Complementary, Integrative, and Nondrug Therapy Use for Pain Among US Military Veterans on Long-term Opioids

Profiles of Nonpharmacologic Treatment Receipt in the First 10 Weeks Following a New Back Pain Diagnosis Among Active Duty Soldiers: A Latent Class Analysis

INTRODUCTION

US service members experience high rates of back pain. Guidelines prioritize nonpharmacologic treatment (NPT) as first-line pain treatments; however, NPT utilization patterns research is limited. This study examined NPT patterns of care within the first 10 weeks following an index back pain diagnosis.

MATERIALS AND METHODS

Data were from the Substance Use and Psychological Injury Combat Study and included 222,427 active duty soldiers with an index back pain diagnosis following return from Afghanistan/Iraq deployment in 2008-2014. We fit a series of latent class analysis models to identify homogenous subgroups of soldiers with NPT utilization during the 10-week period and measured associations with soldier characteristics and clinical characteristics within 90 days before the back pain diagnosis, with the distinct NPT utilization classes. Approval for this study was granted by the Brandeis University Committee for Protection of Human Subjects (Institutional Review Board #14153) and the Uniformed Services University Institutional Review Board.

RESULTS

Only half of the soldiers received any NPT within their 10-week early treatment window. Latent class analysis identified 4 classes over the 10-week early treatment window: Class 1 (None/Low NPT, 65%); Class 2 (High and Decreasing NPT, 15%); Class 3 (Low and Increasing NPT, 13%), and Class 4 (Sustained NPT, 7%). Soldier clinical characteristics from the 90-day preperiod window were most important in distinguishing class membership in relation to Class 1, particularly comorbid pain conditions, diagnosis of traumatic brain injury, receipt of prescription opioids, and receipt of invasive surgery.

CONCLUSIONS

Patterns of weekly NPT utilization during an early treatment window following a new back pain diagnosis varied temporally, with approximately half of soldiers using NPT. Half of the soldiers did not receive any NPT within their 10-week early treatment window, which highlights opportunities for increasing use of NPT utilization among military members with a new back pain episode. Future research is needed in the Military Health System to examine the extent to which NPT patterns are associated with pain management outcomes.

Patterns of Opioid Prescriptions in the Veterans Health Administration for Patients With Chronic Low-Back Pain After the Onset of the COVID-19 Pandemic: A Retrospective Cohort Analysis

The COVID-19 pandemic led to severe disruptions in health care and a relaxation of rules surrounding opioid prescribing-changes which led to concerns about increased reliance on opioids for chronic pain and a resurgence of opioid-related harms. Although some studies found that opioid prescriptions increased in the first 6 months of the pandemic, we know little about the longer-term effects of the pandemic on opioid prescriptions. Further, despite the prevalence of pain in veterans, we know little about patterns of opioid prescriptions in the Veterans Health Administration (VA) associated with the pandemic. Using a retrospective cohort of VA patients with chronic low-back pain, we examined the proportion of patients with an opioid prescription and mean morphine milligram equivalents over a 3-year period-1 year prior to and 2 years after the pandemic's onset. Analyses revealed that both measures fell during the entire observation period. The largest decrease in the odds of filling an opioid prescription occurred in the first quarter of the pandemic, but this downward trend continued throughout the observation period, albeit at a slower pace. Clinically meaningful differences in opioid prescriptions and dose over time did not emerge based on patient race or rurality; however, differences emerged between female and male veterans, with decreases in opioid prescriptions slowing more markedly for women after the pandemic onset. These findings suggest that the pandemic was not associated with short- or long-term increases in opioid prescriptions or doses in the VA. PERSPECTIVE: This article examines opioid prescribing over a 3-year period-1 year prior to and 2 years after the onset of the COVID-19 pandemic-for VA patients with chronic low-back pain. Results indicate that, despite disruptions to health care, opioid prescriptions and doses decreased over the entire observation period.

Comprehensive Caregiver Supports and Ascertainment and Treatment of Veteran Pain

Disabled Veterans commonly experience pain. The Program of Comprehensive Assistance for Family Caregivers (PCAFC) provides training, a stipend, and services to family caregivers of eligible Veterans to support their caregiving role. We compared ascertainment of veteran pain and pain treatment through health care encounters and medications (pain indicators) of participants (treated group) and non-participants (comparison group) using inverse probability treatment weights. Modeled results show that the proportion of Veterans with a pain indicator in the first year post-application was higher than that pre-application for both groups. However, the proportion of Veterans with a pain indicator was substantially higher in the treatment group: 76.1% versus 63.9% in the comparison group (p < .001). Over time, the proportion of Veterans with any pain indicator fell and group differences lessened. However, differences persisted through 8 years post-application (p < .001). PCAFC caregivers appear to help Veterans engage in pain treatment at higher rates than caregivers not in PCAFC.

The association between exercise and prescription opioid misuse: A scoping review

Exercise prevents chronic diseases and modulates pain. People experiencing pain often use opioids for relief, increasing the risk of prescription opioid misuse. Nonetheless, exercise may influence prescription opioid misuse through the release of endorphins or induced injury-related pain. We aimed to summarize the existing literature on the association between exercise and prescription opioid misuse. We identified studies published through December 2021 in Cochrane, Embase, Medline, and Pubmed, using search terms like "opioid-related disorders," "opioid misuse," "exercise," and "sports." Observational and experimental studies with adult samples published in English were included. Exclusion criteria included participants < 18 years old, studies including heroin use as the outcome, and studies conducted among pregnant or institutionalized individuals. The risk of bias and quality assessment were conducted independently by two authors using the National Institutes of Health Study Quality Assessment Tools, and decisions were cross-checked with a third author. Our search yielded 10,796 records, of which eight studies were included. These studies were heterogeneous clinically and methodologically. Three were intervention trials, three were cross-sectional, and two were cohort studies. Three studies evaluated yoga, two evaluated exercise, and three evaluated sports. Significant findings showed lower prescription opioid misuse among people who exercise, except for one study that showed greater odds of prescription opioid misuse among college athletes. We conclude that the findings on the association between exercise and prescription opioid misuse vary, even within similar study types and samples. Future researchers should consider large samples, standardized questions, and common outcome measures in research on exercise and prescription opioid misuse. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Exploring Gender Differences in Veterans in a Secondary Analysis of a Randomized Controlled Trial of Mindfulness for Chronic Pain

Background

Although studies have documented higher rates of chronic pain among women Veterans compared to men Veterans, there remains a lack of comprehensive information about potential contributors to these disparities.

Materials and Methods

This study examined gender differences in chronic pain and its contributors among 419 men and 392 women Veterans, enrolled in a mindfulness trial for chronic pain. We conducted descriptive analyses summarizing distributions of baseline measures, obtained by survey and through the electronic health record. Comparisons between genders were conducted using chi-square tests for categorical variables and t-tests for continuous measures.

Results

Compared to men, women Veterans were more likely to have chronic overlapping pain conditions and had higher levels of pain interference and intensity. Women had higher prevalence of psychiatric and sleep disorder diagnoses, greater levels of depression, anxiety, post-traumatic stress disorder, fatigue, sleep disturbance, stress and pain catastrophizing, and lower levels of pain self-efficacy and participation in social roles and activities. However, women were less likely to smoke or have a substance abuse disorder and used more nonpharmacological pain treatment modalities.

Conclusion

Among Veterans seeking treatment for chronic pain, women differed from men in their type of pain, had greater pain intensity and interference, and had greater prevalence and higher levels of many known biopsychosocial contributors to pain. Results point to the need for pain treatment that addresses the comprehensive needs of women Veterans.

Clinical Trial Registration Number: NCT04526158. Patient enrollment began on December 4, 2020.

Evaluating the benefits of a second pain treatment following a clinical trial

OBJECTIVE

To examine the value of including an open label phase after a clinical trial of pain treatments by examining participant characteristics and potential benefits.

METHOD

Secondary data analysis. Veterans with chronic pain who completed a randomized controlled trial (RCT) comparing hypnosis, mindfulness meditation, and pain education were invited to participate in an open label phase. Average and worst pain intensities, pain interference, and depression were assessed pre- and postopen label phase; global impressions of change and treatment satisfaction were assessed at postopen label phase only.

RESULTS

Of those who were offered the open label phase, 40% (n = 68) enrolled. Enrollees were likely to be older, to have attended more sessions in the RCT, to be satisfied with their first treatment, and to perceive improvement in their ability to manage pain after the RCT. In the open label phase, depression and worst pain decreased across all three treatment conditions. No other improvements were observed. However, most Veterans perceived improvements in pain intensity, ability to manage pain, and pain interference, and were satisfied with the second intervention.

CONCLUSIONS

There appears to be some value to adding an open label phase to the end of a trial of pain treatments. A substantial portion of study participants elected to participate and reported it to be beneficial. Exploring data from an open label phase can illuminate important aspects of patient experience, barriers to and facilitators of care, as well as treatment preferences. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Pharmacological Prescribing and Satisfaction with Pain Treatment Among Non-Hispanic Black Men with Chronic Pain

Introduction

Pharmacological strategies are often central to chronic pain management; however, pain treatment among non-Hispanic Black men may differ because of their disease profiles and healthcare interactions. However, less is known about pain medication prescribing and patients' satisfaction with pain treatment and management among non-Hispanic Black men with self-reported chronic pain.

Purpose

This study assessed factors associated with non-Hispanic Black men being prescribed/recommended narcotics/opioids for chronic pain and their satisfaction with pain treatment/management.

Methods

Data were analyzed from 286 non-Hispanic Black men with chronic pain who completed an internet-delivered questionnaire. Participants were recruited nationwide using a Qualtrics web-based panel. Logistic regression was used to identify factors associated with being prescribed/recommended narcotics/opioids for pain management treatment. Then, ordinary least squares regression was used to identify factors associated with their satisfaction level with the pain treatment/management received.

Results

On average, participants were 56.2 years old and 48.3% were prescribed/recommended narcotics/opioids for chronic pain. Men with more chronic conditions (Odds Ratio [OR] = 0.57, P = 0.043) and depression/anxiety disorders (OR = 0.53, P = 0.029) were less likely to be prescribed/recommended narcotics/opioids. Men who were more educated (OR = 2.09, P = 0.044), reported more frequent chronic pain (OR = 1.28, P = 0.007), and were allowed to participate more in decisions about their pain treatment/management (OR = 1.11, P = 0.029) were more likely to be prescribed/recommended narcotics/opioids. On average, men with more frequent chronic pain (B = -0.25, P = 0.015) and pain problems (B = -0.16, P = 0.009) were less satisfied with their pain treatment/management. Men who were allowed to participate more in decisions about their pain treatment/management reported higher satisfaction with their pain treatment/management (B = 0.55, P < 0.001).

Conclusion

Playing an active role in pain management can improve non-Hispanic Black men's satisfaction with pain treatment/management. This study illustrates the importance of patient-centered approaches and inclusive patient-provider interactions to improve chronic pain management.

Feasibility of Mindfulness-Based Intervention for Veterans Managing Chronic Pain

Background. Chronic pain impacts people's activity participation, productivity, mental health, and sense of wellbeing. Purpose. This study aimed to (1) evaluate the feasibility of the Mindfulness-Based Chronic Pain Management (MBCPMTM) program on reducing pain perception and enhancing the quality of life, and (2) understand veterans' experience with the program. Method. The pretest-posttest single-group, mixed-methods design was used. Thirty-one veterans were offered the 12-week intervention. The Pain Catastrophizing Scale (PCS) and the Patient-Reported Outcomes Measurement Information System-29 were administered before and after the program. Focus groups and individual interviews were conducted to understand the experience. Findings. Participants' PCS scores improved (Z = -3.116, p = .002), but the pain intensity did not change significantly. Themes from qualitative data include: (1) We are not alone! (2) I have a sense of awareness, choices, and control; and (3) It does work! Implications. The study shows preliminary feasibility of MBCPMTM for veterans. This promising effect supports future rigorous testing of this intervention.

Association Between Exposure to Complementary and Integrative Therapies and Opioid Analgesic Daily Dose Among Patients on Long-term Opioid Therapy

OBJECTIVES

To describe the association between exposure to selected complementary and integrative health (CIH) modalities and the trajectory of prescribed opioid analgesic dose within a national cohort of patients receiving long-term opioid therapy (LTOT) in the Veterans Health Administration (VHA).

MATERIALS AND METHODS

Using national data from VHA electronic health records between October 1, 2017 and September 30, 2019, CIH use was analyzed among 57,437 patients receiving LTOT within 18 VHA facilities serving as evaluation sites of VHA's Whole Health System of Care. Using linear mixed effects modeling controlling for covariates, opioid dose was modeled as a function of time, CIH exposure, and their interaction.

RESULTS

Overall, 11.91% of patients on LTOT used any of the focus CIH therapies; 43.25% of those had 4 or more encounters. Patients used acupuncture, chiropractic care, and meditation modalities primarily. CIH use was associated with being female, Black, having a mental health diagnosis, obesity, pain intensity, and baseline morphine-equivalent daily dose. Mean baseline morphine-equivalent daily dose was 40.81 milligrams and dose decreased on average over time. Controlling for covariates, patients with any CIH exposure experienced 38% faster dose tapering, corresponding to a mean difference in 12-month reduction over patients not engaging in CIH of 2.88 milligrams or 7.06% of the mean starting dose.

DISCUSSION

Results support the role of CIH modalities in opioid tapering. The study design precludes inference about the causal effects of CIH on tapering. Analyses did not consider the trend in opioid dose before cohort entry nor the use of other nonopioid treatments for pain. Future research should address these questions and consider tapering-associated adverse events.

Dose of Exercise Therapy Among Active Duty Soldiers With Chronic Pain Is Associated With Lower Risk of Long-Term Adverse Outcomes After Linking to the Veterans Health Administration

INTRODUCTION

Research in soldiers who had been deployed to Iraq or Afghanistan suggests that nonpharmacological treatments may be protective against adverse outcomes. However, the degree to which exercise therapy received in the U.S. Military Health System (MHS) among soldiers with chronic pain is associated with adverse outcomes after soldiers transition to the Veterans Health Administration (VHA) is unclear. The objective of this study was to determine if exercise therapy received in the MHS among soldiers with chronic pain is associated with long-term adverse outcomes after military separation and enrollment into the VHA and whether this association is moderated by prescription opioid use before starting exercise therapy.

MATERIALS AND METHODS

We conducted a longitudinal cohort study of electronic medical records of active duty Army soldiers with documented chronic pain after an index deployment to Iraq or Afghanistan (years 2008-2014) who subsequently enrolled in the VHA (N = 93,967). Coarsened exact matching matched 37,310 soldiers who received exercise therapy and 28,947 soldiers who did not receive exercise therapy in the MHS. Weighted multivariable Cox proportional hazard models tested for differences in adverse outcomes between groups with different exercise therapy exposure vs. no exercise therapy.Exercise therapy was identified by procedure codes on ambulatory records in the MHS and expressed as the number of exercise therapy visits in 1 year after the first diagnosis with a chronic pain condition. The number of visits was then stratified into seven dose groups.The primary outcomes were weighted proportional hazards for: (1) alcohol and drug disorders, (2) suicide ideation, (3) intentional self-injury, and (4) all-cause mortality. Outcomes were determined based on ICD-9 and ICD-10 diagnoses recorded in VHA healthcare records from enrollment till September 30, 2020.

RESULTS

Our main analysis indicated significantly lower hazard ratios (HRs) for all adverse outcomes except intentional self-injury, for soldiers with at least eight visits for exercise therapy, compared to soldiers who received no exercise therapy. In the proportional hazard model for any adverse outcome, the HR was 0.91 (95% CI 0.84-0.99) for soldiers with eight or nine exercise therapy visits and 0.91 (95% CI 0.86-0.96) for soldiers with more than nine visits. Significant exercise therapy × prior opioid prescription interactions were observed. In the group that was prescribed opioids before starting exercise therapy, significantly lower HRs were observed for soldiers with more than nine exercise therapy visits, compared to soldiers who received no exercise therapy, for alcohol and drug disorders (HR = 0.85, 95% CI 0.77-0.92), suicide ideation (HR = 0.77, 95% CI 0.66-0.91), and for self-injury (HR = 0.58, 95% CI 0.41-0.83).

CONCLUSIONS

Exercise therapy should be considered in the multimodal treatment of chronic pain, especially when pain is being managed with opioids, as it may lower the risk of serious adverse outcomes associated with chronic pain and opioid use. Our findings may generalize only to those active duty soldiers with chronic pain who enroll into VHA after separating from the military.

Subgroups of High-Risk Veterans Affairs Patients Based on Social Determinants of Health Predict Risk of Future Hospitalization

OBJECTIVE

Population segmentation has been recognized as a foundational step to help tailor interventions. Prior studies have predominantly identified subgroups based on diagnoses. In this study, we identify clinically coherent subgroups using social determinants of health (SDH) measures collected from Veterans at high risk of hospitalization or death.

STUDY DESIGN AND SETTING

SDH measures were obtained for 4684 Veterans at high risk of hospitalization through mail survey. Eleven self-report measures known to impact hospitalization and amenable to intervention were chosen a priori by the study team to identify subgroups through latent class analysis. Associations between subgroups and demographic and comorbidity characteristics were calculated through multinomial logistic regression. Odds of 180-day hospitalization were compared across subgroups through logistic regression.

RESULTS

Five subgroups of high-risk patients emerged-those with: minimal SDH vulnerabilities (8% hospitalized), poor/fair health with few SDH vulnerabilities (12% hospitalized), social isolation (10% hospitalized), multiple SDH vulnerabilities (12% hospitalized), and multiple SDH vulnerabilities without food or medication insecurity (10% hospitalized). In logistic regression, the "multiple SDH vulnerabilities" subgroup had greater odds of 180-day hospitalization than did the "minimal SDH vulnerabilities" reference subgroup (odds ratio: 1.53, 95% confidence interval: 1.09-2.14).

CONCLUSION

Self-reported SDH measures can identify meaningful subgroups that may be used to offer tailored interventions to reduce their risk of hospitalization and other adverse events.