Veterans Affairs Medical Center, Portland, OR 97239, USA.
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Haskell SG, Brandt CA, Krebs EE, Skanderson M, Kerns RD, Goulet JL. Pain among Veterans of Operations Enduring Freedom and Iraqi Freedom: do women and men differ? PAIN MEDICINE 2010; 10:1167-73. [PMID: 19818028 DOI: 10.1111/j.1526-4637.2009.00714.x] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To evaluate sex differences in the prevalence of overall pain, moderate-severe pain, and persistent pain among Veterans of Operations Enduring Freedom and Iraqi Freedom seen at VA outpatient clinics, and to evaluate sex differences in pain assessment. DESIGN The observational cohort consisted of Veterans discharged from the U.S. military from October 1, 2001 to November 30, 2007 that enrolled for Veterans Administration (VA) services or received VA care before January 1, 2008. We limited the sample to the 153,212 Veterans (18,481 female, 134,731 male) who had 1 year of observation after their last deployment. RESULTS Pain was assessed in 59.7% (n = 91,414) of Veterans in this sample. Among those assessed, 43.3% (n = 39,591) reported any pain, 63.2% (n = 25,028) of whom reported moderate-severe pain. Over 20% (n = 3,427) of Veterans with repeated pain measures reported persistent pain. We found no significant difference in the probability of pain assessment by sex (RR = 0.98, 95% CI 0.96, 1.00). Female Veterans were less likely to report any pain (RR 0.89, 95% CI 0.86, 0.92). Among those with any pain, female Veterans were more likely to report moderate-severe pain (RR 1.05, 95% CI 1.01, 1.09) and less likely to report persistent pain (RR 0.90, 95% CI 0.81, 0.99). CONCLUSIONS As the VA plans care for the increasing numbers of female Veterans returning from Iraq and Afghanistan, a better understanding of the prevalence of pain, as well as sex-specific variations in the experience and treatment of pain, is important for policy makers and providers who seek to improve identification and management of diverse pain disorders.
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Abstract
The veterans health care system administered by the U.S. Department of Veterans Affairs (VA) was established after World War I to provide health care for veterans who suffered from conditions related to their military service. It has grown to be the nation's largest integrated health care system. As the system grew, a number of factors contributed to its becoming increasingly dysfunctional. By the mid-1990s, VA health care was widely criticized for providing fragmented and disjointed care of unpredictable and irregular quality, which was expensive, difficult to access, and insensitive to individual needs. Between 1995 and 1999, the VA health care system was reengineered, focusing especially on management accountability, care coordination, quality improvement, resource allocation, and information management. Numerous systemic changes were implemented, producing dramatically improved quality, service, and operational efficiency. VA health care is now considered among the best in America, and the VA transformation is viewed as a model for health care reform.
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Dobkin PL, Boothroyd LJ. Organizing health services for patients with chronic pain: when there is a will there is a way. PAIN MEDICINE 2009; 9:881-9. [PMID: 18950443 DOI: 10.1111/j.1526-4637.2007.00326.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
SETTING Due to its magnitude as a health problem, its associated burden, and the viability of modes of intervention, chronic pain (CP) should be considered a priority within health care systems. The lives of many patients with CP are devastated by this problem and health care professionals have a responsibility to assist them in reducing their suffering. Countries, regions, and systems differ considerably with regard to how they organize, administer, and finance services for CP patients. OBJECTIVE In this review, we highlight initiatives in three jurisdictions--France, Australia, and the Veterans' Health Administration in the United States--which demonstrate that when there is a will there is a way to change health care services for patients with CP. This work is a synopsis of a health technology assessment report we completed on behalf of the Quebec Health Services and Technology Assessment Agency (http://www.aetmis.gouv.qc.ca) at the request of the Ministry of Health and Social Services in Quebec, Canada, to inform policymakers at various levels of the health care system. DESIGN A literature search of published and unpublished "gray" literature was used to identify organizational themes according to structure, process, and outcome elements of health care services. For each theme, literature was reviewed in a qualitative manner; in addition, "real world" information was sought from example jurisdictions that have prioritized management of CP. Our conclusions point to key issues to consider when organizing health services for CP patients.
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Affiliation(s)
- Patricia L Dobkin
- Quebec Health Services and Technology Assessment Agency, Agence d'évaluation des technologies et des modes d'intervention en santé, Montreal, Quebec, Canada.
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Goldberg GR, Morrison RS. Pain management in hospitalized cancer patients: a systematic review. J Clin Oncol 2007; 25:1792-801. [PMID: 17470871 DOI: 10.1200/jco.2006.07.9038] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To assist cancer centers in improving pain management, we conducted a systematic review of institutional interventions designed to improve the assessment and treatment of pain in hospitalized cancer patients. METHODS We performed a MEDLINE search for all English-language articles published from January 1966 through February 2006 using the medical subject headings terms of pain or pain measurement and outcome assessment (health care) or quality assurance (health care). Selected bibliographies were also searched. Studies were reviewed if they included clinical interventions directed at improving the treatment of cancer pain across an institution or nursing unit. Meta-analyses and randomized controlled trials or other controlled studies were included where possible. If no such trials were identified, then the best evidence available from studies with other designs was included. RESULTS Five interventions were identified. These interventions included professional and patient education, instituting regular pain assessment (pain as a vital sign), audit of pain results and feedback to clinical staff, computerized decisional support systems, and specialist-level pain consultation services. Most studies were small in size and used quasiexperimental pre-post test designs. Successes were reported in increasing patient satisfaction, increasing documentation of pain intensity, and improving nurses' knowledge and attitudes. No study reported successful interventions that consistently improved patients' pain severity. CONCLUSION Although professional knowledge and attitudes about pain and nursing pain assessment rates have been shown to be improvable, no systematic, hospital-wide intervention has yet to be associated with improvement in pain severity. Future research on the development of new interventions, perhaps targeted specifically at physicians, is urgently needed.
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Affiliation(s)
- Gabrielle R Goldberg
- Division of Hematology and Medical Oncology, Samuel Bronfman Department of Medicine, Mount Sinai School of Medicine, New York 10029, USA
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Abstract
The treatment of bone metastases represents a paradigm for evaluating palliative care in terms of symptom relief, toxicities of therapy, and the financial burden to the patient, caregivers, and society. Despite enormous expenditures to treat metastases, patients continue to sustain symptoms of the disease, and uninterrupted aggressive therapies are pursued until death that incur toxicity in approximately 25% of patients. This approach is inconsistent with the goals of palliative care, which should efficiently provide comfort using antineoplastic therapies or supportive care approaches to the patient with the fewest treatment-related side effects, recognizing that the patient will die of the disease.The development of therapies such as bisphosphonates is important in advancing options for palliative care; however, clinical trials demonstrating the efficacy of bisphosphonates have not addressed important issues for clinical practice. The primary study endpoints should primarily address pertinent patient outcomes such as pain relief rather than asymptomatic radiographic findings. These studies should define clear indications of when to start and stop the therapy, the appropriate patient populations to receive the therapy, and the cost effectiveness of the treatment relative to other available therapies such as radiation. Cost-utility analyses, which account for a broader domain of cost effectiveness, need to be performed as part of clinical trials, especially for palliative care endpoints. Clinical trials that include these criteria are critical to future practice guideline development. As health care resources continue to become more limited, the criteria for care must be better defined to avoid administration of therapy with limited benefit. Leadership must come from the specialty as clinical trials and clinical practice increasingly interface with health care policy. Goals of therapy must remain clear for the benefit of the individual and all patients.
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Affiliation(s)
- Nora Janjan
- Department of Radiation Oncology, University of Texas, M.D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA.
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Mills PD, Neily J, Mims E, Burkhardt ME, Bagian J. Improving the bar-coded medication administration system at the Department of Veterans Affairs. Am J Health Syst Pharm 2006; 63:1442-7. [PMID: 16849710 DOI: 10.2146/ajhp050452] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Peter D Mills
- National Center for Patient Safety, Department of Veterans Affairs, White River Junction, VT 05009, USA.
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Lorenz KA, Lynn J, Dy S, Wilkinson A, Mularski RA, Shugarman LR, Hughes R, Asch SM, Rolon C, Rastegar A, Shekelle PG. Quality measures for symptoms and advance care planning in cancer: a systematic review. J Clin Oncol 2006; 24:4933-8. [PMID: 17050878 DOI: 10.1200/jco.2006.06.8650] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Measuring quality of care for symptom management and ascertaining patient goals offers an important step toward improving palliative cancer management. This study was designed to identify systematically the quality measures and the evidence to support their use in pain, dyspnea, depression, and advance care planning (ACP), and to identify research gaps. METHODS English-language documents were selected from MEDLINE, Cumulative Index to Nursing and Allied Health, PsycINFO (1995 to 2005); Internet-based searches; and contact with measure developers. We used terms for each domain to select studies throughout the cancer care continuum. We included measures that expressed a normative relationship to quality, specified the target population, and specified the indicated care. Dual data review and abstraction was performed by palliative care researchers describing populations, testing, and attributes for each measure. RESULTS A total of 4,599 of 5,182 titles were excluded at abstract review. Of 537 remaining articles, 19 contained measures for ACP, six contained measures for depression, five contained measures for dyspnea, and 20 contained measures for pain. We identified 10 relevant measure sets that included 36 fully specified or fielded measures and 14 additional measures (16 for pain, five for dyspnea, four for depression, and 25 for ACP). Most measures were unpublished, and few had been tested in a cancer population. We were unable to describe the specifications of all measures fully and did not search for measures for pain and depression that were not cancer specific. CONCLUSION Measures are available for assessing quality and guiding improvement in palliative cancer care. Existing measures are weighted toward ACP, and more nonpain symptom measures are needed. Additional testing is needed before the measures are used for accountability, and basic research is required to address measurement when self-report is impaired.
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Affiliation(s)
- Karl A Lorenz
- Veterans Affairs Greater Los Angeles Healthcare System, Division of General Internal Medicine, Los Angeles, CA 90073, USA.
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Newton PJ, Davidson PM, Halcomb EJ, Denniss AR, Westgarth F. An introduction to the collaborative methodology and its potential use for the management of heart failure. J Cardiovasc Nurs 2006; 21:161-8. [PMID: 16699354 DOI: 10.1097/00005082-200605000-00002] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Heart failure (HF) is responsible for significant disease burden in developed countries internationally. Despite significant advances and a strong evidence base in therapies and treatment strategies for HF, access to these therapies continues to remain elusive to a significant proportion of the HF population. The reasons for this are multifactorial and range from the financial cost of treatments to the individual attitudes and beliefs of clinicians. The collaborative methodology, based upon a quality improvement philosophy, has been identified as a potentially useful tool to address this treatment gap. AIM In this manuscript, we review the published literature on the collaborative methodology and assess the evidence for achieving improvement in the management of HF. METHODS Searches of electronic databases, the reference lists of published materials, policy documents, and the Internet were conducted using key words including "collaborative methodology," "breakthrough series," "quality improvement," "total quality improvement," and "heart failure." Because of the paucity of high-level evidence, all English-language articles were included in the review. RESULTS On the basis of the identified search strategy, 43 articles were retrieved. Key themes that emerged from the literature included the following: (1) The collaborative methodology has a significant potential to reduce the treatment gap. (2) Leadership is an important characteristic of the collaborative method. (3) The collaborative methodology facilitates sustainability of the quality improvement process. CONCLUSION The collaborative methodology, when implemented and conducted according to key conceptual principles, has significant potential to improve the outcomes of patients, particularly those with HF and chronic cardiovascular disease.
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Affiliation(s)
- Phillip J Newton
- School of Nursing, Family and Community Health, College of Social and Health Science, University of Western Sydney, West Area Health Service, New South Wales, Australia.
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Maxwell DJ, Graudins L, Kaye KI. Improving Quality Improvement Models. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2006. [DOI: 10.1002/j.2055-2335.2006.tb00587.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- David J Maxwell
- NSW Therapeutic Advisory Group Inc., Darlinghurst, and Faculty of Pharmacy; The University of Sydney; Camperdown
| | | | - Karen I Kaye
- NSW Therapeutic Advisory Group Inc.; Darlinghurst New South Wales
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Affiliation(s)
- Karl A Lorenz
- Veterans Administration Greater Los Angeles Healthcare System, Los Angeles, California 90073, USA.
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Neily J, Howard K, Quigley P, Mills PD. One-year follow-up after a collaborative breakthrough series on reducing falls and fall-related injuries. Jt Comm J Qual Patient Saf 2005; 31:275-85. [PMID: 15960018 DOI: 10.1016/s1553-7250(05)31035-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Multisite facilitated quality improvement (QI) projects, called collaborative Breakthrough Series (BTS), have been shown to improve care, but it is also important to evaluate the lasting effects and spread of changes of BTSs. A project focused on fall and injury-related prevention started in Spring 2001; after the project's end, support was provided through e-mail and periodic conference calls. METHODS One year after project completion, team contacts were interviewed to determine if they had maintained gains or made further improvements. RESULTS For the 34 (of 37 teams) interviewed, 82.4% reported they had stayed together as a team; 97.1%, that they continued to collect data; 93.9%, that they had maintained gains; 82.4%, that they had spread changes to new locations; and 85.3%, that they had begun to work on new topics. High team performance at one year correlated with first-meeting team characteristics Leadership Support (r = .456, p = .019) and Prior Experience with Quality Improvement and Teamwork (r = .393, p = .047) and with follow-up team characteristics Leadership Support (r = .614, p < .001), Teamwork Skills (r = .377, p = .033), and Skills Gained from the Project (r = .410, p = .020). CONCLUSIONS Leadership support, experience with quality improvement and teamwork, teamwork skills, and skills gained from the project were correlated with teams' abilities to achieve and maintain success.
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Affiliation(s)
- Julia Neily
- Field Office, VA National Center for Patient Safety, Veterans Health Administration, White River Junction, Vermont, USA.
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