1
|
Miller EA, McGinnis KA, Edelman EJ, Feinberg T, Gordon KS, Kerns RD, Marshall BDL, Patterson JA, McRae M. Pain, Substance Use Disorders, Mental Health, and Buprenorphine Treatment among Patients With and Without HIV. AIDS Behav 2024:10.1007/s10461-024-04494-w. [PMID: 39264485 DOI: 10.1007/s10461-024-04494-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2024] [Indexed: 09/13/2024]
Abstract
Treatment of opioid use disorder (OUD) with buprenorphine improves outcomes and mortality among people with HIV (PWH). However, engagement is low and is influenced by comorbidities. We examined the impact of patterns of co-occurring pain, substance use disorders (SUDs), and mental health diagnoses on buprenorphine initiation and retention in PWH. The Veterans Aging Cohort Study contained 7,875 patients (2,702 PWH and 5,173 without HIV) with new OUD clinical encounters (2008-2017). Buprenorphine initiation and retention were derived from prescription data. We identified patterns of co-occurring diagnoses (via ICD codes) and assessed the effects of class membership on both outcomes using latent class analysis and regression analyses. The mean age of patients was 55, 98% were male, 58% Black, 8% Hispanic, and only 8% initiated buprenorphine within 12 months of OUD diagnosis. Four classes of co-occurring diagnoses were identified: "Few Co-occurring Diagnoses" (42.3%); "Multiple Pain Conditions" (21.3%); "Pain + SUD" (18.4%) and "Pain + SUD + Mental Health" (18.0%). Patients in the "Pain + SUD" class and "Pain + SUD + Mental Health" class were significantly less likely to initiate buprenorphine and had 59% and 45% lower odds, respectively, of initiating buprenorphine compared with patients in the "Few Co-occurring Diagnoses" class; this effect did not vary by HIV status. Buprenorphine retention was not significantly associated with HIV status or class membership. However, Black Veterans were less likely to initiate or be retained in buprenorphine treatment. Higher comorbidity burden was negatively associated with buprenorphine initiation but not with retention. More research is warranted to determine other factors that may influence treatment retention.
Collapse
Affiliation(s)
- Emily A Miller
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, VA, USA
| | | | - E Jennifer Edelman
- Section of General Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Termeh Feinberg
- Kelly Government Solutions, Silver Spring, MD, USA
- Department of Biostatistics, Yale University School of Public Health, New Haven, CT, USA
- Center for Medical Informatics, Yale University School of Medicine, New Haven, CT, USA
| | - Kirsha S Gordon
- VA Connecticut Healthcare System, West Haven, CT, USA
- Section of General Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Robert D Kerns
- Department of Psychiatry, Yale University School of Medicine, 300 George Street, Suite 901, New Haven, CT, USA
| | - Brandon D L Marshall
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Julie A Patterson
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, VA, USA
| | - MaryPeace McRae
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, VA, USA.
- , 410 North 12th Street, Richmond, VA, 23298, USA.
| |
Collapse
|
2
|
Lor M, Li A, Brown R, Swedlund MP, Hawkins JG, Nolander ET, Chewning B. Improving pain communication between limited English-speaking Hmong patients, medical interpreters, and health care providers in primary care: A pilot study. Res Nurs Health 2024; 47:289-301. [PMID: 38175545 PMCID: PMC11079862 DOI: 10.1002/nur.22363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 11/13/2023] [Accepted: 12/03/2023] [Indexed: 01/05/2024]
Abstract
This pilot study assessed the feasibility of implementing a pain assessment information visualization (InfoViz) tool to address cultural and language barriers among limited English proficiency (LEP) Hmong patients in primary care. We used a static group comparison design to collect data from 20 patient, interpreter, and provider triads under usual care (i.e., interpreter using verbal pain descriptions), followed by another 20 triads under the intervention (i.e., interpreter using verbal pain descriptions and the InfoViz tool). Feasibility outcomes included recruitment and retention rates, InfoViz tool completion, acceptability, and fidelity. We also assessed mutual understanding (MU) and pain electronic health record (EHR) documentation. Descriptive data were calculated and thematic analysis was conducted. Thirty-six LEP Hmong patients (n = 29 female, mean age = 59.03), 27 providers (n = 15 female), and four interpreters participated in this study. The patient recruitment rate was 18% while the retention rate was 81%. Interpreter recruitment rate was 80%, and 75% for retention rate. The intervention fidelity mean score was 83%. In the intervention condition, patient-provider MU of pain severity improved by 30%, coupled with a 28% increase in pain severity EHR documentation compared to usual care. While communication of pain quality did not improve, there was a higher mean number of pain descriptors (3.31 in the intervention vs. 1.79 in usual care) in EHR documentation. All participants had a positive experience with the tool, reporting it as valuable with 100% completeness of all tools. Findings revealed the tool was acceptable and feasible to use among LEP patients-interpreters-providers, providing support for an efficacy study.
Collapse
Affiliation(s)
- Maichou Lor
- University of Wisconsin-Madison, School of Nursing
| | - Angie Li
- University of Wisconsin-Madison, School of Nursing
| | - Roger Brown
- University of Wisconsin-Madison, School of Nursing
| | - Matthew P Swedlund
- University of Wisconsin-Madison, Department of Family Medicine and Community Health
| | | | - Evan T Nolander
- University of Wisconsin-Madison, Department of Family Medicine and Community Health
| | | |
Collapse
|
3
|
Toikumo S, Vickers-Smith R, Jinwala Z, Xu H, Saini D, Hartwell EE, Pavicic M, Sullivan KA, Xu K, Jacobson DA, Gelernter J, Rentsch CT, Stahl E, Cheatle M, Zhou H, Waxman SG, Justice AC, Kember RL, Kranzler HR. A multi-ancestry genetic study of pain intensity in 598,339 veterans. Nat Med 2024; 30:1075-1084. [PMID: 38429522 DOI: 10.1038/s41591-024-02839-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 01/27/2024] [Indexed: 03/03/2024]
Abstract
Chronic pain is a common problem, with more than one-fifth of adult Americans reporting pain daily or on most days. It adversely affects the quality of life and imposes substantial personal and economic costs. Efforts to treat chronic pain using opioids had a central role in precipitating the opioid crisis. Despite an estimated heritability of 25-50%, the genetic architecture of chronic pain is not well-characterized, in part because studies have largely been limited to samples of European ancestry. To help address this knowledge gap, we conducted a cross-ancestry meta-analysis of pain intensity in 598,339 participants in the Million Veteran Program, which identified 126 independent genetic loci, 69 of which are new. Pain intensity was genetically correlated with other pain phenotypes, level of substance use and substance use disorders, other psychiatric traits, education level and cognitive traits. Integration of the genome-wide association studies findings with functional genomics data shows enrichment for putatively causal genes (n = 142) and proteins (n = 14) expressed in brain tissues, specifically in GABAergic neurons. Drug repurposing analysis identified anticonvulsants, β-blockers and calcium-channel blockers, among other drug groups, as having potential analgesic effects. Our results provide insights into key molecular contributors to the experience of pain and highlight attractive drug targets.
Collapse
Affiliation(s)
- Sylvanus Toikumo
- Mental Illness Research, Education and Clinical Center, Crescenz VAMC, Philadelphia, PA, USA
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Rachel Vickers-Smith
- Mental Illness Research, Education and Clinical Center, Crescenz VAMC, Philadelphia, PA, USA
- Department of Epidemiology and Environmental Health, University of Kentucky College of Public Health, Lexington, KY, USA
| | - Zeal Jinwala
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Heng Xu
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Divya Saini
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Emily E Hartwell
- Mental Illness Research, Education and Clinical Center, Crescenz VAMC, Philadelphia, PA, USA
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Mirko Pavicic
- Biosciences Division, Oak Ridge National Laboratory, Oak Ridge, TN, USA
| | - Kyle A Sullivan
- Biosciences Division, Oak Ridge National Laboratory, Oak Ridge, TN, USA
| | - Ke Xu
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
| | - Daniel A Jacobson
- Biosciences Division, Oak Ridge National Laboratory, Oak Ridge, TN, USA
| | - Joel Gelernter
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
| | - Christopher T Rentsch
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
- London School of Hygiene & Tropical Medicine, London, UK
| | - Eli Stahl
- Regeneron Genetics Center, Tarrytown, NY, USA
| | - Martin Cheatle
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Hang Zhou
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
- Section of Biomedical Informatics and Data Science, Yale University School of Medicine, New Haven, CT, USA
| | - Stephen G Waxman
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Amy C Justice
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
- Yale University School of Public Health, New Haven, CT, USA
| | - Rachel L Kember
- Mental Illness Research, Education and Clinical Center, Crescenz VAMC, Philadelphia, PA, USA
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Henry R Kranzler
- Mental Illness Research, Education and Clinical Center, Crescenz VAMC, Philadelphia, PA, USA.
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| |
Collapse
|
4
|
Peng Y, Qian J, Mao Y. Comparison of lidocaine viscous gargle and topical application on laryngeal mask airway in general anesthesia: A randomized clinical trial. Saudi Med J 2024; 45:46-53. [PMID: 38220237 PMCID: PMC10807662 DOI: 10.15537/smj.2024.45.1.20230368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 11/08/2023] [Indexed: 01/16/2024] Open
Abstract
OBJECTIVES To investigate the effects and safety of lidocaine viscous gargle on postoperative sore throat (POST) in patients receiving a laryngeal mask airway (LMA) in general anesthesia. METHODS In this randomized controlled trial, 90 patients undergoing urological surgery were allocated into 2 treatment arms (n=45): lidocaine viscous gargle before LMA insertion (Group G) and topical application of lidocaine viscous on the LMA (Group T). Outcome data were collected before placement of LMA (T0), after insertion of LMA (T1), immediately (T2), one hour (T3), and 24 hours after removal of LMA (T4). We analyzed the incidence of POST, pharynx dryness, and adverse events. RESULTS The incidence of POST was lower in Group G than Group T at T2 (11.1% vs. 28.9%; p=0.063), T3 (11.1% vs. 24.4%; p=0.167), and T4 (2.2% vs. 4.4%; p=0.566), but there was no significant difference between groups. No patient in either group experienced severe pain or treatment-related adverse events. There was a significantly lower incidence of pharynx dryness in Group G than Group T (p<0.05) at T2, T3, and T4. CONCLUSION Lidocaine viscous gargle showed no statistically significant difference in incidence of POST and incidence of pharynx dryness compared with topical application of lidocaine on the LMA. Both approaches were safe for patients receiving LMA.Chinese Clinical Trial Register No.: ChiCTR2200059720.
Collapse
Affiliation(s)
- Yan Peng
- From the Department of Anesthesiology, The First Affiliated Hospital of Soochow University, Soochow, China.
| | - Ju Qian
- From the Department of Anesthesiology, The First Affiliated Hospital of Soochow University, Soochow, China.
| | - Yiqun Mao
- From the Department of Anesthesiology, The First Affiliated Hospital of Soochow University, Soochow, China.
| |
Collapse
|
5
|
Coleman BC, Lisi AJ, Abel EA, Runels T, Goulet JL. Association between early nonpharmacological management and follow-up for low back pain in the veterans health administration. NORTH AMERICAN SPINE SOCIETY JOURNAL 2023; 14:100233. [PMID: 37440983 PMCID: PMC10333712 DOI: 10.1016/j.xnsj.2023.100233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/23/2023] [Accepted: 05/26/2023] [Indexed: 07/15/2023]
Abstract
Background Low back pain (LBP) is a common reason individuals seek healthcare. Nonpharmacologic management (NPM) is often recommended as a primary intervention, and earlier use of NPM for LBP shows positive clinical outcomes. Our purpose was to evaluate how timing of engagement in NPM for LBP affects downstream LBP visits during the first year. Methods This study was a secondary analysis of an observational cohort study of national electronic health record data. Patients entering the Musculoskeletal Diagnosis/Complementary and Integrative Health Cohort with LBP from October 1, 2016 to September 30, 2017 were included. Exclusive patient groups were defined by engagement in NPM within 30 days of entry ("very early NPM"), between 31 and 90 days ("early NPM"), or not within the first 90 days ("no NPM"). The outcome was time, in days, to the final LBP follow-up after 90 days and within the first year. Cox proportional hazards regression was used to model time to final follow up, controlling for additional demographic and clinical covariables. Results The study population included 44,175 patients, with 16.7% engaging in very early NPM and 13.1% in early NPM. Patients with very early NPM (5.2 visits, SD=4.5) or early NPM (5.7 visits, SD=4.6) had a higher mean number of LBP visits within the first year than those not receiving NPM in the first 90 days (3.2 visits, SD = 2.5). The very early NPM (HR=1.50, 95% CI: 1.46-1.54; median=48 days, IQR=97) and early NPM (HR=1.27, 95% CI: 1.23-1.30; median=88 days, IQR=92) had a significantly shorter time to final follow-up than the no NPM group (median=109 days, IQR=150). Conclusions Veterans Health Administration patients receiving NPM for LBP within the first 90 days after initially seeking care demonstrate a significantly faster time to final follow-up visit within the first year compared to those who do not.
Collapse
Affiliation(s)
- Brian C. Coleman
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, 950 Campbell Ave, West Haven, CT 06516, United States
- Yale School of Medicine, Yale University, 333 Cedar Street, New Haven, CT 06510, United States
| | - Anthony J. Lisi
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, 950 Campbell Ave, West Haven, CT 06516, United States
- Yale School of Medicine, Yale University, 333 Cedar Street, New Haven, CT 06510, United States
| | - Erica A. Abel
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, 950 Campbell Ave, West Haven, CT 06516, United States
- Yale School of Medicine, Yale University, 333 Cedar Street, New Haven, CT 06510, United States
| | - Tessa Runels
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, 950 Campbell Ave, West Haven, CT 06516, United States
| | - Joseph L. Goulet
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, 950 Campbell Ave, West Haven, CT 06516, United States
- Yale School of Medicine, Yale University, 333 Cedar Street, New Haven, CT 06510, United States
| |
Collapse
|
6
|
Toikumo S, Vickers-Smith R, Jinwala Z, Xu H, Saini D, Hartwell E, Venegas MP, Sullivan KA, Xu K, Jacobson DA, Gelernter J, Rentsch CT, Stahl E, Cheatle M, Zhou H, Waxman SG, Justice AC, Kember RL, Kranzler HR. The genetic architecture of pain intensity in a sample of 598,339 U.S. veterans. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.03.09.23286958. [PMID: 36993749 PMCID: PMC10055465 DOI: 10.1101/2023.03.09.23286958] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Chronic pain is a common problem, with more than one-fifth of adult Americans reporting pain daily or on most days. It adversely affects quality of life and imposes substantial personal and economic costs. Efforts to treat chronic pain using opioids played a central role in precipitating the opioid crisis. Despite an estimated heritability of 25-50%, the genetic architecture of chronic pain is not well characterized, in part because studies have largely been limited to samples of European ancestry. To help address this knowledge gap, we conducted a cross-ancestry meta-analysis of pain intensity in 598,339 participants in the Million Veteran Program, which identified 125 independent genetic loci, 82 of which are novel. Pain intensity was genetically correlated with other pain phenotypes, level of substance use and substance use disorders, other psychiatric traits, education level, and cognitive traits. Integration of the GWAS findings with functional genomics data shows enrichment for putatively causal genes (n = 142) and proteins (n = 14) expressed in brain tissues, specifically in GABAergic neurons. Drug repurposing analysis identified anticonvulsants, beta-blockers, and calcium-channel blockers, among other drug groups, as having potential analgesic effects. Our results provide insights into key molecular contributors to the experience of pain and highlight attractive drug targets.
Collapse
Affiliation(s)
- Sylvanus Toikumo
- Mental Illness Research, Education and Clinical Center, Crescenz VAMC, Philadelphia, PA, USA
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Rachel Vickers-Smith
- Mental Illness Research, Education and Clinical Center, Crescenz VAMC, Philadelphia, PA, USA
- Department of Epidemiology, University of Kentucky College of Public Health; Center on Drug and Alcohol Research, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Zeal Jinwala
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Heng Xu
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Divya Saini
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Emily Hartwell
- Mental Illness Research, Education and Clinical Center, Crescenz VAMC, Philadelphia, PA, USA
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Mirko P. Venegas
- Biosciences Division, Oak Ridge National Laboratory, Oak Ridge, TN, USA
| | - Kyle A. Sullivan
- Biosciences Division, Oak Ridge National Laboratory, Oak Ridge, TN, USA
| | - Ke Xu
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Yale University School of Medicine, New Haven, CT, USA
| | | | - Joel Gelernter
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Yale University School of Medicine, New Haven, CT, USA
| | - Christopher T. Rentsch
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Yale University School of Medicine, New Haven, CT, USA
- London School of Hygiene & Tropical Medicine, London, UK
| | | | - Eli Stahl
- Regeneron Genetics Center, Tarrytown, NY, USA
| | - Martin Cheatle
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Hang Zhou
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Yale University School of Medicine, New Haven, CT, USA
| | - Stephen G. Waxman
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Yale University School of Medicine, New Haven, CT, USA
| | - Amy C. Justice
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Yale University School of Medicine, New Haven, CT, USA
- Yale University School of Public Health, New Haven, CT, USA
| | - Rachel L. Kember
- Mental Illness Research, Education and Clinical Center, Crescenz VAMC, Philadelphia, PA, USA
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Henry R. Kranzler
- Mental Illness Research, Education and Clinical Center, Crescenz VAMC, Philadelphia, PA, USA
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| |
Collapse
|
7
|
Alotaibi M, Aljahany M, Alhamdan Z, Alsaffar M, Almojally A, Alassaf W. Differences in acute pain perception between patients and physicians in the emergency department. Heliyon 2022; 8:e11462. [PMID: 36406726 PMCID: PMC9667246 DOI: 10.1016/j.heliyon.2022.e11462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 09/12/2022] [Accepted: 11/02/2022] [Indexed: 11/11/2022] Open
Abstract
Background Pain is a subjective complaint that comprises a vast majority of emergency department (ED)1 visits. Owing to its subjectivity, pain reporting is prone to variations that could impact patient care. We aimed to determine the extent of differences in pain rating-scores between patients and their physicians in the ED and impact on patient satisfaction. Methods A prospective cross-sectional sample of eligible patients was recruited from two centers in Saudi Arabia. Pain scorings were performed using validated online questionnaires during patients' ED stay. Results Pain rating scores by physicians was lower than that by patients (6.3 ± 2.0 versus 7.0 ± 3.1, p = 0.004). Additionally, severe pain rating (8–10 rating) was given less frequently by physicians compared with that by patients (26.0% versus 48.1%, p = 0.004). Comparing the ratings by physicians with those by patients, underestimation was observed in 70.1%, overestimation in 16.9%, and matching rating in 13.0% cases. The most frequent analgesic medication administered was paracetamol (79.2%), followed by diclofenac (26.0%), morphine (10.4%), and ketorolac (9.1%). The medications were administered mainly intravenously (87.0%) and, to a lesser extent, intramuscularly (31.2%). Majority of patients (62.5%) reported not to have sufficient pain relief after treatment. Conclusion Most physicians tend to underestimate the level of pain perceived by their patients, which often leads to under-treatment and lower patient satisfaction. The present study revealed a significant difference in pain ratings between patients and physicians. There was a significant difference between patient and physician pain ratings Pain ratings by physicians were lower than those of patients Comparing the physicians' with patients' ratings, underestimation was 70.1% Comparing the physicians' with patients' ratings, overestimation was 16.9%, Comparing the physicians' with patients' ratings, matching rating was 13.0%.
Collapse
Affiliation(s)
- Malak Alotaibi
- Department of Emergency, Prince Mohammad bin Abdulaziz Hospital, Riyadh, Saudi Arabia
| | - Muna Aljahany
- Department of Clinical Sciences, College of Medicine, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
- Corresponding author.
| | - Zaid Alhamdan
- Department of Emergency, King Abdullah bin Abdulaziz Hospital, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Mashael Alsaffar
- Department of Pediatrics, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | | | - Wajdan Alassaf
- Department of Emergency, King Abdullah bin Abdulaziz Hospital, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| |
Collapse
|
8
|
Clarke SL, Tcheandjieu C, Hilliard AT, Lee KM, Lynch J, Chang KM, Miller D, Knowles JW, O’Donnell C, Tsao P, Rader DJ, Wilson PW, Sun YV, Gaziano M, Assimes TL. Coronary Artery Disease Risk of Familial Hypercholesterolemia Genetic Variants Independent of Clinically Observed Longitudinal Cholesterol Exposure. CIRCULATION. GENOMIC AND PRECISION MEDICINE 2022; 15:e003501. [PMID: 35143253 PMCID: PMC10593360 DOI: 10.1161/circgen.121.003501] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 01/17/2022] [Indexed: 01/21/2023]
Abstract
BACKGROUND Familial hypercholesterolemia (FH) genetic variants confer risk for coronary artery disease independent of LDL-C (low-density lipoprotein cholesterol) when considering a single measurement. In real clinical settings, longitudinal LDL-C data are often available through the electronic health record. It is unknown whether genetic testing for FH variants provides additional risk-stratifying information once longitudinal LDL-C is considered. METHODS We used the extensive electronic health record data available through the Million Veteran Program to conduct a nested case-control study. The primary outcome was coronary artery disease, derived from electronic health record codes for acute myocardial infarction and coronary revascularization. Incidence density sampling was used to match case/control exposure windows, defined by the date of the first LDL-C measurement to the date of the first coronary artery disease code of the index case. Adjustments for the first, maximum, or mean LDL-C were analyzed. FH variants in LDLR, APOB, and PCSK9 (Proprotein convertase subtilisin/kexin type 9) were assessed by custom genotype array. RESULTS In a cohort of 23 091 predominantly prevalent cases at enrollment and 230 910 matched controls, FH variant carriers had an increased risk for coronary artery disease (odds ratio [OR], 1.53 [95% CI, 1.24-1.89]). Adjusting for mean LDL-C led to the greatest attenuation of the risk estimate, but significant risk remained (odds ratio, 1.33 [95% CI, 1.08-1.64]). The degree of attenuation was not affected by the number and the spread of LDL-C measures available. CONCLUSIONS The risk associated with carrying an FH variant cannot be fully captured by the LDL-C data available in the electronic health record, even when considering multiple LDL-C measurements spanning more than a decade.
Collapse
Affiliation(s)
- Shoa L. Clarke
- VA Palo Alto Health Care system, Palo Alto, CA
- Dept of Medicine, Division of Cardiovascular Medicine, Stanford Univ School of Medicine, Stanford, CA
| | - Catherine Tcheandjieu
- VA Palo Alto Health Care system, Palo Alto, CA
- Dept of Medicine, Division of Cardiovascular Medicine, Stanford Univ School of Medicine, Stanford, CA
| | - Austin T. Hilliard
- VA Palo Alto Health Care system, Palo Alto, CA
- Dept of Medicine, Division of Cardiovascular Medicine, Stanford Univ School of Medicine, Stanford, CA
| | - Kyung Min Lee
- VA Informatics & Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, UT
| | - Julie Lynch
- VA Informatics & Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, UT
- College of Nursing & Health Sciences, Univ of Massachusetts, Boston, MA
| | - Kyong-Mi Chang
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
- Dept of Medicine, Univ of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Donald Miller
- Edith Nourse Rogers Memorial VA Hospital, Bedford, MA
- Center for Population Health, Univ of Massachusetts, Lowell, MA
| | - Joshua W. Knowles
- Dept of Medicine, Division of Cardiovascular Medicine, Stanford Univ School of Medicine, Stanford, CA
- Diabetes Research Center, Stanford Univ School of Medicine, Stanford, CA
- Cardiovascular Institute, Stanford Univ School of Medicine, Stanford, CA
| | - Christopher O’Donnell
- VA Boston Healthcare System, Boston, MA
- Dept of Medicine, Harvard Medical School, Boston, MA
| | - Phil Tsao
- VA Palo Alto Health Care system, Palo Alto, CA
- Dept of Medicine, Division of Cardiovascular Medicine, Stanford Univ School of Medicine, Stanford, CA
- Cardiovascular Institute, Stanford Univ School of Medicine, Stanford, CA
| | - Daniel J. Rader
- Dept of Medicine, Univ of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Peter W. Wilson
- Atlanta VA Medical Center, Decatur, GA
- Dept of Medicine, Emory Univ School of Medicine, Atlanta, GA
- Dept of Epidemiology, Emory Univ Rollins School of Public Health, Atlanta, GA
| | - Yan V. Sun
- Atlanta VA Medical Center, Decatur, GA
- Dept of Epidemiology, Emory Univ Rollins School of Public Health, Atlanta, GA
| | | | - Themistocles L. Assimes
- VA Palo Alto Health Care system, Palo Alto, CA
- Dept of Medicine, Division of Cardiovascular Medicine, Stanford Univ School of Medicine, Stanford, CA
- Cardiovascular Institute, Stanford Univ School of Medicine, Stanford, CA
| | | |
Collapse
|
9
|
Hayes CJ, Krebs EE, Brown J, Li C, Hudson T, Martin BC. Association Between Pain Intensity and Discontinuing Opioid Therapy or Transitioning to Intermittent Opioid Therapy After Initial Long-Term Opioid Therapy: A Retrospective Cohort Study. THE JOURNAL OF PAIN 2021; 22:1709-1721. [PMID: 34186177 PMCID: PMC10068896 DOI: 10.1016/j.jpain.2021.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 05/21/2021] [Accepted: 05/23/2021] [Indexed: 11/25/2022]
Abstract
The purpose of this study was to evaluate changes in pain intensity among Veterans transitioning from long-term opioid therapy (LTOT) to either intermittent therapy or discontinuation compared to continued LTOT. Pain intensity was assessed using the Numeric Rating Scale in 90-day increments starting in the 90-day period prior to potential opioid transitions and the two ensuing 90-day periods after transition. Primary analyses used a 1:1 greedy propensity matched sample. A total of 29,293 Veterans switching to intermittent opioids and 5,972 discontinuing opioids were matched to Veterans continuing LTOT. Covariates were well balanced after matching except minor differences in baseline mean pain scores. Pain scores were lower in the follow up periods for those switching to intermittent opioids and discontinuing opioids compared to those continuing LTOT (0-90 days: Intermittent: 3.79, 95%CI: 3.76, 3.82; LTOT: 4.09, 95%CI: 4.06, 4.12, P < .0001; Discontinuation: 3.06, 95%CI: 2.99, 3.13; LTOT: 3.86, 95%CI: 3.79, 3.94, P = <.0001; 91-180 days: Intermittent: 3.76, 95%CI: 3.73, 3.79; LTOT: 3.99, 95%CI: 3.96, 4.02, P < .0001; Discontinuation: 3.01, 95%CI: 2.94, 3.09; LTOT: 3.80, 95%CI: 3.73, 3.87, P = <.0001). Sensitivity analyses found similar results. Discontinuing opioid therapy or switching to intermittent opioid therapy was not associated with increased pain intensity. PERSPECTIVE: This article evaluates the association of switching to intermittent opioid therapy or discontinuing opioids with pain intensity after using opioids long-term. Pain intensity decreased after switching to intermittent therapy or discontinuing opioids, but remained relatively stable for those continuing long-term opioid therapy. Switching to intermittent opioids or discontinuing opioids was not associated with increased pain intensity.
Collapse
Affiliation(s)
- Corey J Hayes
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas; Center for Health Services Research, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Erin E Krebs
- Center for Care Delivery and Outcomes Research, Minneapolis VA Healthcare System, 1 Veterans Dr, Minneapolis, Minneapolis; College of Medicine, University of Minnesota, Minneapolis, Minneapolis
| | - Joshua Brown
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Chenghui Li
- Division of Pharmaceutical Evaluation and Policy, College of Pharmacy, University of Arkansas for Medical Sciences, Arkansas
| | - Teresa Hudson
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas; Center for Health Services Research, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Bradley C Martin
- Division of Pharmaceutical Evaluation and Policy, College of Pharmacy, University of Arkansas for Medical Sciences, Arkansas.
| |
Collapse
|
10
|
Abstract
Rationale: Prior research studies on the association of obstructive sleep apnea (OSA) and pain intensity have examined older patients; there is a need to understand the relationship between OSA and pain intensity among younger adults.Objectives: To examine whether young adults with diagnosed OSA are more likely to report higher pain intensity compared with those without OSA.Methods: We conducted a cross-sectional analysis of a cohort study of Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans who had at least one visit to a Veterans Health Administration primary care clinic between 2001 and 2014. OSA was identified using one inpatient or two outpatient International Classification of Diseases, Ninth Revision codes from electronic medical records. Average pain intensity (based on the self-reported 0-10 numeric rating scale over a 12-month period) was categorized as no pain/mild (0-3; no pain) and moderate/severe (4-10; significant pain). Covariates included age, sex, education, race, mental health diagnoses, headache diagnoses, pain diagnoses, hypertension, diabetes, body mass index, and smoking status. Multivariate logistic regression models were used, and multiple imputation was performed to generate values for missing variables.Results: We identified 858,226 young adults (mean age 30 yr [SD = 7]), of whom 91,244 (10.6%) had a diagnosis of OSA and 238,587 (27.8%) reported moderate/severe pain for the 12-month average. with young adults without OSA, those with OSA were more likely to report moderate/severe pain intensity (adjusted odds ratio, 1.09; 95% confidence interval, 1.08-1.11) even after controlling for covariates.Conclusions: We found that young adults with OSA have greater odds of comorbid moderate/severe pain. Because of the high prevalence of chronic pain in younger adults, this study highlights the need to understand the impact of OSA diagnosis and treatment on pain intensity. Future work is needed to determine the role of effective OSA treatment on pain intensity over time in these young adults.
Collapse
|
11
|
Higgins DM, Buta E, Heapy AA, Driscoll MA, Kerns RD, Masheb R, Becker WC, Hausmann LRM, Bair MJ, Wandner L, Janke EA, Brandt CA, Goulet JL. The Relationship Between Body Mass Index and Pain Intensity Among Veterans with Musculoskeletal Disorders: Findings from the MSD Cohort Study. PAIN MEDICINE 2021; 21:2563-2572. [PMID: 32186722 DOI: 10.1093/pm/pnaa043] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To examine the relationship between body mass index (BMI) and pain intensity among veterans with musculoskeletal disorder diagnoses (MSDs; nontraumatic joint disorder; osteoarthritis; low back, back, and neck pain). SETTING Administrative and electronic health record data from the Veterans Health Administration (VHA). SUBJECTS A national cohort of US military veterans with MSDs in VHA care during 2001-2012 (N = 1,759,338). METHODS These cross-sectional data were analyzed using hurdle negative binomial models of pain intensity as a function of BMI, adjusted for comorbidities and demographics. RESULTS The sample had a mean age of 59.4, 95% were male, 77% were white/Non-Hispanic, 79% were overweight or obese, and 42% reported no pain at index MSD diagnosis. Overall, there was a J-shaped relationship between BMI and pain (nadir = 27 kg/m2), with the severely obese (BMI ≥ 40 kg/m2) being most likely to report any pain (OR vs normal weight = 1.23, 95% confidence interval = 1.21-1.26). The association between BMI and pain varied by MSD, with a stronger relationship in the osteoarthritis group and a less pronounced relationship in the back and low back pain groups. CONCLUSIONS There was a high prevalence of overweight/obesity among veterans with MSD. High levels of BMI (>27 kg/m2) were associated with increased odds of pain, most markedly among veterans with osteoarthritis.
Collapse
Affiliation(s)
- Diana M Higgins
- Anesthesiology, Critical Care, and Pain Medicine Service, VA Boston Healthcare System, Boston, Massachusetts.,Boston University School of Medicine, Boston, Massachusetts
| | - Eugenia Buta
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, Connecticut
| | - Alicia A Heapy
- Pain Research Informatics Multimorbidities and Education (PRIME) Center of Innovation, VA Connecticut Healthcare System, West Haven, Connecticut.,Yale School of Medicine, New Haven, Connecticut
| | - Mary A Driscoll
- Pain Research Informatics Multimorbidities and Education (PRIME) Center of Innovation, VA Connecticut Healthcare System, West Haven, Connecticut.,Yale School of Medicine, New Haven, Connecticut
| | - Robert D Kerns
- Pain Research Informatics Multimorbidities and Education (PRIME) Center of Innovation, VA Connecticut Healthcare System, West Haven, Connecticut.,Yale School of Medicine, New Haven, Connecticut
| | - Robin Masheb
- Pain Research Informatics Multimorbidities and Education (PRIME) Center of Innovation, VA Connecticut Healthcare System, West Haven, Connecticut.,Yale School of Medicine, New Haven, Connecticut
| | - William C Becker
- Pain Research Informatics Multimorbidities and Education (PRIME) Center of Innovation, VA Connecticut Healthcare System, West Haven, Connecticut.,Yale School of Medicine, New Haven, Connecticut
| | - Leslie R M Hausmann
- Center for Health Equity Research and Promotion (CHERP), Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Matthew J Bair
- Center for Health Information and Communication (CHIC), VA Health Services Research and Development, Indianapolis, Indiana.,Indiana University School of Medicine and Regenstrief Institute, Indianapolis, Indiana
| | - Laura Wandner
- National Institute of Neurological Disorders and Stroke (NINDS), National Institutes of Health, Bethesda, Maryland
| | - E Amy Janke
- University of the Sciences, Philadelphia, Pennsylvania, USA
| | - Cynthia A Brandt
- Pain Research Informatics Multimorbidities and Education (PRIME) Center of Innovation, VA Connecticut Healthcare System, West Haven, Connecticut.,Yale School of Medicine, New Haven, Connecticut
| | - Joseph L Goulet
- Pain Research Informatics Multimorbidities and Education (PRIME) Center of Innovation, VA Connecticut Healthcare System, West Haven, Connecticut.,Yale School of Medicine, New Haven, Connecticut
| |
Collapse
|
12
|
Nugent SM, Lovejoy TI, Shull S, Dobscha SK, Morasco BJ. Associations of Pain Numeric Rating Scale Scores Collected during Usual Care with Research Administered Patient Reported Pain Outcomes. PAIN MEDICINE 2021; 22:2235-2241. [PMID: 33749760 DOI: 10.1093/pm/pnab110] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE The purpose of this study is to examine the extent to which numeric rating scale (NRS) scores collected during usual care are associated with more robust and validated measures of pain, disability, mental health, and health-related quality of life (HRQOL). DESIGN We conducted a secondary analysis of data from a prospective cohort study. SUBJECTS We included 186 patients with musculoskeletal pain who were prescribed long-term opioid therapy. SETTING VA Portland Health Care System outpatient clinic. METHODS All patients had been screened with the 0-10 NRS during routine outpatient visits. They also completed research visits that assessed pain, mental health and HRQOL every 6 months for 2 years. Accounting for nonindependence of repeated measures data, we examined associations of NRS data obtained from the medical record with scores on standardized measures of pain and its related outcomes. RESULTS NRS scores obtained in clinical practice were moderately associated with pain intensity scores (B's = 0.53-0.59) and modestly associated with pain disability scores (B's = 0.33-0.36) obtained by researchers. Associations between pain NRS scores and validated measures of depression, anxiety, and health related HRQOL were low (B's = 0.09-0.26, with the preponderance of B's < .20). CONCLUSIONS Standardized assessments of pain during usual care are moderately associated with research-administered measures of pain intensity and would be improved from the inclusion of more robust measures of pain-related function, mental health, and HRQOL.
Collapse
Affiliation(s)
- Shannon M Nugent
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon.,Department of Psychiatry, Oregon Health & Science University, Portland, Oregon
| | - Travis I Lovejoy
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon.,Department of Psychiatry, Oregon Health & Science University, Portland, Oregon.,School of Public Health, Oregon Health & Science University, Portland, Oregon.,Veterans Rural Health Resource Center, VA Portland Health Care System, Portland, Oregon, USA
| | - Sarah Shull
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
| | - Steven K Dobscha
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon.,Department of Psychiatry, Oregon Health & Science University, Portland, Oregon
| | - Benjamin J Morasco
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon.,Department of Psychiatry, Oregon Health & Science University, Portland, Oregon
| |
Collapse
|
13
|
Saadoun M, Bauer MR, Adams RS, Highland KB, Larson MJ. Opioid and Nonpharmacologic Treatments Among Soldiers With Chronic Pain and Posttraumatic Stress Disorder. Psychiatr Serv 2021; 72:264-272. [PMID: 33467870 PMCID: PMC8127998 DOI: 10.1176/appi.ps.201900303] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE This study examined the prevalence of chronic pain alone, posttraumatic stress disorder (PTSD) alone, and both chronic pain and PTSD among U.S. Army soldiers during the postdeployment year. METHODS The sample was 576,425 active duty soldiers returning from deployment in Afghanistan or Iraq between October 1, 2008, and September 30, 2014. Bivariate statistics were used to compare health care utilization among subgroups. Multivariate logistic regression with additional covariates was used to identify predictors of receiving an opioid days' supply of >30 days in the postdeployment year among soldiers with chronic pain, focusing on the effect of PTSD alone and on an interaction of PTSD with nonpharmacologic treatments (including therapeutic exercise, chiropractic treatment, acupuncture, and biofeedback). RESULTS In total, 12.2% of the soldiers received a chronic pain diagnosis, 5.1% a PTSD diagnosis, and 1.8% had both. Among soldiers with both conditions, 80.3% received nonpharmacologic treatment, and 31.4% received an opioid days' supply of >30 days. Among soldiers with chronic pain, comorbid PTSD and lack of nonpharmacologic treatment was associated with increased odds of receiving an opioid days' supply of >30 days (odds ratio [OR]=1.4, 95% confidence interval [CI]=1.3-1.6). PTSD combined with specific nonpharmacologic treatment modalities had a variable relationship with opioid receipt, and only PTSD with acupuncture or biofeedback was associated with reduced odds (OR=0.8, 95% CI=0.7-0.9). CONCLUSIONS Soldiers having both chronic pain and PTSD have significant health care needs. Although these soldiers accessed mental health care and received nonpharmacologic treatment, additional interventions are needed to mitigate protracted opioid utilization.
Collapse
Affiliation(s)
- Mayada Saadoun
- Schneider Institutes for Health Policy and Research, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts (Saadoun, Bauer, Adams, Larson); Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, and the Henry M. Jackson Foundation, Bethesda, Maryland (Highland)
| | - Mark R Bauer
- Schneider Institutes for Health Policy and Research, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts (Saadoun, Bauer, Adams, Larson); Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, and the Henry M. Jackson Foundation, Bethesda, Maryland (Highland)
| | - Rachel Sayko Adams
- Schneider Institutes for Health Policy and Research, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts (Saadoun, Bauer, Adams, Larson); Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, and the Henry M. Jackson Foundation, Bethesda, Maryland (Highland)
| | - Krista Beth Highland
- Schneider Institutes for Health Policy and Research, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts (Saadoun, Bauer, Adams, Larson); Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, and the Henry M. Jackson Foundation, Bethesda, Maryland (Highland)
| | - Mary Jo Larson
- Schneider Institutes for Health Policy and Research, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts (Saadoun, Bauer, Adams, Larson); Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, and the Henry M. Jackson Foundation, Bethesda, Maryland (Highland)
| |
Collapse
|
14
|
Travaglini LE, Kuykendall L, Bennett ME, Abel EA, Lucksted A. Relationships between chronic pain and mood symptoms among veterans with bipolar disorder. J Affect Disord 2020; 277:765-771. [PMID: 33065815 DOI: 10.1016/j.jad.2020.08.069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 07/13/2020] [Accepted: 08/25/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Chronic pain is highly prevalent among individuals with mood disorders. While much is known about the relationship between pain and unipolar depression, little is known about pain experiences among people with bipolar disorder. This pilot study addresses this gap by examining pain and its relationship to mood and functioning in a sample of US military veterans with bipolar disorder. METHODS Qualitative interviews were conducted with 15 veterans with bipolar disorder and chronic pain who were recruited from outpatient services within a Veterans Affairs medical center. RESULTS Veterans reported a bidirectional relationship between pain and bipolar depression. When discussing manic episodes, individuals' experiences varied between notable reductions in pain (usually in euphoric states), increases in pain (usually in angry/irritable states), and feeling disconnected from pain. Many reported that increased activity when manic contributed to worse pain after an episode. Veterans clearly articulated how these connections negatively affected their functioning and quality of life. LIMITATIONS This was a small, retrospective study that included a non-random sample of veteran participants from one VA medical center. All veterans were engaged in outpatient mental health care, so the majority reported that their mood has been well-stabilized through medications and/or psychotherapy. CONCLUSIONS Chronic pain experiences appear to be related to depressive and manic mood states and significantly affects functioning and quality of life in Veterans with bipolar disorder. This study highlights the need to assess chronic pain among veterans with bipolar disorder, as changes in mood could have significant implications for functioning and pain management.
Collapse
Affiliation(s)
- Letitia E Travaglini
- VA Capital Healthcare Network Mental Illness, Research, Education, and Clinical Center (MIRECC), Baltimore, MD 21201, United States.
| | - Lorrianne Kuykendall
- VA Capital Healthcare Network Mental Illness, Research, Education, and Clinical Center (MIRECC), Baltimore, MD 21201, United States
| | - Melanie E Bennett
- VA Capital Healthcare Network Mental Illness, Research, Education, and Clinical Center (MIRECC), Baltimore, MD 21201, United States; Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD 21201, United States
| | - Erica A Abel
- VA Connecticut Healthcare System, Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, West Haven, CT 06516, United States; Department of Psychiatry, Yale School of Medicine, New Haven, CT 06511, United States
| | - Alicia Lucksted
- VA Capital Healthcare Network Mental Illness, Research, Education, and Clinical Center (MIRECC), Baltimore, MD 21201, United States; Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD 21201, United States
| |
Collapse
|
15
|
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.
Collapse
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
| |
Collapse
|
16
|
Barnett PG, Jacobs JC, Jarvik JG, Chou R, Boothroyd D, Lo J, Nevedal A. Assessment of Primary Care Clinician Concordance With Guidelines for Use of Magnetic Resonance Imaging in Patients With Nonspecific Low Back Pain in the Veterans Affairs Health System. JAMA Netw Open 2020; 3:e2010343. [PMID: 32658287 PMCID: PMC7358914 DOI: 10.1001/jamanetworkopen.2020.10343] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
IMPORTANCE Magnetic responance imaging (MRI) of the lumbar spine that is not concordant with treatment guidelines for low back pain represents an unnecessary cost for US health plans and may be associated with adverse effects. Use of MRI in the US Department of Veterans Affairs (VA) primary care clinics remains unknown. OBJECTIVE To assess the use of MRI scans during the first 6 weeks (early MRI scans) of episodes of nonspecific low back pain in VA primary care sites and to determine if historical concordance can identify clinicians and sites that are the least concordant with guidelines. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of electronic health records from 944 VA primary care sites from the 3 years ending in 2016. Data were analyzed between January 2017 and August 2019. Participants were patients with new episodes of nonspecific low back pain and the primary care clinicians responsible for their care. EXPOSURES MRI scans. MAIN OUTCOMES AND MEASURES The proportion of early MRI scans at VA primary care clinics was assessed. Clinician concordance with published guidelines over 2 years was used to select clinicians expected to have low concordance in a third year. RESULTS A total of 1 285 405 new episodes of nonspecific low back pain from 920 547 patients (mean [SD] age, 56.7 [15.8] years; 93.6% men) were attributed to 9098 clinicians (mean [SD] age, 52.1 [10.1] years; 55.7% women). An early MRI scan of the lumbar spine was performed in 31 132 of the episodes (2.42%; 95% CI, 2.40%-2.45%). Historical concordance was better than a random draw in selecting the 10% of clinicians who were subsequently the least concordant with published guidelines. For primary care clinicians, the area under the receiver operating characteristic curve was 0.683 (95% CI, 0.658-0.701). For primary care sites, the area was under this curve was 0.8035 (95% CI, 0.754-0.855). The 10% of clinicians with the least historical concordance were responsible for just 19.2% of the early MRI scans performed in the follow-up year. CONCLUSIONS AND RELEVANCE VA primary care clinics had low rates of use of early MRI scans. A history of low concordance with imaging guidelines was associated with subsequent low concordance but with limited potential to select clinicians most in need of interventions to implement guidelines.
Collapse
Affiliation(s)
- Paul G. Barnett
- Veterans Affairs Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
| | - Josephine C. Jacobs
- Veterans Affairs Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
| | - Jeffrey G. Jarvik
- Department of Radiology, University of Washington, Seattle
- Department of Neurological Surgery, University of Washington, Seattle
- Department of Health Services, University of Washington, Seattle
| | - Roger Chou
- Department of Clinical Epidemiology and Medical Informatics, Oregon Health & Science University, Portland
- Department of Medicine, Oregon Health & Science University, Portland
| | - Derek Boothroyd
- Quantitative Research Unit, Stanford University Medical School, Stanford, California
| | - Jeanie Lo
- Veterans Affairs Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California
| | - Andrea Nevedal
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
| |
Collapse
|
17
|
Factors Associated With Posttraumatic Stress Disorder Among Veterans of Recent Wars Receiving Veterans Affairs Chiropractic Care. J Manipulative Physiol Ther 2020; 43:753-759. [PMID: 32534740 DOI: 10.1016/j.jmpt.2019.10.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 08/16/2019] [Accepted: 10/22/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Post-traumatic stress disorder (PTSD) is thought to complicate pain management outcomes, which is consistent with the impact of other psychosocial factors in the biopsychosocial model of pain. This study aimed to identify patient sociodemographic and clinical characteristics associated with PTSD prevalence among veterans of Operations Enduring Freedom/Iraqi Freedom/New Dawn (OEF/OIF/OND) who received Veterans Affairs (VA) chiropractic care. METHODS A cross-sectional analysis of electronic health record data from a national cohort study of OEF/OIF/OND veterans with at least 1 visit to a VA chiropractic clinic from 2001 to 2014 was performed. The primary outcome measure was a prior PTSD diagnosis. Variables including sex, race, age, body mass index, pain intensity, alcohol and substance use disorders, and smoking status were examined in association with PTSD diagnosis using logistic regression. RESULTS We identified 14,025 OEF/OIF/OND veterans with at least 1 VA chiropractic visit, with a mean age of 38 years and 54.2% having a diagnosis of PTSD. Male sex (adjusted odds ratio [OR] = 1.23, 95% CI = 1.11-1.37), younger age (OR = 0.99, CI = 0.98-0.99), moderate-to-severe pain intensity (numerical rating scale ≥ 4) (OR = 1.72, CI = 1.59-1.87), body mass index ≥ 30 (OR = 1.34, CI = 1.24-1.45), current smoking (OR = 1.32, CI = 1.20-1.44), and having an alcohol or substance use disorder (OR = 4.51, CI = 4.01-5.08) were significantly associated with a higher likelihood of PTSD diagnosis. CONCLUSION Post-traumatic stress disorder is a common comorbidity among OEF/OIF/OND veterans receiving VA chiropractic care and is significantly associated with several patient characteristics. Recognition of these factors is important for the appropriate diagnosis and management of veterans with PTSD seeking chiropractic treatment for pain conditions.
Collapse
|
18
|
Zhao C, Quan X, He J, Zhao R, Zhang Y, Li X, Sun S, Ma R, Zhang Q. Identification of significant gene biomarkers of low back pain caused by changes in the osmotic pressure of nucleus pulposus cells. Sci Rep 2020; 10:3708. [PMID: 32111963 PMCID: PMC7048739 DOI: 10.1038/s41598-020-60714-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 02/13/2020] [Indexed: 12/12/2022] Open
Abstract
The incidence of intervertebral disc (IVD) degeneration disease, caused by changes in the osmotic pressure of nucleus pulposus (NP) cells, increases with age. In general, low back pain is associated with IVD degeneration. However, the mechanism and molecular target of low back pain have not been elucidated, and there are no data suggesting specific biomarkers of low back pain. Therefore, the research aims to identify and verify the significant gene biomarkers of low back pain. The differentially expressed genes (DEGs) were screened in the Gene Expression Omnibus (GEO) database, and the identification and analysis of significant gene biomarkers were also performed with various bioinformatics programs. A total of 120 patients with low back pain were recruited. Before surgery, the degree of pain was measured by the numeric rating scale (NRS), which enables comparison of the pain scores from individuals. After surgery, IVD tissues were obtained, and NP cells were isolated. The NP cells were cultured in two various osmotic media, including iso-osmotic media (293 mOsm/kg H2O) to account for the morbid environment of NP cells in IVD degeneration disease and hyper-osmotic media (450 mOsm/kg H2O) to account for the normal condition of NP cells in healthy individuals. The relative mRNA expression levels of CCL5, OPRL1, CXCL13, and SST were measured by quantitative real-time PCR in the in vitro analysis of the osmotic pressure experiments. Finally, correlation analysis and a neural network module were employed to explore the linkage between significant gene biomarkers and pain. A total of 371 DEGs were identified, including 128 downregulated genes and 243 upregulated genes. Furthermore, the four genes (CCL5, OPRL1, SST, and CXCL13) were identified as significant gene biomarkers of low back pain (P < 0.001) based on univariate linear regression, and CCL5 (odds ratio, 34.667; P = 0.003) and OPRL1 (odds ratio, 19.875; P < 0.001) were significantly related to low back pain through multivariate logistic regression. The expression of CCL5 and OPRL1 might be correlated with low back pain in patients with IVD degeneration disease caused by changes in the osmotic pressure of NP cells.
Collapse
Affiliation(s)
- Changsong Zhao
- Department of Orthopaedics, Beijing Ditan Hospital, Capital Medical University, 100015, Beijing, China
| | - Xuemin Quan
- Department of Orthopaedics, Beijing Ditan Hospital, Capital Medical University, 100015, Beijing, China
| | - Jie He
- Department of Orthopaedics, Beijing Ditan Hospital, Capital Medical University, 100015, Beijing, China
| | - Rugang Zhao
- Department of Orthopaedics, Beijing Ditan Hospital, Capital Medical University, 100015, Beijing, China
| | - Yao Zhang
- Department of Orthopaedics, Beijing Ditan Hospital, Capital Medical University, 100015, Beijing, China
| | - Xin Li
- Department of Orthopaedics, Beijing Ditan Hospital, Capital Medical University, 100015, Beijing, China
| | - Sheng Sun
- Department of Orthopaedics, Beijing Ditan Hospital, Capital Medical University, 100015, Beijing, China
| | - Rui Ma
- Department of Orthopaedics, Beijing Ditan Hospital, Capital Medical University, 100015, Beijing, China
| | - Qiang Zhang
- Department of Orthopaedics, Beijing Ditan Hospital, Capital Medical University, 100015, Beijing, China.
| |
Collapse
|
19
|
Five-year Pain Intensity and Treatment Trajectories of Post-9/11 Veterans With Mild Traumatic Brain Injury. THE JOURNAL OF PAIN 2020; 21:1005-1017. [PMID: 31981717 DOI: 10.1016/j.jpain.2019.12.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 12/30/2019] [Accepted: 12/31/2019] [Indexed: 11/23/2022]
Abstract
Pain is a pervasive problem that affects nearly half of the U.S. Veterans deployed in support of the Global War on Terror (Post-9/11 Veterans) and over half of the Post-9/11 Veterans with diagnosed traumatic brain injury (TBI). The goal of the current study was to identify pain phenotypes based on distinct longitudinal patterns of pain scores in light of pain treatment among Post-9/11 Veterans over 5 years of care using latent growth mixture analysis stratified by TBI status. Five pain phenotypes emerged: 1) simple low impact stable pain, 2) complex low impact stable pain, 3) complex low impact worsening pain, 4) complex moderate impact worsening pain, and 5) complex high impact stable pain. Baseline pain scores and slopes were significantly higher in Veterans with mild TBI for some phenotypes. The mild TBI cohort was younger, had more men, more whites, less blacks, less education, more unmarried, more Marines and Army, more active duty in comparison to the no TBI cohort. Distinct trajectories in pain treatment were apparent among the pain intensity subgroups. PERSPECTIVE: The complexity of pain in patients with mTBI is categorically different than those with no TBI. Pain in patients with mTBI is heterogeneous with distinct phenotypes which may explain poor outcomes in this group. Identification of the individual differences may have a significant impact on the success of interventions.
Collapse
|
20
|
Skjold C, Møller AM, Wildgaard K. Pre-operative femoral nerve block for hip fracture-A systematic review with meta-analysis. Acta Anaesthesiol Scand 2020; 64:23-33. [PMID: 31596943 DOI: 10.1111/aas.13491] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 09/19/2019] [Accepted: 09/23/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Pre-operative pain management of hip fracture patients is complex. Femoral nerve block (FNB) is used for hip fractures to reduce pain and demand for systematic analgesia. The objective of the study was to systematically investigate the efficacy of single-shot FNB for hip fracture patients. METHODS Five databases were searched from inception until 8 May 2019. We included randomized controlled trials (RCT's) assessing pain relief in patients with hip fractures. Intervention was pre-operative FNB compared to any systemic analgesic (eg opioids, non-steroidal anti-inflammatory drugs or paracetamol). Primary outcomes assessed were pre-operative pain and use of rescue analgesics. Secondary outcome was cognitive impairment. We present a bias assessment, a meta-analysis and a grading of certainty of evidence. RESULTS We included five trials (n = 254), where participants received FNB 30 minutes or more prior to surgery; all were judged as having high risk of bias. All studies found significantly decreased pain scores at least once in the intervention group compared to the control group. Meta-analysis on the primary outcome of pain showed significance. Mean difference was -2.13 point (in cm) (CI:-3.53,-0.72) on visual analogue scale in the intervention group, but is judged low on certainty. CONCLUSIONS The quantity of evidence supporting pre-operative single-shot FNB for hip fractures is very low, and the certainty of evidence supporting pre-operative single-shot FNB for hip fractures is low. No studies using ultrasound guided technique were identified. Data on non-ultrasound guided FNB's suggest a decreased pain score compared to the use of systemic analgesia.
Collapse
Affiliation(s)
- C. Skjold
- Department of Anaesthesiology Herlev Anaesthesia Critical and Emergency Care Science Unit Herlev Denmark
| | - A. M. Møller
- Department of Anaesthesiology Herlev Anaesthesia Critical and Emergency Care Science Unit Herlev Denmark
| | - K. Wildgaard
- Department of Anaesthesiology Herlev Anaesthesia Critical and Emergency Care Science Unit Herlev Denmark
| |
Collapse
|
21
|
Rentsch CT, Edelman EJ, Justice AC, Marshall BDL, Xu K, Smith AH, Crystal S, Gaither JR, Gordon AJ, Smith RV, Kember RL, Polimanti R, Gelernter J, Fiellin DA, Tate JP, Kranzler HR, Becker WC. Patterns and Correlates of Prescription Opioid Receipt Among US Veterans: A National, 18-Year Observational Cohort Study. AIDS Behav 2019; 23:3340-3349. [PMID: 31317364 PMCID: PMC7344341 DOI: 10.1007/s10461-019-02608-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
A better understanding of predisposition to transition to high-dose, long-term opioid therapy after initial opioid receipt could facilitate efforts to prevent opioid use disorder (OUD). We extracted data on 69,268 patients in the Veterans Aging Cohort Study who received any opioid prescription between 1998 and 2015. Using latent growth mixture modelling, we identified four distinguishable dose trajectories: low (53%), moderate (29%), escalating (13%), and rapidly escalating (5%). Compared to low dose trajectory, those in the rapidly escalating dose trajectory were proportionately more European-American (59% rapidly escalating vs. 38% low); had a higher prevalence of HIV (31% vs. 29%) and hepatitis C (18% vs. 12%); and during follow-up, had a higher incidence of OUD diagnoses (13% vs. 3%); were hospitalised more often [18.1/100 person-years (PYs) vs. 12.5/100 PY]; and had higher all-cause mortality (4.7/100 PY vs. 1.8/100 PY, all p < 0.0001). These measures can potentially be used in future prevention research, including genetic discovery.
Collapse
Affiliation(s)
- Christopher T Rentsch
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
- Veterans Aging Cohort Study Coordinating Center, VA Connecticut Healthcare System, West Haven, CT, 06516, USA.
| | - E Jennifer Edelman
- Internal Medicine, Yale School of Medicine, New Haven, CT, 06515, USA
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, 06515, USA
| | - Amy C Justice
- Veterans Aging Cohort Study Coordinating Center, VA Connecticut Healthcare System, West Haven, CT, 06516, USA
- Internal Medicine, Yale School of Medicine, New Haven, CT, 06515, USA
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, 06515, USA
| | - Brandon D L Marshall
- Department of Epidemiology, Brown School of Public Health, Providence, RI, 02903, USA
| | - Ke Xu
- Department of Psychiatry, Yale School of Medicine and VA Connecticut Healthcare System, West Haven, CT, 06516, USA
| | - Andrew H Smith
- Department of Psychiatry, Yale School of Medicine and VA Connecticut Healthcare System, West Haven, CT, 06516, USA
| | - Stephen Crystal
- Institute for Health, Health Care Policy, and Aging Research, Rutgers University, New Brunswick, NJ, 08901, USA
| | - Julie R Gaither
- Yale Center for Medical Informatics, Yale School of Medicine, New Haven, CT, 06515, USA
- Pain Research, Informatics, Multi-morbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, 06516, USA
| | - Adam J Gordon
- VA COIN Informatics, Decision-Enhancement and Analytic Sciences Center, Salt Lake City VA Health Care System, University of Utah School of Medicine, Salt Lake City, UT, 84132, USA
| | - Rachel V Smith
- School of Nursing, University of Louisville, Louisville, KY, 40202, USA
| | - Rachel L Kember
- Department of Genetics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA
- Mental Illness Research, Education and Clinical Center, Crescenz Veterans Affairs Medical Center, Philadelphia, PA, 19104, USA
| | - Renato Polimanti
- Department of Psychiatry, Yale School of Medicine and VA Connecticut Healthcare System, West Haven, CT, 06516, USA
| | - Joel Gelernter
- Department of Psychiatry, Yale School of Medicine and VA Connecticut Healthcare System, West Haven, CT, 06516, USA
- Departments of Genetics and Neuroscience, Yale School of Medicine, New Haven, CT, 06515, USA
| | - David A Fiellin
- Internal Medicine, Yale School of Medicine, New Haven, CT, 06515, USA
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, 06515, USA
| | - Janet P Tate
- Veterans Aging Cohort Study Coordinating Center, VA Connecticut Healthcare System, West Haven, CT, 06516, USA
- Internal Medicine, Yale School of Medicine, New Haven, CT, 06515, USA
| | - Henry R Kranzler
- Mental Illness Research, Education and Clinical Center, Crescenz Veterans Affairs Medical Center, Philadelphia, PA, 19104, USA
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - William C Becker
- Internal Medicine, Yale School of Medicine, New Haven, CT, 06515, USA
- Pain Research, Informatics, Multi-morbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, 06516, USA
| |
Collapse
|
22
|
Reif S, Adams RS, Ritter GA, Williams TV, Larson MJ. Prevalence of Pain Diagnoses and Burden of Pain Among Active Duty Soldiers, FY2012. Mil Med 2019; 183:e330-e337. [PMID: 29547946 DOI: 10.1093/milmed/usx200] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 11/17/2017] [Accepted: 12/06/2017] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Soldiers are at risk for acute and chronic pain due to the mental and physical challenges of military duties and ongoing training for force readiness. With the burden of pain on any individual attributable across pain sources, a broad perspective that goes beyond prior characterizations of pain is important. We aim to further the understanding of pain's effects among non-deployed active duty soldiers and the Military Health System (MHS), by describing prevalence of 10 painful conditions, reported pain levels, duration of pain and impact of pain on military duty limitations. METHODS Data are from the MHS Data Repository including outpatient MHS direct care encounters, claims for outpatient purchased care from civilian providers, and vital records, for all soldiers continuously enrolled in TRICARE and not deployed in FY 2012. Ten pain-related diagnostic categories were conceptually derived for this analysis and identified using ICD-9-CM diagnostic codes. We report the FY 2012 prevalence at the soldier-level (N = 297,120) for each pain category as a primary diagnosis, as well as in any diagnostic position, and at the soldier-level for reported pain level, duration, and military duty limitations. Institutional Review Board approval was obtained prior to analyses. RESULTS Overall, 63% of soldiers had at least one pain diagnosis and 59% had a primary pain diagnosis during FY 2012. Back and neck pain (22%), non-traumatic joint disorders (28%), and other musculoskeletal pain (30%) were the most frequent categories for primary diagnosis. Nearly two-thirds of soldiers had a primary pain diagnosis in more than one category, and 23% in four or more categories. Moderate or severe pain levels were reported at least once during the year by 55% of soldiers who had a primary pain diagnosis. In the subsample of soldiers with primary pain in the first quarter, duration and chronicity of pain diagnoses varied by pain category: the back and neck pain category was the most common for both persistent pain occurring in each quarter of FY 2012 (23%) and chronic pain lasting for at least 3 mo (62%). In most pain categories, the majority of soldiers were released without duty limitations. CONCLUSION These data provide a deeper understanding of pain diagnoses and burden of pain among active duty soldiers. A substantial proportion of soldiers with pain diagnoses were seen for pain self-reported as only mild, or that did not result in significant restrictions in military duty limitations. However, given the prevalence of multiple pain diagnoses and common reports of moderate or severe pain and long duration, complex interventions may be required to minimize the effect of pain on force readiness. This encounters-based analysis is likely an underestimate of presence of pain, and does not include contextual factors that could better describe the true effect of pain among this population.
Collapse
Affiliation(s)
- Sharon Reif
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA
| | - Rachel Sayko Adams
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA
| | - Grant A Ritter
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA
| | - Thomas V Williams
- Defense Health Agency, 7700 Arlington Boulevard, Falls Church, VA.,NORC at the University of Chicago, 4350 East-West Highway, Bethesda, MD
| | - Mary Jo Larson
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA
| |
Collapse
|
23
|
Adams RS, Thomas CP, Ritter GA, Lee S, Saadoun M, Williams TV, Larson MJ. Predictors of Postdeployment Prescription Opioid Receipt and Long-term Prescription Opioid Utilization Among Army Active Duty Soldiers. Mil Med 2019; 184:e101-e109. [PMID: 30007291 DOI: 10.1093/milmed/usy162] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 06/10/2018] [Indexed: 12/12/2022] Open
Abstract
Introduction Little is known about long-term prescription opioid utilization in the Military Health System. The objectives of this study were to examine predictors of any prescription opioid receipt, and predictors of long-term opioid utilization among active duty soldiers in the year following deployment. Materials and Methods The analytic sample consisted of Army active duty soldiers returning from deployment to Operation Enduring Freedom, Operation Iraqi Freedom, or Operation New Dawn in fiscal years 2008-2014 (N = 540,738). The Heckman probit procedure was used to jointly examine predictors of any opioid prescription receipt and long-term opioid utilization (i.e., an episode of 90 days or longer where days-supply covered at least two-thirds of days) in the postdeployment year. Predictors were based on diagnoses and characteristics of opioid prescriptions. Results More than one-third of soldiers (34.8%, n = 188,211) had opioid receipt, and among those soldiers, 3.3% had long-term opioid utilization (or 1.1% of the cohort, n = 6,188). The largest magnitude predictors of long-term opioid utilization were receiving a long-acting opioid within the first 30 days of the episode, diagnoses of chronic pain (no specified source), back/neck pain, or peripheral/central nervous system pain, and severe pain score in vital records. Conclusions Soldiers returning from deployment were more likely to receive an opioid prescription than the overall active duty population, and 1.1% initiated a long-term opioid episode. We report a declining rate of opioid receipt and long-term opioid utilization among Army members from fiscal years 2008-2014. This study demonstrates that the most important predictors of opioid receipt were not demographic factors, but generally clinical indicators of acute pain or physical trauma.
Collapse
Affiliation(s)
- Rachel Sayko Adams
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA
| | - Cindy Parks Thomas
- Schneider Institute for Health Policy, Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA
| | - Grant A Ritter
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA
| | - Sue Lee
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA
| | - Mayada Saadoun
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA
| | | | - Mary Jo Larson
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA
| |
Collapse
|
24
|
Treatment of Low Back Pain With Opioids and Nonpharmacologic Treatment Modalities for Army Veterans. Med Care 2019; 56:855-861. [PMID: 30134347 DOI: 10.1097/mlr.0000000000000977] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND In the Veterans Health Administration (VHA) there is growing interest in the use of nonpharmacologic treatment (NPT) for low back pain (LBP) as pain intensity and interference do not decrease with opioid use. OBJECTIVES To describe overall and facility-level variation in the extent to which specific NPT modalities are used in VHA for LBP, either alone or as adjuncts to opioid medications, and to understand associations between veterans' clinical and demographic characteristics and type of treatment. RESEARCH DESIGN This retrospective cohort study examined use of opioids and 21 specific NPT modalities used by veterans. SUBJECTS VHA-enrolled Iraq and Afghanistan veterans who utilized care in ("linked" to) 130 VHA facilities within 12 months after their separation from the Army between fiscal years 2008-2011, and who were diagnosed with LBP within 12 months after linkage (n=49,885). MEASURES Measures included per patient: days' supply of opioids, number of visits for NPT modalities, and pain scores within one year after a LBP diagnosis. RESULTS Thirty-four percent of veterans filled a prescription for opioids, 35% utilized at least 1 NPT modality, and 15% used both within the same year. Most patients with LBP receiving NPT, on average, had moderate pain (36%), followed by low pain (27%), severe pain (15%), and no pain (11%). Eleven percent had no pain scores recorded. CONCLUSIONS About 65% of VHA patients with a LBP diagnosis did not receive NPT, and about 43% of NPT users also were prescribed an opioid. Understanding utilization patterns and their relationship with patient characteristics can guide pain management decisions and future study.
Collapse
|
25
|
Changes in pain intensity after discontinuation of long-term opioid therapy for chronic noncancer pain. Pain 2019; 159:2097-2104. [PMID: 29905648 DOI: 10.1097/j.pain.0000000000001315] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Little is known about changes in pain intensity that may occur after discontinuation of long-term opioid therapy (LTOT). The objective of this study was to characterize pain intensity after opioid discontinuation over 12 months. This retrospective U.S. Department of Veterans Affairs (VA) administrative data study identified N = 551 patients nationally who discontinued LTOT. Data over 24 months (12 months before and after discontinuation) were abstracted from VA administrative records. Random-effects regression analyses examined changes in 0 to 10 pain numeric rating scale scores over time, whereas growth mixture models delineated pain trajectory subgroups. Mean estimated pain at the time of opioid discontinuation was 4.9. Changes in pain after discontinuation were characterized by slight but statistically nonsignificant declines in pain intensity over 12 months after discontinuation (B = -0.20, P = 0.14). Follow-up growth mixture models identified 4 pain trajectory classes characterized by the following postdiscontinuation pain levels: no pain (average pain at discontinuation = 0.37), mild clinically significant pain (average pain = 3.90), moderate clinically significant pain (average pain = 6.33), and severe clinically significant pain (average pain = 8.23). Similar to the overall sample, pain trajectories in each of the 4 classes were characterized by slight reductions in pain over time, with patients in the mild and moderate pain trajectory categories experiencing the greatest pain reductions after discontinuation (B = -0.11, P = 0.05 and B = -0.11, P = 0.04, respectively). Pain intensity after discontinuation of LTOT does not, on average, worsen for patients and may slightly improve, particularly for patients with mild-to-moderate pain at the time of discontinuation. Clinicians should consider these findings when discussing risks of opioid therapy and potential benefits of opioid taper with patients.
Collapse
|
26
|
Highland KB, Tran J, Edwards H, Bedocs P, Suen J, Buckenmaier CC. Feasibility of App-Based Postsurgical Assessment of Pain, Pain Impact, and Regional Anesthesia Effects: A Pilot Randomized Controlled Trial. PAIN MEDICINE 2019; 20:1592-1599. [DOI: 10.1093/pm/pny288] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Abstract
Objective
Postsurgical follow-up calls enable nurses to assess a patient’s condition, provide tailored education, and improve the patient’s experience. Despite the benefits, barriers to phone-based assessments may include patient nonresponse and lack of time due to demanding clinical schedules. The purpose of this trial was to examine the feasibility and utility of a smartphone app, mCare, for assessing pain, pain impact, and peripheral nerve block effects in patients.
Design
Pilot randomized control trial.
Setting and Patients
Eligible patients at a military treatment facility undergoing same-day surgery were randomized to the mCare group (N = 24) or the standard-of-care telephone (N = 26) group.
Results
Outcomes included initial response (assessment completion) rates and participant and nurse satisfaction. There were no differences in the response rates upon initial contact attempt, and patients in both groups reported similar levels of satisfaction and convenience. Nurses reported greater satisfaction with the app compared with standard-of-care telephone calls.
Conclusions
Before wider implementation, further considerations of app-based assessment need to be fully explored.
Collapse
Affiliation(s)
- Krista B Highland
- Defense and Veterans Center for Integrative Pain Management, Uniformed Services University Henry M. Jackson Foundation, Rockville, Maryland, USA
| | - Julie Tran
- Defense and Veterans Center for Integrative Pain Management, Uniformed Services University Henry M. Jackson Foundation, Rockville, Maryland, USA
| | - Hisani Edwards
- Defense and Veterans Center for Integrative Pain Management, Uniformed Services University Henry M. Jackson Foundation, Rockville, Maryland, USA
| | - Peter Bedocs
- Defense and Veterans Center for Integrative Pain Management, Uniformed Services University Henry M. Jackson Foundation, Rockville, Maryland, USA
| | - Joshua Suen
- Defense and Veterans Center for Integrative Pain Management, Uniformed Services University Henry M. Jackson Foundation, Rockville, Maryland, USA
| | - Chester C Buckenmaier
- Defense and Veterans Center for Integrative Pain Management, Uniformed Services University Henry M. Jackson Foundation, Rockville, Maryland, USA
| |
Collapse
|
27
|
Buis LR, McCant FA, Gierisch JM, Bastian LA, Oddone EZ, Richardson CR, Kim HM, Evans R, Hooks G, Kadri R, White-Clark C, Damschroder LJ. Understanding the Effect of Adding Automated and Human Coaching to a Mobile Health Physical Activity App for Afghanistan and Iraq Veterans: Protocol for a Randomized Controlled Trial of the Stay Strong Intervention. JMIR Res Protoc 2019; 8:e12526. [PMID: 30694208 PMCID: PMC6371069 DOI: 10.2196/12526] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 12/05/2018] [Accepted: 12/25/2018] [Indexed: 12/18/2022] Open
Abstract
Background Although maintaining a healthy weight and physical conditioning are requirements of active military duty, many US veterans rapidly gain weight and lose conditioning when they separate from active-duty service. Mobile health (mHealth) interventions that incorporate wearables for activity monitoring have become common, but it is unclear how to optimize engagement over time. Personalized health coaching, either through tailored automated messaging or by individual health coaches, has the potential to increase the efficacy of mHealth programs. In an attempt to preserve conditioning and ward off weight gain, we developed Stay Strong, a mobile app that is tailored to veterans of recent conflicts and tracks physical activity monitored by Fitbit Charge 2 devices and weight measured on a Bluetooth-enabled scale. Objective The goal of this study is to determine the effect of activity monitoring plus health coaching compared with activity monitoring alone. Methods In this randomized controlled trial, with Stay Strong, a mobile app designed specifically for veterans, we plan to enroll 350 veterans to engage in an mHealth lifestyle intervention that combines the use of a wearable physical activity tracker and a Bluetooth-enabled weight scale. The Stay Strong app displays physical activity and weight data trends over time. Enrolled participants are randomized to receive the Stay Strong app (active comparator arm) or Stay Strong + Coaching, an enhanced version of the program that adds coaching features (automated tailored messaging with weekly physical activity goals and up to 3 telephone calls with a health coach—intervention arm) for 1 year. Our primary outcome is change in physical activity at 12 months, with weight, pain, patient activation, and depression serving as secondary outcome measures. All processes related to recruitment, eligibility screening, informed consent, Health Insurance Portability and Accountability Act authorization, baseline assessment, randomization, the bulk of intervention delivery, and outcome assessment will be accomplished via the internet or smartphone app. Results The study recruitment began in September 2017, and data collection is expected to conclude in 2019. A total of 465 participants consented to participate and 357 (357/465, 77%) provided baseline levels of physical activity and were randomized to 1 of the 2 interventions. Conclusions This novel randomized controlled trial will provide much-needed findings about whether the addition of telephone-based human coaching and other automated supportive-coaching features will improve physical activity compared with using a smartphone app linked to a wearable device alone. Trial Registration ClinicalTrials.gov NCT02360293; https://clinicaltrials.gov/ct2/show/NCT02360293 (Archived by WebCite at http://www.webcitation.org/75KQeIFwh) International Registered Report Identifier (IRRID) DERR1-10.2196/12526
Collapse
Affiliation(s)
- Lorraine R Buis
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Felicia A McCant
- Durham Center of Innovation to Accelerate Discover and Practice Transformation, Durham VA Health Care System, Durham, NC, United States
| | - Jennifer M Gierisch
- Durham Center of Innovation to Accelerate Discover and Practice Transformation, Durham VA Health Care System, Durham, NC, United States.,Department of Population Health Sciences, Duke University Medical Center, Durham, NC, United States.,Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, Durham, NC, United States
| | - Lori A Bastian
- Division of General Internal Medicine, Department of Medicine, Yale University, New Haven, CT, United States.,Pain Research, Informatics, Multimorbidities, and Education Center, VA Connecticut, West Haven, CT, United States
| | - Eugene Z Oddone
- Durham Center of Innovation to Accelerate Discover and Practice Transformation, Durham VA Health Care System, Durham, NC, United States.,Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, Durham, NC, United States
| | | | - Hyungjin Myra Kim
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States
| | - Richard Evans
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States
| | - Gwendolyn Hooks
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States
| | - Reema Kadri
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Courtney White-Clark
- Durham Center of Innovation to Accelerate Discover and Practice Transformation, Durham VA Health Care System, Durham, NC, United States
| | - Laura J Damschroder
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States
| |
Collapse
|
28
|
Lisi AJ, Corcoran KL, DeRycke EC, Bastian LA, Becker WC, Edmond SN, Goertz CM, Goulet JL, Haskell SG, Higgins DM, Kawecki T, Kerns RD, Mattocks K, Ramsey C, Ruser CB, Brandt CA. Opioid Use Among Veterans of Recent Wars Receiving Veterans Affairs Chiropractic Care. PAIN MEDICINE 2018; 19:S54-S60. [PMID: 30203014 DOI: 10.1093/pm/pny114] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Anthony J Lisi
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
- Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Kelsey L Corcoran
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
- Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Eric C DeRycke
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Lori A Bastian
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
- Yale School of Medicine, Yale University, New Haven, Connecticut
| | - William C Becker
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
- Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Sara N Edmond
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
- Yale School of Medicine, Yale University, New Haven, Connecticut
| | | | - Joseph L Goulet
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
- Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Sally G Haskell
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
- Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Diana M Higgins
- VA Boston Healthcare System, Boston, Massachusetts
- School of Medicine, Boston University, Boston, Massachusetts
| | - Todd Kawecki
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
- Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Robert D Kerns
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
- Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Kristin Mattocks
- VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts
- University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Christine Ramsey
- Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Christopher B Ruser
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
- Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Cynthia A Brandt
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
- Yale School of Medicine, Yale University, New Haven, Connecticut
| |
Collapse
|
29
|
Larson MJ, Adams RS, Ritter GA, Linton A, Williams TV, Saadoun M, Bauer MR. Associations of Early Treatments for Low-Back Pain with Military Readiness Outcomes. J Altern Complement Med 2018; 24:666-676. [PMID: 29589956 PMCID: PMC6065526 DOI: 10.1089/acm.2017.0290] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Chronic low-back pain (LBP) is a frequent cause of work absence and disability, and is frequently associated with long-term use of opioids. OBJECTIVE To describe military readiness-related outcomes at follow-up in soldiers with LBP grouped by the type of early treatment received for their LBP. Treatment groups were based on receipt of opioid or tramadol prescription and receipt of nonpharmacologic treatment modalities (NPT). Design, Subjects, Measures: A retrospective longitudinal analysis of U.S. soldiers with new LBP episodes persisting more than 90 days between October 2012 and September 2014. Early treatment groups were constructed based on utilization of services within 30 days of the first LBP claim. Outcomes were measured 91-365 days after the first LBP claim. Outcomes were constructed to measure five indicators of limitations of military readiness: military duty limitations, pain-related hospitalization, emergency room visit for LBP, pain score of moderate/severe, and prescription for opioid/tramadol. RESULTS Among soldiers with no opioid receipt in the prior 90 days, there were 30,612 new episodes of LBP, which persisted more than 90 days. Multivariable logistic regression models found that compared to the reference group (no NPT, no opioids/tramadol receipt), soldiers who received early NPT-only had lower likelihoods for military duty limitations, pain-related hospitalization, and opioid/tramadol prescription at follow-up, while soldiers' that started with opioid receipt (at alone or follow-up in conjunction with NPT) exhibited higher likelihoods on many of these negative outcomes. CONCLUSION This observational study of soldiers with a new episode of LBP and no opioid receipt in the prior 90 days suggests that early receipt of NPT may be associated with small, significant gains in ability to function as a soldier and reduced reliance on opioid/tramadol medication. While further research is warranted, increased access to NPT at the beginning of LBP episodes should be considered.
Collapse
Affiliation(s)
- Mary Jo Larson
- The Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts
| | - Rachel Sayko Adams
- The Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts
| | - Grant A. Ritter
- The Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts
| | - Andrea Linton
- AXIOM Resource Management, Inc., Falls Church, Virginia
| | | | - Mayada Saadoun
- The Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts
| | - Mark R. Bauer
- The Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts
| |
Collapse
|
30
|
Abstract
INTRODUCTION Chronic pain is highly prevalent, and the ability to routinely measure patients' pain and treatment response using validated patient-reported outcome (PRO) assessments is important to clinical care. Despite this recognition, systematic use in everyday clinical care is rare. AIMS The aims of this study were to (1) describe infrastructure designed to automate PRO data collection, (2) compare study-enhanced PRO completion rates to those in clinical care, and (3) evaluate patient response rates by method of PRO administration and sociodemographic and/or clinical characteristics. SETTING The Pain Program for Active Coping and Training (PPACT) is a pragmatic clinical trial conducted within three regions of the Kaiser Permanente health care system. PROGRAM DESCRIPTION PPACT evaluates the effect of integrative primary care-based pain management services on outcomes for chronic pain patients on long-term opioid treatment. We implemented a tiered process for quarterly assessment of PROs to supplement clinical collection and ensure adequate trial data using three methods: web-based personal health records (PHR), automated interactive voice response (IVR) calls, and live outreach. PROGRAM EVALUATION Among a subset of PPACT participants examined (n = 632), the tiered study-enhanced PRO completion rates were higher than in clinical care: 96% completed ≥ 1 study-administered PRO with mean of 3.46 (SD = 0.85) vs. 74% completed in clinical care with a mean of 2.43 (SD = 2.08). Among all PPACT participants at 3 months (n = 831), PRO completion was 86% and analyses of response by key characteristics found only that participant age predicted an increased likelihood of responding to PHR and IVR outreach. DISCUSSION Adherence to pain-related PRO data collection using our enhanced tiered approach was high. No demographic or clinical identifiers other than age were associated with differential response by modality. Successful ancillary support should employ multimodal electronic health record functionalities for PRO administration. Using automated modalities is feasible and may facilitate better sustainability for regular PRO administration within health care systems. Clinical Trials Registration Number: NCT02113592.
Collapse
|
31
|
Hedian HF, Greene JA, Niessen TM. The Electronic Health Record and the Clinical Examination. Med Clin North Am 2018; 102:475-483. [PMID: 29650069 DOI: 10.1016/j.mcna.2017.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
This review examines how the adoption of the electronic health record (EHR) has changed the most fundamental unit of medicine: the clinical examination. The impact of the EHR on the clinical history, physical examination, documentation, and the doctor-patient relationship is described. The EHR now has a dominant role in clinical care and will be a central factor in clinical work of the future. Conversation needs to be shifted toward defining best practices with current EHRs inside and outside of the examination room.
Collapse
Affiliation(s)
- Helene F Hedian
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, 10753 Falls Road, Suite 325, Lutherville, MD 21093, USA.
| | - Jeremy A Greene
- Department of Medicine, Johns Hopkins University School of Medicine, 1900 East Monument Street, Welch 324, Baltimore, MD 21205, USA; Department of the History of Medicine, Johns Hopkins University School of Medicine, 1900 East Monument Street, Welch 324, Baltimore, MD 21205, USA
| | - Timothy M Niessen
- Division of General Internal Medicine, Hospitalist Program, Johns Hopkins University School of Medicine, Meyer 8-134-H, 600 North Wolfe Street, Baltimore, MD 21287, USA
| |
Collapse
|
32
|
Bastian LA, Driscoll MA, Heapy AA, Becker WC, Goulet JL, Kerns RD, DeRycke EC, Perez E, Lynch SM, Mattocks K, Kroll-Desrosiers AR, Brandt CA, Skanderson M, Bathulapalli H, Haskell SG. Cigarette Smoking Status and Receipt of an Opioid Prescription Among Veterans of Recent Wars. PAIN MEDICINE 2018; 18:1089-1097. [PMID: 27659441 DOI: 10.1093/pm/pnw223] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Objective Cigarette smokers seeking treatment for chronic pain have higher rates of opioid use than nonsmokers. This study aims to examine whether veterans of Operations Enduring Freedom/Iraqi Freedom/New Dawn (OEF/OIF/OND) who smoke are more likely to receive an opioid prescription than nonsmokers, adjusting for current pain intensity. Design Cross-sectional analysis of a cohort study of OEF/OIF/OND veterans who had at least one visit to a Veterans Health Administration primary care clinic between 2001 and 2012. Methods Smoking status was defined as current, former, and never. Current pain intensity (+/- 30 days of smoking status), based on the 0-10 numeric rating scale, was categorized as no pain/mild (0-3) and moderate/severe (4-10). Opioid receipt was defined as at least one prescription filled +/- 30 days of smoking status. Results We identified 406,954 OEF/OIF/OND veterans: The mean age was 30 years, 12.5% were women (n = 50,988), 66.3% reported no pain or mild pain intensity, 33.7% reported moderate or severe pain intensity, 37.2% were current smokers, and 16% were former smokers. Overall, 33,960 (8.3%) veterans received one or more opioid prescription. Current smoking (odds ratio [OR] = 1.56, 95% confidence interval [CI] = 1.52-1.61) and former smoking (OR = 1.27, 95% CI = 1.22-1.32) were associated with a higher likelihood of receipt of an opioid prescription compared with never smoking, after controlling for other covariates. Conclusions We found an association between smoking status and receipt of an opioid prescription. The effect was stronger for current smokers than former smokers, highlighting the need to determine whether smoking cessation is associated with a reduction in opioid use among veterans.
Collapse
Affiliation(s)
- Lori A Bastian
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut.,Yale University School of Medicine, New Haven, Connecticut
| | - Mary A Driscoll
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut.,Yale University School of Medicine, New Haven, Connecticut
| | - Alicia A Heapy
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut.,Yale University School of Medicine, New Haven, Connecticut
| | - William C Becker
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut.,Yale University School of Medicine, New Haven, Connecticut
| | - Joseph L Goulet
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut.,Yale University School of Medicine, New Haven, Connecticut
| | - Robert D Kerns
- Yale University School of Medicine, New Haven, Connecticut
| | - Eric C DeRycke
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Elliottnell Perez
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Shaina M Lynch
- University of Connecticut School of Medicine, Farmington, Connecticut
| | - Kristin 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.,Yale University School of Medicine, New Haven, Connecticut
| | - Melissa Skanderson
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Harini Bathulapalli
- 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.,Yale University School of Medicine, New Haven, Connecticut
| |
Collapse
|
33
|
Karcioglu O, Topacoglu H, Dikme O, Dikme O. A systematic review of the pain scales in adults: Which to use? Am J Emerg Med 2018; 36:707-714. [PMID: 29321111 DOI: 10.1016/j.ajem.2018.01.008] [Citation(s) in RCA: 494] [Impact Index Per Article: 82.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Accepted: 01/03/2018] [Indexed: 12/15/2022] Open
|
34
|
Ruben MA, Blanch-Hartigan D, Shipherd JC. To Know Another’s Pain: A Meta-analysis of Caregivers’ and Healthcare Providers’ Pain Assessment Accuracy. Ann Behav Med 2018; 52:662-685. [DOI: 10.1093/abm/kax036] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Mollie A Ruben
- School of Arts and Sciences, Massachusetts College of Pharmacy and Health Sciences University, Boston, MA
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, US Department of Veterans Affairs, Boston, MA
| | | | - Jillian C Shipherd
- National Center for PTSD, Women’s Health Sciences, VA Boston Healthcare System, Boston, MA
- Boston University School of Medicine, Boston, MA
- Lesbian, Gay, Bisexual, and Transgender (LGBT) Program, Veterans Health Administration, Washington, DC
| |
Collapse
|
35
|
|
36
|
Lisi AJ, Brandt CA. Trends in the Use and Characteristics of Chiropractic Services in the Department of Veterans Affairs. J Manipulative Physiol Ther 2018; 39:381-386. [PMID: 27288324 DOI: 10.1016/j.jmpt.2016.04.005] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Revised: 04/06/2016] [Accepted: 04/07/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVES The purpose of this study was to analyze national trends and key features of the Department of Veterans Affairs' (VA's) chiropractic service delivery and chiropractic provider workforce since their initial inception. METHODS This was a serial cross-sectional analysis of the VA administrative data sampled from the first record of chiropractic services in VA through September 30, 2015. Data were obtained from VA's Corporate Data Warehouse and analyzed with descriptive statistics. RESULTS From October 1, 2004, through September 30, 2015, the annual number of patients seen in VA chiropractic clinics increased from 4052 to 37349 (821.7%), and the annual number of chiropractic visits increased from 20072 to 159366 (693.9%). The typical VA chiropractic patient is male, is between the ages of 45 and 64, is seen for low back and/or neck conditions, and receives chiropractic spinal manipulation and evaluation and management services. The total number of VA chiropractic clinics grew from 27 to 65 (9.4% annually), and the number of chiropractor employees grew from 13 to 86 (21.3% annually). The typical VA chiropractor employee is a 45.9-year-old man, has worked in VA for 4.5 years, and receives annual compensation of $97860. VA also purchased care from private sector chiropractors starting in 2000, growing to 159533 chiropractic visits for 19435 patients at a cost of $11155654 annually. CONCLUSIONS Use of chiropractic services and the chiropractic workforce in VA have grown substantially over more than a decade since their introduction.
Collapse
Affiliation(s)
- Anthony J Lisi
- Chiropractic Section Chief, VA Connecticut Healthcare System, West Haven, CT; Assistant Clinical Professor, Yale Center for Medical Informatics, Yale University School of Medicine, New Haven, CT.
| | - Cynthia A Brandt
- Staff Physician, VA Connecticut Healthcare System, West Haven, CT; Professor, Yale Center for Medical Informatics, Yale University School of Medicine, New Haven, CT
| |
Collapse
|
37
|
Dequeker S, Van Lancker A, Van Hecke A. Hospitalized patients’ vs. nurses’ assessments of pain intensity and barriers to pain management. J Adv Nurs 2017; 74:160-171. [DOI: 10.1111/jan.13395] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Sara Dequeker
- Department of Public Health; Faculty of Medicine and Health Sciences; University Center for Nursing and Midwifery; Ghent University; Ghent Belgium
| | - Aurélie Van Lancker
- Department of Public Health; Faculty of Medicine and Health Sciences; University Center for Nursing and Midwifery; Ghent University; Ghent Belgium
| | - Ann Van Hecke
- Department of Public Health; Faculty of Medicine and Health Sciences; University Center for Nursing and Midwifery; Ghent University; Ghent Belgium
- Ghent University Hospital; Ghent Belgium
| |
Collapse
|
38
|
Hausmann LRM, Brandt CA, Carroll CM, Fenton BT, Ibrahim SA, Becker WC, Burgess DJ, Wandner LD, Bair MJ, Goulet JL. Racial and Ethnic Differences in Total Knee Arthroplasty in the Veterans Affairs Health Care System, 2001-2013. Arthritis Care Res (Hoboken) 2017; 69:1171-1178. [PMID: 27788302 PMCID: PMC5538734 DOI: 10.1002/acr.23137] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 10/03/2016] [Accepted: 10/25/2016] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To examine black-white and Hispanic-white differences in total knee arthroplasty from 2001 to 2013 in a large cohort of patients diagnosed with osteoarthritis (OA) in the Veterans Affairs (VA) health care system. METHODS Data were from the VA Musculoskeletal Disorders cohort, which includes data from electronic health records of more than 5.4 million veterans with musculoskeletal disorders diagnoses. We included white (non-Hispanic), black (non-Hispanic), and Hispanic (any race) veterans, age ≥50 years, with an OA diagnosis from 2001-2011 (n = 539,841). Veterans were followed from their first OA diagnosis until September 30, 2013. As a proxy for increased clinical severity, analyses were also conducted for a subsample restricted to those who saw an orthopedic or rheumatology specialist (n = 148,844). We used Cox proportional hazards regression to examine racial and ethnic differences in total knee arthroplasty by year of OA diagnosis, adjusting for age, sex, body mass index, physical and mental diagnoses, and pain intensity scores. RESULTS We identified 12,087 total knee arthroplasty procedures in a sample of 473,170 white, 50,172 black, and 16,499 Hispanic veterans. In adjusted models examining black-white and Hispanic-white differences by year of OA diagnosis, total knee arthroplasty rates were lower for black than for white veterans diagnosed in all but 2 years. There were no Hispanic-white differences regardless of when diagnosis occurred. These patterns held in the specialty clinic subsample. CONCLUSION Black-white differences in total knee arthroplasty appear to be persistent in the VA, even after controlling for potential clinical confounders.
Collapse
Affiliation(s)
- Leslie R M Hausmann
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, and University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Cynthia A Brandt
- VA Connecticut Healthcare System, Pain Research, Informatics, Multimorbidities, and Education Center, West Haven, and Yale School of Medicine, New Haven, Connecticut
| | | | - Brenda T Fenton
- VA Connecticut Healthcare System, Pain Research, Informatics, Multimorbidities, and Education Center, West Haven, and Yale School of Public Health, New Haven, Connecticut
| | - Said A Ibrahim
- Corporal Michael J. Crescenz VA Medical Center, Center for Health Equity Research and Promotion, and University of Pennsylvania, Philadelphia
| | - William C Becker
- VA Connecticut Healthcare System, Pain Research, Informatics, Multimorbidities, and Education Center, West Haven, and Yale School of Medicine, New Haven, Connecticut
| | - Diana J Burgess
- Minneapolis VA Healthcare System, Center for Chronic Disease Outcomes Research and University of Minnesota, Minneapolis
| | - Laura D Wandner
- Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Matthew J Bair
- Richard L. Roudebush VA Medical Center, Center for Health Information and Communication, Indiana University School of Medicine, and Regenstrief Institute, Indianapolis
| | - Joseph L Goulet
- VA Connecticut Healthcare System, Pain Research, Informatics, Multimorbidities, and Education Center, West Haven, and Yale School of Medicine, New Haven, Connecticut
| |
Collapse
|
39
|
Abstract
Musculoskeletal disorders (MSDs) are highly prevalent, painful, and costly disorders. The MSD Cohort was created to characterize variation in pain, comorbidities, treatment, and outcomes among patients with MSD receiving Veterans Health Administration care across demographic groups, geographic regions, and facilities. We searched electronic health records to identify patients treated in Veterans Health Administration who had ICD-9-CM codes for diagnoses including, but not limited to, joint, back, and neck disorders, and osteoarthritis. Cohort inclusion criteria were 2 or more outpatient visits occurring within 18 months of one another or one inpatient visit with an MSD diagnosis between 2000 and 2011. The first diagnosis is the index date. Pain intensity numeric rating scale (NRS) scores, comorbid medical and mental health diagnoses, pain-related treatments, and other characteristics were collected retrospectively and prospectively. The cohort included 5,237,763 patients; their mean age was 59, 6% were women, 15% identified as black, and 18% reported severe pain (NRS ≥ 7) on the index date. Nontraumatic joint disorder (27%), back disorder (25%), and osteoarthritis (21%) were the most common MSD diagnoses. Patients entering the cohort in recent years had more concurrent MSD diagnoses and higher NRS scores. The MSD Cohort is a rich resource for collaborative pain-relevant health service research.
Collapse
|
40
|
Booker SS, Herr KA. Pain Management for Older African Americans in the Perianesthesia Setting: The "Eight I's". J Perianesth Nurs 2017; 30:181-8. [PMID: 26003763 DOI: 10.1016/j.jopan.2015.01.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 01/13/2015] [Accepted: 01/18/2015] [Indexed: 10/23/2022]
Abstract
National legislation (Affordable Care Act) emphasizes quality and equitable pain care for all patient populations, but frequently, pain management is not effective and equitable in African American (AA) elders, placing them at higher risk for severe pain and persistent pain. Research shows that AAs are less likely to receive guideline-based pain care. This underscores the need for perianesthesia nurses to be knowledgeable and capable of integrating cultural practices and evidence-based recommendations into their care of older AAs to ensure adequate pain management in this vulnerable population. This article describes differences and disparities in pain management in AA older adults and provides a cultural framework to guide perianesthesia pain management.
Collapse
|
41
|
Pain intensity rating training: results from an exploratory study of the ACTTION PROTECCT system. Pain 2017; 157:1056-1064. [PMID: 27058680 DOI: 10.1097/j.pain.0000000000000502] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Clinical trial participants often require additional instruction to prevent idiosyncratic interpretations regarding completion of patient-reported outcomes. The Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) public-private partnership developed a training system with specific, standardized guidance regarding daily average pain intensity ratings. A 3-week exploratory study among participants with low-back pain, osteoarthritis of the knee or hip, and painful diabetic peripheral neuropathy was conducted, randomly assigning participants to 1 of 3 groups: training with human pain assessment (T+); training with automated pain assessment (T); or no training with automated pain assessment (C). Although most measures of validity and reliability did not reveal significant differences between groups, some benefit was observed in discriminant validity, amount of missing data, and ranking order of least, worst, and average pain intensity ratings for participants in Group T+ compared with the other groups. Prediction of greater reliability in average pain intensity ratings in Group T+ compared with the other groups was not supported, which might indicate that training produces ratings that reflect the reality of temporal pain fluctuations. Results of this novel study suggest the need to test the training system in a prospective analgesic treatment trial.
Collapse
|
42
|
Tighe PJ, King CD, Zou B, Fillingim RB. Time to Onset of Sustained Postoperative Pain Relief (SuPPR): Evaluation of a New Systems-level Metric for Acute Pain Management. Clin J Pain 2016; 32:371-9. [PMID: 26247416 DOI: 10.1097/ajp.0000000000000285] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Prior work on postoperative pain trajectories has examined pain score changes over time using daily averages of pain scores. However, little is known about the time required until patients consistently report minimal postoperative pain. MATERIALS AND METHODS We conducted a retrospective cohort study of surgical case data from 7293 adult patients to examine the impact of age, sex, and the type of surgery on the time to sustained postoperative pain relief (SuPPR). We defined SuPPR as the time required until a patient reports the first of multiple (2, 3, 4, or 5 sequential measurements; eg, SuPPR-2, SuPPR-3), uninterrupted, mild pain scores (≤4/10). RESULTS Overall, SuPPR times ranged from 3 minutes for SuPPR-2 and 9 minutes for SuPPR-5 to 160.1 hours for SuPPR-2 and 183.1 hours for SuPPR-5. For the SuPPR-2 outcome, the median time to event was 10.9 hours (interquartile range, 3 to 26.1 h) after surgery. For the SuPPR-5 outcomes, the median time to event was 31.5 hours (interquartile range, 17.8 to 54.2 h) after surgery. The peak median difference between 2 sequential SuPPR definitions was between SuPPR-3 and SuPPR-2 at 9 hours, with subsequent decreases to 6.5 hours between SuPPR-4 and SuPPR-3, and 5.2 hours between SuPPR-5 and SuPPR-4. There were statistically different differences across SuPPR-2 through SuPPR-5 definitions by age, sex, and type of surgery. DISCUSSION Although additional analyses are necessary, SuPPR may represent a novel method for evaluating acute pain service performance.
Collapse
Affiliation(s)
- Patrick J Tighe
- *Pain Research and Intervention Center of Excellence (PRICE), University of Florida Departments of †Anesthesiology ‡Biostatistics, University of Florida College of Medicine, Gainesville, FL
| | | | | | | |
Collapse
|
43
|
Abel EA, Brandt CA, Czlapinski R, Goulet JL. Pain research using Veterans Health Administration electronic and administrative data sources. ACTA ACUST UNITED AC 2016; 53:1-12. [PMID: 27005814 DOI: 10.1682/jrrd.2014.10.0246] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Revised: 07/06/2015] [Indexed: 11/05/2022]
Abstract
Health services researchers are using Veterans Health Administration (VHA) electronic health record (EHR) data sources to examine the prevalence, treatment, and outcomes of pain among Veterans in VHA care. Little guidance currently exists on using these data; thus, findings may vary depending on the methods, data sources, and definitions used. We sought to identify current practices in order to provide guidance to future pain researchers. We conducted an anonymous survey of VHA-affiliated researchers participating in a monthly national pain research teleconference. Thirty-two researchers (89%) responded: 75% conducted pain-focused research, 78% used pain intensity numeric rating screening scale (NRS) scores to identify pain, 41% used International Classification of Diseases-9th Revision codes, and 57% distinguished between chronic and acute pain using either NRS scores or pharmacy data. The NRS and pharmacy data were rated as the most valid pain data sources. Of respondents, 48% reported the EHR data sources were adequate for pain research, while 45% had published peer-reviewed articles based on the data. Despite limitations, VHA researchers are increasingly using EHR data for pain research, and several common methods were identified. More information on the performance characteristics of these data sources and definitions is needed.
Collapse
Affiliation(s)
- Erica A Abel
- Department of Veterans Affairs Connecticut Healthcare System, West Haven, CT
| | | | | | | |
Collapse
|
44
|
Statistical Models for the Analysis of Zero-Inflated Pain Intensity Numeric Rating Scale Data. THE JOURNAL OF PAIN 2016; 18:340-348. [PMID: 27919777 DOI: 10.1016/j.jpain.2016.11.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 11/10/2016] [Accepted: 11/18/2016] [Indexed: 01/14/2023]
Abstract
Pain intensity is often measured in clinical and research settings using the 0 to 10 numeric rating scale (NRS). NRS scores are recorded as discrete values, and in some samples they may display a high proportion of zeroes and a right-skewed distribution. Despite this, statistical methods for normally distributed data are frequently used in the analysis of NRS data. We present results from an observational cross-sectional study examining the association of NRS scores with patient characteristics using data collected from a large cohort of 18,935 veterans in Department of Veterans Affairs care diagnosed with a potentially painful musculoskeletal disorder. The mean (variance) NRS pain was 3.0 (7.5), and 34% of patients reported no pain (NRS = 0). We compared the following statistical models for analyzing NRS scores: linear regression, generalized linear models (Poisson and negative binomial), zero-inflated and hurdle models for data with an excess of zeroes, and a cumulative logit model for ordinal data. We examined model fit, interpretability of results, and whether conclusions about the predictor effects changed across models. In this study, models that accommodate zero inflation provided a better fit than the other models. These models should be considered for the analysis of NRS data with a large proportion of zeroes. PERSPECTIVE We examined and analyzed pain data from a large cohort of veterans with musculoskeletal disorders. We found that many reported no current pain on the NRS on the diagnosis date. We present several alternative statistical methods for the analysis of pain intensity data with a large proportion of zeroes.
Collapse
|
45
|
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.
Collapse
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
| |
Collapse
|
46
|
Becker WC, Gordon K, Edelman EJ, Kerns RD, Crystal S, Dziura JD, Fiellin LE, Gordon AJ, Goulet JL, Justice AC, Fiellin DA. Trends in Any and High-Dose Opioid Analgesic Receipt Among Aging Patients With and Without HIV. AIDS Behav 2016; 20:679-86. [PMID: 26384973 PMCID: PMC5006945 DOI: 10.1007/s10461-015-1197-5] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Harms of opioid analgesics, especially high-dose therapy among individuals with comorbidities and older age, are increasingly recognized. However, trends in opioid receipt among HIV-infected patients are not well characterized. We examined trends, from 1999 to 2010, in any and high-dose (≥120 mg/day) opioid receipt among patients with and without HIV, by age strata, controlling for demographic and clinical correlates. Of 127,216 patients, 64 % received at least one opioid prescription. Opioid receipt increased substantially among HIV-infected and uninfected patients over the study; high-dose therapy was more prevalent among HIV-infected patients. Trends in high-dose receipt stratified by three age groups revealed an increasing trend in each age strata, higher among HIV-infected patients. Correlates of any opioid receipt included HIV, PTSD and major depression. Correlates of high-dose receipt included HIV, PTSD, major depression and drug use disorders. These findings suggest a need for appropriate balance of risks and benefits, especially as these populations age.
Collapse
Affiliation(s)
- William C Becker
- Internal Medicine, West Haven VA Medical Center, VA Connecticut Healthcare System, Mail Stop 151B, 950 Campbell Avenue, West Haven, CT, 06516, USA.
- Internal Medicine, Yale University School of Medicine, New Haven, CT, USA.
| | - Kirsha Gordon
- Internal Medicine, West Haven VA Medical Center, VA Connecticut Healthcare System, Mail Stop 151B, 950 Campbell Avenue, West Haven, CT, 06516, USA
| | - E Jennifer Edelman
- Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Robert D Kerns
- Psychology, VA Connecticut Healthcare System, West Haven, CT, USA
- Psychology, Yale University School of Medicine, New Haven, CT, USA
| | - Stephen Crystal
- Center for Health Services Research, Rutgers University, New Brunswick, NJ, USA
| | - James D Dziura
- Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Lynn E Fiellin
- Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Adam J Gordon
- University of Pittsburgh and Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Joseph L Goulet
- Psychology, VA Connecticut Healthcare System, West Haven, CT, USA
- Psychology, Yale University School of Medicine, New Haven, CT, USA
| | - Amy C Justice
- Internal Medicine, West Haven VA Medical Center, VA Connecticut Healthcare System, Mail Stop 151B, 950 Campbell Avenue, West Haven, CT, 06516, USA
- Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - David A Fiellin
- Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| |
Collapse
|
47
|
|
48
|
Abstract
The objective of this study was to determine the effects of age, sex, and type of surgery on postoperative pain trajectories derived in a clinical setting from pain assessments in the first 24 hours after surgery. This study is a retrospective cohort study using a large electronic medical records system to collect and analyze surgical case data. The sample population included adult patients undergoing nonambulatory nonobstetric surgery in a single institution over a 1-year period. Analyses of postoperative pain trajectories were performed using a linear mixed-effects model. Pain score observations (91,708) from 7293 patients were included in the statistical analysis. On average, the pain score decreased about 0.042 (95% confidence interval [CI]: -0.044 to -0.040) points on the numerical rating scale (NRS) per hour after surgery for the first 24 postoperative hours. The pain score reported by male patients was approximately 0.27 (95% CI: -0.380 to -0.168) NRS points lower than that reported by females. Pain scores significantly decreased over time in all age groups, with a slightly more rapid decrease for younger patients. Pain trajectories differed by anatomic location of surgery, ranging from -0.054 (95% CI: -0.062 to -0.046) NRS units per hour for integumentary and nervous surgery to -0.104 (95% CI: -0.110 to -0.098) NRS units per hour for digestive surgery, and a positive trajectory (0.02 [95% CI: 0.016 to 0.024] NRS units per hour) for musculoskeletal surgery. Our data support the important role of time after surgery in considering the influence of biopsychosocial and clinical factors on acute postoperative pain.
Collapse
|
49
|
|
50
|
Abstract
IMPORTANCE Patients with sexually transmitted infection (STI) diagnosis should be tested for human immunodeficiency virus (HIV), regardless of previous HIV test results. OBJECTIVE Estimate HIV testing rates among recent service Veterans with an STI diagnosis and variation in testing rates by patient characteristics. DESIGN, SETTING, AND PARTICIPANTS The sample comprised 243,843 Veterans who initiated Veterans Health Administration (VHA) services within 1 year after military separation. Participants were followed for 2 years to determine STI diagnoses and HIV testing rates. We used relative risks regression to examine variation in testing rates. MAIN OUTCOMES AND MEASURES We used VHA administrative data to identify STI diagnoses and HIV testing and results. RESULTS Veterans with an STI diagnosis (n = 1815) had higher HIV testing rates than those without (34.9% vs. 7.3%, P<0.0001), but were not more likely to have a positive test result (1.1% vs. 1.4%, P = 0.53). Among Veterans with an STI diagnosis, testing increased from 25% to 45% over the observation period; older age was associated with a lower rate of testing, whereas race and ethnicity, multiple deployments, posttraumatic stress disorder, and substance abuse disorders were associated with a higher rate. CONCLUSIONS AND RELEVANCE Since VHA implemented routine HIV testing, overall rates of testing have increased. However, among Veterans at significant risk for HIV because of an STI diagnosis, only 45% had an HIV test in the most recent year of observation. Other patient characteristics such as alcohol and drug abuse were associated with being tested for HIV. Providers should be reminded that an STI is a sufficient reason to test for HIV.
Collapse
|