Persistent Pain and Comorbidity Among Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn Veterans

Qualitative Evaluation Informs the Implementation of a Telehealth Program to Manage Chronic Pain

In response to the opioid epidemic and high rates of chronic pain among the veteran population, the U.S. Department of Veterans Affairs implemented the TelePain-Empower Veterans Program (EVP), a nonpharmacological pain management program for veterans. Delivered virtually, TelePain-EVP incorporates integrated health components (Whole Health, Acceptance and Commitment Therapy, and Mindful Movement) through interdisciplinary personalized coaching. The objective of this quality improvement project was to evaluate the implementation of TelePain-EVP to identify determinants to implementation, benefits and challenges to participation, and recommendations for future direction. We used a qualitative descriptive design to conduct semistructured telephone interviews with TelePain-EVP leaders (n = 3), staff (n = 10), and veterans (n = 22). The interview guides aligned with the Consolidated Framework for Implementation Research (CFIR). Thematic content analysis organized and characterized findings. Several CFIR domains emerged as determinants relevant to program implementation, including innovation (eg, design); individuals (eg, deliverers, recipients); inner (eg, communications) and outer settings (eg, local conditions); and implementation process (eg, reflecting and evaluating). Identified determinants included facilitators (eg, virtual delivery) and barriers (eg, staff shortages). Participants reported improvements in pain management coping skills, interpersonal relationships, and sense of community, but no self-reported reductions in pain or medication use. Program improvement recommendations included using centralized staff to address vacancies, collecting electronic data, offering structured training, and providing course materials to veteran participants. Qualitative data can inform the sustained implementation of TelePain-EVP and other similar telehealth pain management programs. These descriptive data should be triangulated with quantitative data to objectively assess participant TelePain-EVP outcomes and associated participant characteristics. PERSPECTIVE: A qualitative evaluation of a telehealth program to manage chronic pain, guided by the CFIR framework, identified determinants of program implementation. Additionally, participants reported improvements in pain management coping skills, interpersonal relationships, and sense of community, but no self-reported reductions in pain or medication use.

Development of Chronic Pain Conditions Among Women in the Military Health System

Importance

The incidence of chronic pain has been increasing over the last decades and may be associated with the stress of deployment in active-duty servicewomen (ADSW) as well as women civilian dependents whose spouse or partner served on active duty.

Objective

To assess incidence of chronic pain among active-duty servicewomen and women civilian dependents with service during 2006 to 2013 compared with incidence among like individuals at a time of reduced combat exposure and deployment intensity (2014-2020).

Design, Setting, and Participants

This cohort study used claims data from the Military Health System data repository to identify ADSW and dependents who were diagnosed with chronic pain. The incidence of chronic pain among individuals associated with service during 2006 to 2013 was compared with 2014 to 2020 incidence. Data were analyzed from September 2023 to April 2024.

Main Outcomes and Measures

The primary outcome was the diagnosis of chronic pain. Multivariable logistic regression analyses were used to adjust for confounding, and secondary analyses were performed to account for interactions between time period and proxies for socioeconomic status and combat exposure.

Results

A total of 3 473 401 individuals (median [IQR] age, 29.0 [22.0-46.0] years) were included, with 644 478 ADSW (18.6%). Compared with ADSW in 2014 to 2020, ADSW in 2006 to 2013 had significantly increased odds of chronic pain (odds ratio [OR], 1.53; 95% CI, 1.48-1.58). The odds of chronic pain among dependents in 2006 to 2013 was also significantly higher compared with dependents from 2014 to 2020 (OR, 1.96; 95% CI, 1.93-1.99). The proxy for socioeconomic status was significantly associated with an increased odds of chronic pain (2006-2013 junior enlisted ADSWs: OR, 1.95; 95% CI, 1.83-2.09; 2006-2013 junior enlisted dependents: OR, 3.05; 95% CI, 2.87-3.25).

Conclusions and Relevance

This cohort study found significant increases in the diagnosis of chronic pain among ADSW and civilian dependents affiliated with the military during a period of heightened deployment intensity (2006-2013). The effects of disparate support structures, coping strategies, stress regulation, and exposure to military sexual trauma may apply to both women veterans and civilian dependents.

Massage Therapy Utilization in the Military Health System

INTRODUCTION

Massage therapy is an evidence-based approach for pain management. Information regarding its utilization in the Military Health System (MHS) is lacking. The goal of this study is to evaluate massage therapy utilization patterns across the MHS to include who receives (patient characteristics and diagnoses) and provides (e.g., massage therapists) massage therapy and where (e.g., clinic type).

MATERIALS AND METHODS

Medical record data of adult TRICARE Prime enrollees receiving outpatient massage therapy (Current Procedural Terminology codes: 97124 and 97140) from June 1, 2021, to May 31, 2023, were extracted from the MHS Data Repository. After identifying the index massage therapy visit, records for 6 months pre- and post-index were included. Descriptive statistics described massage therapy utilization patterns overall. Bivariate analysis compared patients who received massage therapy from massage therapists versus nonmassage therapist clinicians.

RESULTS

Of patients who received massage therapy (n = 179,215), the median number of visits was 2 (interquartile range 1 to 4), the median age was 32 years (interquartile range 25 to 40), they were mostly assigned male (72%), White (53%), Senior Enlisted (51%), with a musculoskeletal diagnosis (90%), and recent non-steroidal anti-inflammatory drug (NSAID) prescription (58%). Massage therapy was primarily delivered by physical therapists (49%) in physical therapy clinics (74%). Massage therapists provided 0.2% of massage therapy. Patients who received massage therapy from massage therapists versus nonmassage therapists significantly varied across several patient and care characteristics.

CONCLUSIONS

While massage therapy codes are documented frequently, massage therapists do not commonly provide massage therapy relative to nonmassage therapist providers. Access to massage therapists may be stymied by both lack of massage therapists and need for tertiary pain management referrals to access massage therapist-delivered care. Future research will leverage a health equity framework to (1) evaluate accessibility to massage therapy provided by massage therapists and (2) evaluate real-world evidence of massage therapy effectiveness.

MMPI-2-RF Profiles of Treatment-Seeking Veterans in a VA Pain Clinic and Associations with Markers of Physical Performance

Chronic pain is a debilitating condition for many military Veterans and is associated with posttraumatic stress disorder (PTSD). This study examined the Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) in 144 Veterans (88.2% male, mean age = 57.95 years) recruited from a VA outpatient pain clinic and associations with self-reported pain severity, pain-related interference in daily activities, prescription opioid use, and objective metrics of physical performance on tasks impacted by pain (walking, stair climbing, grip strength, indexed by a single latent variable). Among the cohort with valid responses on the MMPI-2-RF (n = 117) and probable PTSD, mean Somatic Complaints (RC1) and Ideas of Persecution (RC6) scores were clinically elevated. All MMPI-2-RF scales were more strongly correlated with self-reported pain interference than severity. Regressions revealed associations between self-rated pain interference (but not pain or PTSD severity) and physical performance scores (β = .36, p = .001). MMPI-2-RF overreporting Validity and Higher-Order scales contributed incremental variance in predicting physical performance, including Infrequent Psychopathology Responses (β = .33, p = .002). PTSD severity was associated with prescription opioid use when accounting for the effects of over-reported somatic and cognitive symptoms (odds ratio 1.05, p ≤ .025). Results highlight the role of symptom overreporting and perceptions of functional impairment to observable behaviors among individuals with chronic pain.

A network analysis of pain intensity and pain-related measures of physical, emotional, and social functioning in US military service members with chronic pain

OBJECTIVE

The purpose of this study was to apply network analysis methodology to better understand the relationships between pain-related measures among people with chronic pain.

METHODS

We analyzed data from a cross-sectional sample of 4614 active duty service members with chronic pain referred to 1 military interdisciplinary pain management center between 2014 and 2021. Using a combination of Patient-Reported Outcomes Measurement Information System measures and other pain-related measures, we applied the "EBICglasso" algorithm to create regularized partial correlation networks that would identify the most influential measures.

RESULTS

Pain interference, depression, and anxiety had the highest strength in these networks. Pain catastrophizing played an important role in the association between pain and other pain-related health measures. Bootstrap analyses showed that the networks were very stable and the edge weights accurately estimated in 2 analyses (with and without pain catastrophizing).

CONCLUSIONS

Our findings offer new insights into the relationships between symptoms using network analysis. Important findings highlight the strength of association between pain interference, depression and anxiety, which suggests that if pain is to be treated depression and anxiety must also be addressed. What was of specific importance was the role that pain catastrophizing had in the relationship between pain and other symptoms suggesting that pain catastrophizing is a key symptom on which to focus for treatment of chronic pain.

Treating a common comorbidity: Pain outcomes following a 3-week cognitive processing therapy-based intensive treatment for posttraumatic stress disorder address

Posttraumatic stress disorder (PTSD) commonly co-occurs with pain and has been implicated in the maintenance of chronic pain. However, limited research has examined whether intervening for PTSD can hinder or optimize treatment outcomes for co-occurring pain and PTSD. In the present study, we examined changes in pain, PTSD, and depressive symptoms among 125 veterans completing a 3-week cognitive processing therapy (CPT)-based intensive treatment program (ITP) for PTSD. We also explored whether pretreatment pain interference predicted changes in PTSD and depressive symptom severity and whether larger changes in pain interference over the course of treatment were associated with larger changes in PTSD and depressive symptom severity. Linear mixed models revealed that participants' pain interference decreased throughout treatment, d = 0.15, p = .039. Higher levels of pretreatment pain interference were associated with higher PTSD, p = .001, and depressive symptom severity, p = .014, over time. Larger reductions in pain interference corresponded to more improvement in PTSD symptoms, β = -.03; p < .001, but not depressive symptoms. These findings indicate that ITPs for PTSD can reduce pain interferences, albeit to a small degree, and that reductions in pain interference can contribute to reductions in PTSD symptom severity. Future studies should examine which treatment components contribute to larger changes in symptom severity for veterans with co-occurring pain and PTSD.

Well-Being as a predictor of academic success in student veterans and factor validation of the PERMA + 4 well-being measurement scale

Objective: The study sought to test whether well-being predicts academic performance for student service members/veterans (SSM/Vs) and to assess the factor structure of the PERMA + 4 measurement scale for use in this student population. Participants: Post-9/11 SSM/Vs (N = 199) from seven colleges and universities in the U.S. completed an online survey. Methods: A cross-sectional survey research design was used to assess PERMA + 4 and academic success. The PERMA + 4 framework and the measurement scale were examined using confirmatory factor analysis (CFA), and logistic regressions to determine if PERMA + 4 predicted academic performance in SSM/Vs. Results: Findings indicate that PERMA + 4 is a predictor of SSM/Vs academic performance, and CFA confirmed the factor structure of PERMA + 4 for use with SSM/Vs. Conclusions: The findings suggest that screening for the building blocks of well-being in SSM/Vs with a validated and comprehensive multidimensional instrument could be useful for mitigating transition challenges into college life and informing appropriate supports.

Musculoskeletal Pain During Pregnancy Among Veterans: Associations With Health and Health Care Utilization

INTRODUCTION

Musculoskeletal (MSK) pain is more likely to be diagnosed in veterans compared with the general population; however, MSK pain during pregnancy has not been studied in veterans. This study examined health and health care use differences between pregnant veterans with and without MSK pain (MSK-).

METHODS

Veterans who delivered a newborn before June 1, 2021, were identified from an existing cohort (n = 1,181). Survey and Veterans Health Administration (VA) electronic health record data were obtained on participants. Veterans meeting inclusion criteria were identified as those with MSK pain (MSK+) and were compared with MSK- participants. We examined differences between primary outcomes of VA health care engagement (including mental health diagnoses, health care visits, receipt of prescription opioids, and complementary and integrative health use) and secondary outcomes (including postpartum variables) between MSK pain groups. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were calculated.

RESULTS

There were 172 veterans (14.6%) who met MSK pain eligibility criteria. In adjusted models, MSK+ veterans were more likely to be diagnosed with major depressive disorder (aOR, 1.76; 95% CI, 1.22-2.53) and post-traumatic stress disorder (aOR, 1.79; 95% CI, 1.21-2.64) during pregnancy compared with MSK- veterans. The use of VA mental health care (aOR, 1.52; 95% CI, 1.09-2.12) and the odds of receiving an opioid prescription during pregnancy (aOR, 2.76; 95% CI, 1.53-5.00) was higher in MSK+ veterans compared with MSK- veterans. Only a small proportion (3.6%) of our entire cohort used complementary and integrative health approaches during pregnancy. MSK+ veterans were more likely to deliver by cesarean section compared with MSK- veterans (36% vs. 26%).

CONCLUSIONS

MSK+ veterans were more likely to be diagnosed with mental health conditions and to use VA mental health care during pregnancy compared with MSK- veterans. Because veterans receive their obstetrical care in the community, understanding the unique needs of pregnant MSK+ veterans in comparison with MSK- veterans is important to provide comprehensive care during the perinatal period.

Mechanisms and treatments of chronic pain after traumatic brain injury

While pain after trauma generally resolves, some trauma patients experience pain for months to years after injury. An example, relevant to both combat and civilian settings, is chronic pain after traumatic brain injury (TBI). Headache as well as pain in the back and extremities are common locations for TBI-related chronic pain to be experienced. TBI-related pain can exist alone or can exacerbate pain from other injuries long after healing has occurred. Consequences of chronic pain in these settings include increased suffering, higher levels of disability, serious emotional problems, and worsened cognitive deficits. The current review will examine recent evidence regarding dysfunction of endogenous pain modulatory mechanisms, neuroplastic changes in the trigeminal circuitry and alterations in spinal nociceptive processing as contributors to TBI-related chronic pain. Key pain modulatory centers including the locus coeruleus, periaqueductal grey matter, and rostroventromedial medulla are vulnerable to TBI. Both the rationales and existing evidence for the use of monoamine reuptake inhibitors, CGRP antagonists, CXCR2 chemokine receptor antagonists, and interventional therapies will be presented. While consensus guidelines for the management of chronic post-traumatic TBI-related pain are lacking, several approaches to this clinically challenging situation deserve focused evaluation and may prove to be viable therapeutic options.

Association of Chronic Pain With Alcohol Consumption and Tobacco Use in Active Duty Soldiers

INTRODUCTION

Chronic pain and lifestyle habits, namely alcohol consumption and tobacco use, impact soldier readiness. This study examines the relationship between chronic pain and these lifestyle habits in soldiers seen at the Interdisciplinary Pain Management Center (IPMC).

MATERIALS AND METHODS

This cross-sectional retrospective review utilized data from active duty soldiers receiving treatment at the IPMC. Soldiers (N = 203, 85% men) treated at the IPMC completed an intake questionnaire that included the Defense and Veterans Pain Rating Scale, the Alcohol Use Disorders Identification Test-Concise, and inquiries about tobacco use. Tobacco use was quantified as the amount and frequency of cigarettes smoked. Other tobacco products were converted to an equivalent number of cigarettes. Data were analyzed using descriptive statistics, Pearson's correlation, and independent samples t-test analyses.

RESULTS

The mean duration of pain reported was 34.73 ± 38.66 months (median = 24.00). Soldiers engaging in hazardous drinking reported significantly higher interference with sleep (mean = 6.53 versus 5.40, P = .03) and greater negative effect on mood (mean = 6.33 versus 5.30, P = .04) compared to the no hazardous drinking group. Nonsignificant differences were found between tobacco users and non-tobacco users regarding pain intensity and pain effect on activity, sleep, mood, and stress (all P > .05). Among tobacco users, a significant negative correlation was found between a daily number of cigarettes used and sleep interference (r = -0.29, P = .024) as well as effect on mood (r = -0.33, P = .010). Years of tobacco use showed a significant negative correlation with the average pain intensity (r = -0.32, P = .025).

CONCLUSIONS

The results suggest that addressing alcohol consumption is an essential part of chronic pain treatment. The finding of a negative association between years of nicotine use and pain intensity suggests that nicotine use may have served as a coping mechanism. Further research is needed.

Musculoskeletal Injury Concealment in the Reserve Officers' Training Corps: A Survey of Cadets' Reporting Behaviors

BACKGROUND

Among service members, musculoskeletal injuries threaten military readiness and place a substantial burden on medical and financial resources. Emerging research suggests that service members regularly conceal injuries, especially in training environments. The Reserve Officers' Training Corps (ROTC) is a critical training environment for future U.S. military commissioned officers. Training activities expose cadets to a high risk of injury while in the ROTC. The purpose of this study was to explore injury-reporting behaviors in cadets and factors associated with injury concealment.

MATERIALS AND METHODS

We invited Army, Air Force, and Naval cadets from six host universities participating in officer training to complete an online, self-reported survey regarding injury reporting and concealment. Cadets answered questions about pain or injuries experienced during officer training. Survey questions pertained to an injury's anatomic location, onset, severity, functional limitations, and whether or not the injury had been reported. Cadets also selected factors that influenced the decision to report or conceal injuries from predetermined lists in a "choose any" fashion. A series of χ2 tests of independence compared the relationship between injury reporting and other injury characteristics for each individual injury.

RESULTS

One hundred fifty-nine cadets (121 Army, 26 Air Force, and 12 Naval) completed the survey. Eighty-five cadets disclosed a total of 219 injuries. Two-thirds of injuries (144/219) were concealed. Twenty-six percent of participants (22/85) reported all injuries, whereas the remainder (63/85, 74%) had at least one concealed injury. In relation to injury reporting/concealment, there was a weak association with injury onset (χ21 = 4.24, P = .04, V = 0.14), a moderate association with anatomic location (χ212 = 22.64, P = .03, V = 0.32), and relatively strong associations with injury severity (χ23 = 37.79, P < .001, V = 0.42) and functional limitations (χ23 = 42.91, P < .001, V = 0.44).

CONCLUSIONS

Two-thirds of injuries went unreported in this sample of ROTC cadets. Functional limitations, symptom severity, and injury onset may be the largest factors that influence the decision to report or conceal musculoskeletal injuries. This study establishes the foundation for researching injury reporting in cadets and adds to the existing military evidence on the topic.

Empower Veterans Program (EVP): a chronic pain management program demonstrates positive outcomes among veterans

BACKGROUND

Chronic pain is a highly prevalent health condition among veterans. Traditional pharmacological interventions present unique challenges for chronic pain management including prescription opioid addiction and overdose. In alignment with the 2016 Comprehensive Addiction and Recovery Act and VA's Stepped Care Model to meet veterans' pain management needs, the Offices of Rural Health and Pain Management, Opioid Safety, and Prescription Drug Monitoring Program (PMOP) funded an enterprise-wide initiative to implement a Step 3 integrated tele-pain program: Empower Veterans Program (EVP). EVP provides veterans with chronic pain self-care skills using a whole health driven approach to pain management.

OBJECTIVES

The Comprehensive Addiction and Recovery Act prompted the strategic approach to offer non-pharmacological options to meet veterans' pain management needs. EVP, a 10-week interdisciplinary group medical appointment, leverages Acceptance and Commitment Therapy, Mindful Movement, and Whole Health to provide veterans with chronic pain self-care skills. This evaluation was conducted to describe participant characteristics, graduation, and satisfaction rates; and assess pre-post patient-reported outcomes (PRO) associated with EVP participation.

METHODS

A sample of 639 veterans enrolled in EVP between May, 2015 and December, 2017 provided data to conduct descriptive analyses to assess participant demographics, graduation, and satisfaction rates. PRO data were analyzed using a within-participants pre-post design, and linear mixed-effects models were used to examine pre-post changes in PRO.

RESULTS

Of 639 participants, 444 (69.48%) graduated EVP. Participant median program satisfaction rating was 8.41 (Interquartile Range: 8.20-9.20). Results indicate pre-post EVP improvements (Bonferroni-adjusted p < .003) in the three primary pain outcomes (intensity, interference, catastrophizing), and 12 of 17 secondary outcomes, including physical, psychological, health-related quality of life (HRQoL), acceptance, and mindfulness measures.

DISCUSSION

Data suggest that EVP has significant positive outcomes in pain, psychological, physical, HRQoL, acceptance, and mindfulness measures for veterans with chronic pain through non-pharmacological means. Future evaluations of intervention dosing effect and long-term effectiveness of the program is needed.

Neuroendocrine and neuroimmune mechanisms underlying comorbidity of pain and obesity

Pain and obesity, as well as their associated impairments, are major health concerns. Understanding the relationship between the two is the focus of a growing body of research. However, early researches attribute increased mechanical stress from excessive weight as the main factor of obesity-related pain, which not only over-simplify the association, but also fail to explain some controversial outcomes arising from clinical investigations. This review focuses on neuroendocrine and neuroimmune modulators importantly involved in both pain and obesity, analyzing nociceptive and anti-nociceptive mechanisms based on neuroendocrine pathways including galanin, ghrelin, leptin and their interactions with other neuropeptides and hormone systems which have been reported to play roles in pain and obesity. Mechanisms of immune activities and metabolic alterations are also discussed, due to their intense interactions with neuroendocrine system and crucial roles in the development and maintenance of inflammatory and neuropathic pain. These findings have implications for health given rising rates of obesity and pain-related diagnoses, by providing novel weight-control and analgesic therapies targeted on specific pathways.

The Role of Psychological Factors in Chronic Pain Treatment Outcomes in the Military

PURPOSE

Chronic pain treatment in the military includes complementary and integrative health (CIH) therapies that may affect psychological factors such as pain catastrophizing, chronic pain acceptance, pain self-efficacy, and patient activation. The unique roles that psychosocial factors play in how CIH approaches reduce pain are not clear. This study examined if a holistic pain management program improved pain outcomes through psychological mediators in service members with chronic pain.

DESIGN

Secondary analysis of a clinical trial.

METHODS

Active-duty service members (n = 210) were randomly assigned to a 3-week course of standard rehabilitative care or standard rehabilitative care combined with CIH therapies. Both treatments were followed by a 3-week functional restoration program. Study measures were completed pre- and post-treatment using the Military Health System's Pain Assessment Screening Tool and Outcomes Registry. Mediation analyses tested the indirect effects of the change in psychological factors before functional restoration on the change in pain impact (e.g., pain intensity, pain interference, functional status) after functional restoration.

RESULTS

All psychological factors except for chronic pain acceptance were related to improved pain impact (p<.05). Furthermore, a change in psychological factors prior to functional restoration was related to the change in pain impact after functional restoration. However, the addition of CIH therapies to standard rehabilitative care did not result in changes in pain outcomes mediated by the psychological factors.

CONCLUSIONS

Although psychological factors were related to pain outcomes, the effect of CIH therapies on chronic pain did not occur via a change in the four psychological factors.

Patterns of Change in Pain-related Physical, Mental, and Social Health Outcomes in a Military Population

OBJECTIVE

Military persons frequently experience pain conditions stemming from noncombat and combat injuries. This study assessed the patterns of change over time and the associations of pain intensity and interference with physical, mental, and social health domains in a military sample.

METHODS

A secondary analysis of Pain Assessment Screening Tool and Outcomes Registry (PASTOR) was conducted using data collected over 10 months. Participants selected for analysis completed ≥3 assessments with an interval of ≥14 days between assessments. The Defense and Veterans Pain Rating Scale (DVPRS) measured average and worst pain intensity, and Patient-Reported Outcomes Measurement Information System (PROMIS®) T-scores measured pain and health outcomes.

RESULTS

The sample (N = 190) majority reported being active duty (96%); serving in the U.S. Army (93%); and being enlisted (86%). The percent difference from assessment one to assessment three showed improvement for DVPRS average pain (-4.85%) and worst pain (-2.16%), and PROMIS Pain Interference T-score (-1.98%). Improvements were observed for all PROMIS outcomes except depression. The Defense and Veterans Pain Rating Scale average and worst pain intensity and PROMIS pain interference were strongly correlated with physical function. Multilevel models showed that an increase in average and worst pain, and pain interference were associated with a decrease in satisfaction with social roles.

CONCLUSION

Analysis identified patterns of change over time in physical, mental, and social health outcomes, as well as associations important to understanding the complexities of pain. This work has implications for pain management nursing in ambulatory settings where ongoing collection and analyses of multivariable outcomes data can inform clinical care.

The Imbalance of Astrocytic Mitochondrial Dynamics Following Blast-Induced Traumatic Brain Injury

Mild blast-induced traumatic brain injury (bTBI) is a modality of injury that has been of major concern considering a large number of military personnel exposed to explosive blast waves. bTBI results from the propagation of high-pressure static blast forces and their subsequent energy transmission within brain tissue. Exposure to this overpressure energy causes a diffuse injury that leads to acute cell damage and, if chronic, leads to detrimental long-term cognitive deficits. The literature presents a neuro-centric approach to the role of mitochondria dynamics dysfunction in bTBI, and changes in astrocyte-specific mitochondrial dynamics have not been characterized. The balance between fission and fusion events is known as mitochondrial dynamics. As a result of fission and fusion, the mitochondrial structure is constantly altering its shape to respond to physiological stimuli or stress, which in turn affects mitochondrial function. Astrocytic mitochondria are recognized to play an essential role in overall brain metabolism, synaptic transmission, and neuron protection. Mitochondria are vulnerable to injury insults, leading to the increase in mitochondrial fission, a mechanism controlled by the GTPase dynamin-related protein (Drp1) and the phosphorylation of Drp1 at serine 616 (p-Drp1^s616). This site is critical to mediate the Drp1 translocation to mitochondria to promote fission events and consequently leads to fragmentation. An increase in mitochondrial fragmentation could have negative consequences, such as promoting an excessive generation of reactive oxygen species or triggering cytochrome c release. The aim of the present study was to characterize the unique pattern of astrocytic mitochondrial dynamics by exploring the role of DRP1 with a combination of in vitro and in vivo bTBI models. Differential remodeling of the astrocytic mitochondrial network was observed, corresponding with increases in p-Drp1^S616 four hours and seven days post-injury. Further, results showed a time-dependent reactive astrocyte phenotype transition in the rat hippocampus. This discovery can lead to innovative therapeutics targets to help prevent the secondary injury cascade after blast injury that involves mitochondria dysfunction.

Complementary Approaches for Military Women with Chronic Pelvic Pain: A Randomized Trial

Introduction: Active duty (AD) women suffer with chronic pelvic pain (CPP) while providers tackle diagnoses and treatments to keep them functional without contributing to the opioid epidemic. The purpose of this randomized trial was to determine the effectiveness of noninvasive, self-explanatory mindfulness-based stress reduction (MBSR) or self-paced healthy lifestyle (HL) interventions on CPP in AD women. Methods: A 6-week, interventional prospective study with AD women aged 21-55 years at Mountain Home (MTHM), Idaho, was conducted. Women were randomly assigned to MBSR (N = 21) or HL (N = 20) interventions. The primary outcome was pain perception. The secondary outcomes were depression and circulating cytokine levels. Results: Women in the MBSR group exhibited reduced pain interference (p < 0.01) and depression (p < 0.05) alongside decreased interleukin (IL)-4 (p < 0.05), IL-6 (p < 0.05), eotaxin (p < 0.05), monocyte chemoattractant protein-1 (p = 0.06), and interleukin-1 receptor antagonist (IL-1ra) (p < 0.01) and increased vascular endothelial growth factor (p < 0.05). Women in the HL group did not have changes in pain; however, they did exhibit reduced depression (p < 0.05) alongside decreased granulocyte-macrophage colony-stimulating factor (p < 0.05) and increased tumor necrosis factor alpha (p < 0.05), stromal cell-derived factor-1 (p < 0.01), and IL-1ra (p < 0.01). Conclusions: AD women receiving MBSR or HL had reduced depression scores and altered circulating cytokine levels; however, only those receiving MBSR had reduced pain perception. Findings support MBSR as an effective and viable behavioral treatment for AD women suffering from CPP and provide premise for larger randomized controlled studies. Clinical Trial Registration: MOCHI-An RCT of mindfulness as a treatment for CPP in AD Women NCT04104542 (September 26, 2019).

Non-pharmacological Treatment for Chronic Pain in US Veterans Treated Within the Veterans Health Administration: Implications for Expansion in US Healthcare Systems

BACKGROUND

Consensus guidelines recommend multimodal chronic pain treatment with increased use of non-pharmacological treatment modalities (NPM), including as first-line therapies. However, with many barriers to NPM uptake in US healthcare systems, NPM use may vary across medical care settings. Military veterans are disproportionately affected by chronic pain. Many veterans receive treatment through the Veterans Health Administration (VHA), an integrated healthcare system in which specific policies promote NPM use.

OBJECTIVE

To examine whether veterans with chronic pain who utilize VHA healthcare were more likely to use NPM than veterans who do not utilize VHA healthcare.

DESIGN

Cross-sectional nationally representative study.

PARTICIPANTS

US military veterans (N = 2,836).

MAIN MEASURES

In the 2019 National Health Interview Survey, veterans were assessed for VHA treatment, chronic pain (i.e., past 3-month daily or almost daily pain), symptoms of depression and anxiety, substance use, and NPM (i.e., physical therapy, chiropractic/spinal manipulation, massage, psychotherapy, educational class/workshop, peer support groups, or yoga/tai chi).

KEY RESULTS

Chronic pain (45.2% vs. 26.8%) and NPM use (49.8% vs. 39.4%) were more prevalent among VHA patients than non-VHA veterans. After adjusting for sociodemographic characteristics, psychiatric symptoms, physical health indicators, and use of cigarettes or prescription opioids, VHA patients were more likely than non-VHA veterans to use any NPM (adjusted odds ratio [aOR] = 1.52, 95% CI: 1.07-2.16) and multimodal NPM (aOR = 1.80, 95% CI: 1.12-2.87) than no NPM. Among veterans with chronic pain, VHA patients were more likely to use chiropractic care (aOR = 1.90, 95% CI = 1.12-3.22), educational class/workshop (aOR = 3.02, 95% CI = 1.35-6.73), or psychotherapy (aOR = 4.28, 95% CI = 1.69-10.87).

CONCLUSIONS

Among veterans with chronic pain, past-year VHA use was associated with greater likelihood of receiving NPM. These findings may suggest that the VHA is an important resource and possible facilitator of NPM. VHA policies may offer guidance for expanding use of NPM in other integrated US healthcare systems.

Weight-centric treatment of depression and chronic pain

Background

Depression and chronic pain are two major chronic non-communicable diseases (CNCD). Considering the bidirectional relationship between obesity and CNCD, it is of the utmost importance to understand the effect of medications utilized to treat these diseases on body weight.

Methods

This is a clinical review on the effect of medications for depression and chronic pain on body weight. We searched PubMed, Scopus, MEDLINE, and Google Scholar databases for studies on the topic from January 1, 1950 to April 1, 2022 in English language. Additionally, we present expert opinions in the fields of obesity, depression and chronic pain, providing a weight-centric approach to treat depression and chronic pain.

Results

Several antidepressant and chronic pain medications are associated with weight gain. Selective serotonin reuptake inhibitors, serotonin and norepinephrine reuptake inhibitors, tricyclic antidepressants, monoamine oxidases, mirtazapine and trazodone are common antidepressants that can increase body weight while bupropion is significantly associated with weight loss. Gabapentin and pregabalin are common chronic pain medications that are linked to weight gain. On the other hand, topiramate is associated with significant weight loss. Obesity, depression and chronic pain experts recommend avoiding medications that can increase body weight if another effective alternative is available.

Conclusion

By shifting prescribing practices toward a weight-conscious approach (i.e., switching from weight gain medications to weight loss/neutral), it is possible to mitigate the incidence of drug-induced weight gain.

Activation of the Locus Coeruleus Mediated by Designer Receptor Exclusively Activated by Designer Drug Restores Descending Nociceptive Inhibition after Traumatic Brain Injury in Rats

Disruption of endogenous pain control mechanisms including descending pain inhibition has been linked to several forms of pain including chronic pain after traumatic brain injury (TBI). The locus coeruleus (LC) is the principal noradrenergic (NA) nucleus participating in descending pain inhibition. We therefore hypothesized that selectively stimulating LC neurons would reduce nociception after TBI. All experiments used a well-characterized rat lateral fluid percussion model of TBI. NA neurons were stimulated by administering clozapine N-oxide (CNO) to rats selectively expressing a designer receptor exclusively activated by designer drug (DREADD) viral construct in their LC's. Mechanical nociceptive thresholds were measured using von Frey fibers. The efficacy of diffuse noxious inhibitory control (DNIC), a critical endogenous pain control mechanism, was assessed using the hindpaw administration of capsaicin. Immunohistochemical analyses demonstrated the selective expression of the DREADD construct in LC neurons after stereotactic injection. During the 1st week after TBI, when rats demonstrated hindlimb (HL) nociceptive sensitization, CNO administration provided transient anti-allodynia in DREADD-expressing rats but not in rats injected with control virus. Seven weeks after TBI we observed a complete loss of DNIC in response to capsaicin. However, CNO administration largely restored DNIC in TBI DREADD-expressing rats but not those injected with control virus. Unexpectedly, the effects of LC activation in the DREADD-expressing rats were blocked by the α-1 adrenergic receptor antagonist prazosin, but not the α-2 adrenergic receptor antagonist atipamezole. These results suggest that directly stimulating the LC after TBI can reduce both early and late manifestations of dysfunctional endogenous pain regulation. Clinical approaches to activating descending pain circuits may reduce suffering in those with pain after TBI.

Measuring pain care quality in the Veterans Health Administration primary care setting

ABSTRACT

The lack of a reliable approach to assess quality of pain care hinders quality improvement initiatives. Rule-based natural language processing algorithms were used to extract pain care quality (PCQ) indicators from documents of Veterans Health Administration primary care providers for veterans diagnosed within the past year with musculoskeletal disorders with moderate-to-severe pain intensity across 2 time periods 2013 to 2014 (fiscal year [FY] 2013) and 2017 to 2018 (FY 2017). Patterns of documentation of PCQ indicators for 64,444 veterans and 124,408 unique visits (FY 2013) and 63,427 veterans and 146,507 visits (FY 2017) are described. The most commonly documented PCQ indicators in each cohort were presence of pain, etiology or source, and site of pain (greater than 90% of progress notes), while least commonly documented were sensation, what makes pain better or worse, and pain's impact on function (documented in fewer than 50%). A PCQ indicator score (maximum = 12) was calculated for each visit in FY 2013 (mean = 7.8, SD = 1.9) and FY 2017 (mean = 8.3, SD = 2.3) by adding one point for every indicator documented. Standardized Cronbach alpha for total PCQ scores was 0.74 in the most recent data (FY 2017). The mean PCQ indicator scores across patient characteristics and types of healthcare facilities were highly stable. Estimates of the frequency of documentation of PCQ indicators have face validity and encourage further evaluation of the reliability, validity, and utility of the measure. A reliable measure of PCQ fills an important scientific knowledge and practice gap.

The Lived Experience of Military Women With Chronic Pain: A Phenomenological Study

Introduction

Chronic pain, a persistent or recurrent pain lasting more than 3 months, is a widespread problem among military women due to combat-related injuries and post-deployment stressors. Risk factors associated with chronic pain include gender, mental health, post-traumatic stress disorder, and prior physical or military sexual trauma. The most common prevalence of chronic pain is musculoskeletal (e.g., low back and neck), migraine, osteoarthritis, and fibromyalgia. Following deployment, 25% of military women are at risk for chronic pain. Military women are prescribed opioids for pain at a higher rate than men and are at risk for prescription opioid addiction. The unique medical needs of military women, including chronic pain, are poorly understood by health care providers and need to be addressed to achieve full integration into the military. The purpose of this study was to explore a typical day for military women living with chronic pain by examining the participants’ daily life experiences.

Material and Methods

Using van Manen’s approach, 13 active duty, retired, and veteran women were interviewed to explore these lived experiences. The study was approved by the Institutional Review Board at the University of San Diego.

Results

Eight themes emerged from an analysis of the participants’ experiences: (1) chronic pain is a frustrating, persistent, daily, and an hourly struggle; (2) resilience in living with chronic pain is the new normal; (3) mission first and the impact of invisible pain; (4) self-care management and internal locus of control with nonpharmacological therapies; (5) pain accepted and managed to improve quality of life; (6) coronavirus disease 2019 (COVID-19) diminished social interactions; (7) pain of sexual trauma is not reported; and (8) disparities in health care due to self-perception of provider bias as pain is not understood.

Conclusions

The study generated new knowledge in Force Health Protection, ensuring (1) a fit and operational readiness force; (2) pre- to post-deployment care for women warriors; and (3) access to health care. The study findings supported previous research and could help direct future research into nursing, medicine, and allied health treatments for military and veterans’ gender-specific health care, education, and training. Furthermore, the military women in this study provided insight into the need for future research to explore unconscious gender bias, health disparities, and a raised awareness of military women living with chronic pain. Findings from this study merit further exploration using other qualitative research methodologies including mixed methods.

Understanding Pain and Trauma Symptoms in Veterans From Resting-State Connectivity: Unsupervised Modeling

Trauma and posttraumatic stress are highly comorbid with chronic pain and are often antecedents to developing chronic pain conditions. Pain and trauma are associated with greater utilization of medical services, greater use of psychiatric medication, and increased total cost of treatment. Despite the high overlap in the clinic, the neural mechanisms of pain and trauma are often studied separately. In this study, resting-state functional magnetic resonance imaging (rs-fMRI) scans were completed among a diagnostically heterogeneous sample of veterans with a range of back pain and trauma symptoms. Using Group Iterative Multiple Model Estimation (GIMME), an effective functional connectivity analysis, we explored an unsupervised model deriving subgroups based on path similarity in a priori defined regions of interest (ROIs) from brain regions implicated in the experience of pain and trauma. Three subgroups were identified by patterns in functional connection and differed significantly on several psychological measures despite similar demographic and diagnostic characteristics. The first subgroup was highly connected overall, was characterized by functional connectivity from the nucleus accumbens (NAc), the anterior cingulate cortex (ACC), and the posterior cingulate cortex (PCC) to the insula and scored low on pain and trauma symptoms. The second subgroup did not significantly differ from the first subgroup on pain and trauma measures but was characterized by functional connectivity from the ACC and NAc to the thalamus and from ACC to PCC. The third subgroup was characterized by functional connectivity from the thalamus and PCC to NAc and scored high on pain and trauma symptoms. Our results suggest that, despite demographic and diagnostic similarities, there may be neurobiologically dissociable biotypes with different mechanisms for managing pain and trauma. These findings may have implications for the determination of appropriate biotype-specific interventions that target these neurological systems.

Early Relationships of a Low-Energy Diet With Symptoms of Fibromyalgia

OBJECTIVE

Previous studies have demonstrated that weight loss has been shown to improve pain in weight-bearing joints, and more recent studies suggest that weight loss may be accompanied by improvements in pain in non-weight-bearing regions. In previous work, we demonstrated that these symptoms improve substantially in patients with obesity undergoing 12 weeks of a very low-energy diet (VLED) restricted to 800 kcal as part of a weight-loss program. Preclinical models also have shown analgesic effects of calorie restriction. The purpose of the current observational study was to determine the time course and trajectory of improvement in pain and other symptoms, especially during the early phase of a VLED intervention, prior to major weight loss.

METHODS

Participants were 195 individuals with obesity who had elevated levels of pain and associated symptoms at baseline (score of ≥4 on Fibromyalgia Survey Criteria) and completed a minimum of 3 weeks of a VLED intervention. The primary outcome was improvement in Fibromyalgia Survey Criteria at week 3. In secondary analyses, we created groups of those showing little/no improvement, moderate improvement, and high improvement (little/no improvement mean, 2.21; SD, 1.02; moderate improvement mean, 2.25; SD, 0.81; high improvement mean, 2.42; SD, 0.95; F2,189  = 1.01, P = 0.37), then compared baseline characteristics.

RESULTS

A large proportion of study participants (72%) experienced symptom reductions of 30% or greater by week 3, but there were no differences in the amount of weight lost at this time point. Those who showed little or no improvement (less than 30%) had a higher body mass index at baseline and were more likely to report a diagnosis of depression (both P < 0.05).

CONCLUSION

This degree of improvement after 3 weeks of a VLED is encouraging. These findings help establish the temporal pattern of symptom improvement associated with caloric restriction and suggest that the palliative effects of this diet are at least partly due to the diet itself, rather than the weight loss that ensues.

Engaging Education About Risks of Opioid Use With Patients Before Elective Surgery of the Lower Extremity Did Not Reduce Postoperative Opioid Utilization: A Randomized Controlled Trial

INTRODUCTION

After elective orthopaedic surgery, many individuals go on to become long-term opioid users. Mitigating this risk has become a priority for surgeons, other members of the medical care team, and healthcare systems. The purpose of this study was to compare opioid utilization after lower extremity orthopaedic surgery between patients who received an interactive video education session highlighting the risks of opioid use and those who did not.

METHODS

Patients undergoing elective surgery of the lower extremity in the orthopaedic clinic at the Brooke Army Medical Center between July 2015 and February 2017 were recruited at their preoperative appointment and randomized in a 1:1 ratio to receive a one-time interactive opioid education session or usual care education. Unique days' supply of opioids and unique prescriptions were compared using a generalized linear model. Individuals were also grouped by whether they had become long-term opioid users after surgery, and frequencies within each intervention group were compared.

RESULTS

There were 120 patients, 60 randomized to each group and followed for 1 year. There were no significant differences between opioid days' supply (mean diff = 8.33, 95% confidence interval -4.21 to 20.87) and unique prescriptions after surgery (mean diff = 0.45, 95% confidence interval -0.25 to 1.15). Most participants did not have any opioids past the initial 30 days after surgery, regardless of intervention (n = 77), and only three became long-term opioid users (one in usual care and two in interactive education). Sixteen in usual education and 18 in enhanced education filled at least one prescription in 6 months or later after the surgical procedure.

CONCLUSION

Opioid use beyond 30 days of surgery was no different for participants who received enhanced education compared with usual education. Few became long-term opioid users after surgery (2.5%), although 28.3% were still filling opioid prescriptions 6 months after surgery.

Associations between residual hyperarousal and insomnia symptoms in veterans following a 2-week intensive outpatient program for posttraumatic stress disorder

Many returning military service members and veterans who were deployed following the September 11, 2001, terrorist attacks (9/11) suffer from posttraumatic stress disorder (PTSD) and insomnia. Although intensive treatment programs for PTSD have shown promise in the treatment of PTSD symptoms, recent research has demonstrated that sleep disturbance shows little improvement following intensive trauma-focused treatment. The aim of the present study was to evaluate changes in self-reported insomnia symptoms among veterans and service members following participation in a 2-week intensive program for PTSD. We further aimed to investigate if residual PTSD symptoms, specifically hyperarousal, were associated with residual insomnia symptoms. Participants (N = 326) completed self-report assessments of insomnia, PTSD symptoms, and depressive symptoms at pre- and posttreatment. At pretreatment, 73.9% of participants (n = 241) met the criteria for moderate or severe insomnia, whereas at posttreatment 67.7% of participants (n = 203) met the criteria. Results of paired t tests demonstrated statistically significant differences between pre- and posttreatment Insomnia Severity Index scores; however, the effect size was small, d = 0.34. Analyses revealed that posttreatment hyperarousal symptoms were associated with posttreatment insomnia. These findings suggest that although an intensive program for service members and veterans with PTSD may significantly reduce insomnia symptoms, clinically meaningful residual insomnia symptoms remain. Further research is warranted to elucidate the association between residual hyperarousal and insomnia symptoms following intensive trauma-focused treatment.

Anxiety and depressive symptoms among adults with obesity and chronic pain: the role of anxiety sensitivity

Obesity and chronic pain frequently co-occur, and this co-occurrence can have potential negative consequences, particularly as it relates to mental health. As such, there is a need to understand potential risk factors for poor mental health among this co-morbid population. Thus, the current study examined the predictive role of anxiety sensitivity (and its sub-facets) on anxiety and depressive symptoms among adults (82.5% female, M_age = 40.2 years, SD = 10.92) with obesity and chronic pain. Results revealed that greater levels of anxiety sensitivity were associated with greater levels of both anxiety and depressive symptoms, with medium to large effect sizes. Post hoc analyses also indicated that specific sub-facets of anxiety sensitivity (cognitive and social concerns) were significant predictors of the criterion variables. The current study highlights the potential clinical utility in targeting anxiety sensitivity among individuals with co-occurring obesity and chronic pain in the treatment of anxiety and depressive symptoms.

Risk factors associated with healthcare utilization for spine pain

OBJECTIVE

This study examined potential risk factors associated with healthcare utilization among patients with spine (i.e., neck and back) pain.

METHODS

A two-stage sampling approach examined spine pain episodes of care among veterans with a yearly outpatient visit for six consecutive years. Descriptive and bivariate statistics, followed by logistic regression analyses, examined baseline characteristics of veterans with new episodes of care who either continued or discontinued spine pain care. A multivariable logistic regression model examined correlates associated with seeking continued spine pain care.

RESULTS

Among 331,908 veterans without spine pain episodes of care during the two-year baseline observation period, 16.5% (n = 54,852) had a new episode of care during the following two-year observation period. Of those 54,852 veterans, 37,025 had an outpatient visit data during the final two-year follow-up period, with 53.7% (n = 19,865) evidencing continued spine pain care. Those with continued care were more likely to be overweight or obese, non-smokers, Army veterans, have higher education, and had higher rates of diagnoses of all medical and mental health conditions examined at baseline. Among several important findings, women had 13% lower odds of continued care during the final two-year observation period, OR 0.87 (0.81, 0.95).

CONCLUSIONS

A number of important demographics and clinical correlates were associated with increased likelihood of seeking new and continued episodes of care for spine pain; however, further examination of risk factors associated with healthcare utilization for spine pain is indicated.

Does Engaging Patients with Relevant Education About Long-Term Opioid Use Before Spine Surgery Affect Long-term Opioid Use? A Randomized Controlled Trial

STUDY DESIGN

Parallel-arm randomized controlled trial.

OBJECTIVE

To assess the effectiveness of an enhanced video education session highlighting risks of opioid utilization on longterm opioid utilization after spine surgery.

SUMMARY OF BACKGROUND DATA

Long-term opioid use occurs in more than half of patients undergoing spine surgery and strategies to reduce this use are needed.

METHODS

Patients undergoing spine surgery at Brooke Army Medical Center between July 2015 and February 2017 were recruited at their preoperative appointment, receiving the singlesession interactive video education or control at that same appointment. Opioid utilization was tracked for the full year after surgery from the Pharmacy Data Transaction Service of the Military Health System Data Repository. Self-reported pain also collected weekly for 1 and at 6months.

RESULTS

A total of 120 participants (40 women, 33.3%) with a mean age of 45.9 ± 10.6 years were randomized 1:1 to the enhanced education and usual care control (60 per group). In the year following surgery the cohort had a mean 5.1 (standard deviation [SD] 5.9) unique prescription fills, mean total days' supply was 88.3 (SD 134.9), and mean cumulative morphine milligrams equivalents per participant was 4193.0 (SD 12,187.9) within the year after surgery, with no significant differences in any opioid use measures between groups. Twelve individuals in the standard care group and 13 in the enhanced education group were classified with having long-term opioid utilization.

CONCLUSION

The video education session did not influence opioid use after spine surgery compared to the usual care control. There was no significant difference in individuals classified as long-term opioid users after surgery based on the intervention group. Prior opioid use was a strong predictor of future opioid use in this cohort. Strategies to improve education engagement, understanding, and decision- making continue to be of high importance for mitigating risk of long-term opioid use after spine surgery.Level of Evidence: 1.

Chronic Anxiety- and Depression-Like Behaviors Are Associated With Glial-Driven Pathology Following Repeated Blast Induced Neurotrauma

Long-term neuropsychiatric impairments have become a growing concern following blast-related traumatic brain injury (bTBI) in active military personnel and Veterans. Neuropsychiatric impairments such as anxiety and depression are common comorbidities that Veterans report months, even years following injury. To understand these chronic behavioral outcomes following blast injury, there is a need to study the link between anxiety, depression, and neuropathology. The hippocampus and motor cortex (MC) have been regions of interest when studying cognitive deficits following blast exposure, but clinical studies of mood disorders such as major depressive disorder (MDD) report that these two regions also play a role in the manifestation of anxiety and depression. With anxiety and depression being common long-term outcomes following bTBI, it is imperative to study how chronic pathological changes within the hippocampus and/or MC due to blast contribute to the development of these psychiatric impairments. In this study, we exposed male rats to a repeated blast overpressure (~17 psi) and evaluated the chronic behavioral and pathological effects on the hippocampus and MC. Results demonstrated that the repeated blast exposure led to depression-like behaviors 36 weeks following injury, and anxiety-like behaviors 2-, and 52-weeks following injury. These behaviors were also correlated with astrocyte pathology (glial-fibrillary acid protein, GFAP) and dendritic alterations (Microtubule-Associated Proteins, MAP2) within the hippocampus and MC regions at 52 weeks. Overall, these findings support the premise that chronic glial pathological changes within the brain contribute to neuropsychiatric impairments following blast exposure.

Justice and equity in pragmatic clinical trials: Considerations for pain research within integrated health systems

Introduction

Methods

Results

Conclusions

Women Veterans' Experiences with Integrated, Biopsychosocial Pain Care: A Qualitative Study

OBJECTIVES

Biopsychosocial, integrated pain care models are increasingly implemented in the Veterans Health Administration to improve chronic pain care and reduce opioid-related risks, but little is known about how well these models address women veterans' needs.

DESIGN

Qualitative, interview-based study.

SETTING

San Francisco VA Health Care System Integrated Pain Team (IPT), an interdisciplinary team that provides short-term, personalized chronic pain care emphasizing functional goals and active self-management.

SUBJECTS

Women with chronic pain who completed ≥3 IPT sessions.

METHODS

Semistructured phone interviews focused on overall experience with IPT, perceived effectiveness of IPT care, pain care preferences, and suggested changes for improving gender-sensitive pain care. We used a rapid approach to qualitative thematic analysis to analyze interviews.

RESULTS

Fourteen women veterans (mean age 51 years; range 33-67 years) completed interviews. Interviews revealed several factors impacting women veterans' experiences: 1) an overall preference for receiving both primary and IPT care in gender-specific settings, 2) varying levels of confidence that IPT could adequately address gender-specific pain issues, 3) barriers to participating in pain groups, and 4) barriers to IPT self-management recommendations due to caregiving responsibilities.

CONCLUSIONS

Women veterans reported varied experiences with IPT. Recommendations to improve gender-sensitive pain care include increased provider training; increased knowledge of and sensitivity to women's health concerns; and improved accommodations for prior trauma, family and work obligations, and geographic barriers. To better meet the needs of women veterans with chronic pain, integrated pain care models must be informed by an understanding of gender-specific needs, challenges, and preferences.

Correlates of sleep disturbance in Veterans with traumatic brain injury and chronic pain: A cross-sectional study

BACKGROUND

Few studies have investigated sleep in Veterans with comorbid traumatic brain injury (TBI) and chronic pain.

OBJECTIVE

To describe mood and cognitive correlates with sleep disturbance in a sample of Veterans with both TBI and chronic pain.

RESEARCH METHOD

Cross-sectional, correlational analyses were completed using baseline data from a randomized controlled trial comparing psychosocial treatments for pain in Veterans with TBI. Enrollment occurred between July 2015 and January 2017. Self-report measures of hours slept, insomnia severity, depression and PTSD symptoms were collected along with a brief neuropsychological assessment.

RESULTS

Participants (n = 221) were an average age of 37.2 years (SD = 8.2) and mostly male (89%). Participants reported sleeping an average of 4.9 h a night (SD = 1.4) with an average Insomnia Severity Index (ISI) score of 17.4 (SD = 5.4) suggesting moderate insomnia symptoms. Fewer hours slept was associated with higher depression scores (r = -0.28, p < 0.001) and slower processing speed (r = 0.23, p < 0.001). Increasing insomnia severity was associated with greater depression (r = 0.57, p < 0.001) and PTSD symptoms (r = 0.44, p < 0.001), and slower processing speed (r = -0.22, p < 0.001).

CONCLUSIONS

The average ISI score was above the clinical cut off for insomnia diagnosis. Results suggest that those with more severe insomnia symptoms report higher depression and PTSD symptoms as well as exhibit slower processing speed. Improving sleep in this population may be important for improving outcome following TBI.

Obstructive Sleep Apnea and Pain Intensity in Young Adults

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.

Comparative Analysis of Health Domains for Neuropathic Pain Patients

Active duty military members have significant service-related risks for developing pain from injury. Although estimates for neuropathic pain (NP) are available for civilian populations, the incidence and prevalence for NP in military members is less clear. Understanding correlates of pain in military members is vital to improving their physical, mental, and social health. Using a comparative design, a secondary analysis was conducted on longitudinal PASTOR data from 190 pain management center patients. The objectives were to compare trends in patient-reported outcomes over time between those screening positive and negative for NP (NP+, NP-, respectively) based on PROMIS Neuropathic Pain Scale T-scores. Findings showed improvements in fatigue, sleep-related impairment, and anger over time. There was a difference between those screening NP+ and NP- for sleep-related impairment, and the cross-level interaction effect showed sleep-related impairment worsening over time. These results emphasize the need to identify NP and implement and evaluate targeted therapies.

Predictors of Veterans Health Administration utilization and pain persistence among soldiers treated for postdeployment chronic pain in the Military Health System

BACKGROUND

Chronic pain presents a significant burden for both federal health care systems designed to serve combat Veterans in the United States (i.e., the Military Health System [MHS] and Veterans Health Administration [VHA]), yet there have been few studies of Veterans with chronic pain that have integrated data from both systems of care. This study examined 1) health care utilization in VHA as an enrollee (i.e., linkage to VHA) after military separation among soldiers with postdeployment chronic pain identified in the MHS, and predictors of linkage, and 2) persistence of chronic pain among those utilizing the VHA.

METHODS

Observational, longitudinal study of soldiers returning from a deployment in support of the Afghanistan/Iraq conflicts in fiscal years 2008-2014. The analytic sample included 138,206 active duty soldiers for whom linkage to VHA was determined through FY2019. A Cox proportional hazards model was estimated to examine the effects of demographic characteristics, military history, and MHS clinical characteristics on time to linkage to VHA after separation from the military. Among the subpopulation of soldiers who linked to VHA, we described whether they met criteria for chronic pain in the VHA and pain management treatments received during the first year in VHA.

RESULTS

The majority (79%) of soldiers within the chronic pain cohort linked to VHA after military separation. Significant predictors of VHA linkage included: VHA utilization as a non-enrollee prior to military separation, separating for disability, mental health comorbidities, and being non-Hispanic Black or Hispanic. Soldiers that separated because of misconduct were less likely to link than other soldiers. Soldiers who received nonpharmacological treatments, opioids/tramadol, or mental health treatment in the MHS linked earlier to VHA than soldiers who did not receive these treatments. Among those who enrolled in VHA, during the first year after linking to the VHA, 49.7% of soldiers met criteria for persistent chronic pain in VHA.

CONCLUSIONS

The vast majority of soldiers identified with chronic pain in the MHS utilized care within VHA after military separation. Careful coordination of pain management approaches across the MHS and VHA is required to optimize care for soldiers with chronic pain.

Associations between obstructive sleep apnea and prescribed opioids among veterans

ABSTRACT

Sleep disruption caused by obstructive sleep apnea (OSA) may be associated with hyperalgesia and may contribute to poor pain control and use of prescription opioids. However, the relationship between OSA and opioid prescription is not well described. We examine this association using cross-sectional data from a national cohort of veterans from recent wars enrolled from October 1, 2001 to October 7, 2014. The primary outcome was the relative risk ratio (RRR) of receiving opioid prescriptions for acute (<90 days/year) and chronic (≥90 days/year) durations compared with no opioid prescriptions. The primary exposure was a diagnosis of OSA. We used multinomial logistic regression to control for factors that may affect diagnosis of OSA or receipt of opioid prescriptions. Of the 1,149,874 patients (mean age 38.0 ± 9.6 years) assessed, 88.1% had no opioid prescriptions, 9.4% had acute prescriptions, and 2.5% had chronic prescriptions. Ten percent had a diagnosis of OSA. Patients with OSA were more likely to be older, male, nonwhite, obese, current or former smokers, have higher pain intensity, and have medical and psychiatric comorbidities. Controlling for these differences, patients with OSA were more likely to receive acute (RRR 2.02 [95% confidence interval 1.98-2.06]) or chronic (RRR 2.15 [2.09-2.22]) opioids. Further dividing opioid categories by high vs low dosage did not yield substantially different results. Obstructive sleep apnea is associated with a two-fold likelihood of being prescribed opioids for pain. Clinicians should consider incorporating OSA treatment into multimodal pain management strategies; OSA as a target for pain management should be further studied.

The Relationship Between Body Mass Index and Pain Intensity Among Veterans with Musculoskeletal Disorders: Findings from the MSD Cohort Study

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.

Longitudinal mental health outcomes of combat-injured service members

BACKGROUND

The relationship between traumatic injury and subsequent mental health diagnoses is not well understood and may have significant implications for patient screening and clinical intervention. We sought to determine the adjusted association between traumatic injury and the subsequent development of post-traumatic stress disorder (PTSD), depression, and anxiety.

METHODS

Using Department of Defense and Veterans Affairs datasets between February 2002 and June 2016, we conducted a retrospective cohort study of 7,787 combat-injured United States service members matched 1:1 to combat-deployed, uninjured service members. The primary exposure was combat injury versus no combat injury. Outcomes were diagnoses of PTSD, depression, and anxiety, defined by International Classification of Diseases 9th and 10th Revision Clinical Modification codes.

RESULTS

Compared to noninjured service members, injured service members had higher observed incidence rates per 100 person-years for PTSD (17.1 vs. 5.8), depression (10.4 vs. 5.7), and anxiety (9.1 vs. 4.9). After adjustment, combat-injured patients were at increased risk of development of PTSD (HR 2.92, 95%CI 2.68-3.17), depression (HR 1.47, 95%CI 1.36-1.58), and anxiety (HR 1.34, 95%CI 1.24-1.45).

CONCLUSIONS

Traumatic injury is associated with subsequent development of PTSD, depression, and anxiety. These findings highlight the importance of increased screening, prevention, and intervention in patients with exposure to physical trauma.

Use of Laser in Sleep Disorders: A Review on Low Laser Uvulopalatoplasty

Methods

A comprehensive and systematic literature review was conducted using PubMed, Google Scholar, Cochrane Central Register of Controlled Trials, Embase, Web of Science, the US National Institutes of Health Trials Registry, WHO Library, and Medline. The search strategies were developed to cover publications from January 2010 through March 2020. The past 10 years of the search were performed to report the data following systematic review and meta-analysis protocol (PRISMA-P) 2015 statement.

Results

With the help of keywords, the total number of abstracts identified was 946. These abstracts were further reviewed as per inclusion and exclusion criteria, and 106 abstracts were identified to match the selection criteria. Further review of full articles resulted in 12 articles that matched the inclusion criteria for the study.

Conclusion

Er:YAG can be a good alternative and least invasive therapy for managing snoring and obstructive sleep apnea. Er:YAG therapy is considered to nonsurgical intervention with minimum side effects and can be performed chairside.

Pain Management in Clinical Practice Research Using Electronic Health Records

BACKGROUND

The use of electronic health record (EHR) systems encourages and facilitates the use of data for the development and surveillance of quality indicators, including pain management.

AIM

to conduct an integrative review on pain management research using data extracted from EHR in order to synthesize and analyze the following elements: pain management (assessments, interventions, and outcomes) and study results with potential clinical implications, data source, clinical sample characteristics, and method description.

DESIGN

An integrative review of the literature was undertaken to identify exemplars of scientific research studies that explore pain management using data from EHR, using Cooper's framework.

RESULTS

Our search of 1,061 records from PubMed, Scopus, and Cinahl was narrowed down to 28 eligible articles to be analyzed.

CONCLUSION

Results of this integrative review will make a critical contribution, assisting others in developing research proposals and sound research methods, as well as providing an overview of such studies over the past 10 years. Through this review it is therefore possible to guide new research on clinical pain management using EHR.

Mobile Neurofeedback for Pain Management in Veterans with TBI and PTSD

OBJECTIVE

Chronic pain is common in military veterans with traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD). Neurofeedback, or electroencephalograph (EEG) biofeedback, has been associated with lower pain but requires frequent travel to a clinic. The current study examined feasibility and explored effectiveness of neurofeedback delivered with a portable EEG headset linked to an application on a mobile device.

DESIGN

Open-label, single-arm clinical trial.

SETTING

Home, outside of clinic.

SUBJECTS

N = 41 veterans with chronic pain, TBI, and PTSD.

METHOD

Veterans were instructed to perform "mobile neurofeedback" on their own for three months. Clinical research staff conducted two home visits and two phone calls to provide technical assistance and troubleshoot difficulties.

RESULTS

N = 36 veterans returned for follow-up at three months (88% retention). During this time, subjects completed a mean of 33.09 neurofeedback sessions (10 minutes each). Analyses revealed that veterans reported lower pain intensity, pain interference, depression, PTSD symptoms, anger, sleep disturbance, and suicidal ideation after the three-month intervention compared with baseline. Comparing pain ratings before and after individual neurofeedback sessions, veterans reported reduced pain intensity 67% of the time immediately following mobile neurofeedback. There were no serious adverse events reported.

CONCLUSIONS

This preliminary study found that veterans with chronic pain, TBI, and PTSD were able to use neurofeedback with mobile devices independently after modest training and support. While a double-blind randomized controlled trial is needed for confirmation, the results show promise of a portable, technology-based neuromodulatory approach for pain management with minimal side effects.

An Open-Label Pilot Study Investigating Noninvasive High-Frequency Peripheral Nerve Fiber Stimulation in Chronic Pain

OBJECTIVE

Providing sustained and effective treatment via the peripheral nervous system for the management of chronic pain is challenging. Application of noninvasive high-frequency stimulation at or near the painful area may benefit those with chronic pain. This open-label pilot survey examined the impact of this stimulation on pain intensity, activities of daily living, functional capacity, and medication consumption after 2 weeks of treatment.

METHODS

Stimulation was administered at home using the summation of two high-frequency sinusoidal alternating signals at 3858 and 3980 Hz delivered between two electrodes placed directly over one or two locations of pain. Individuals completed a survey after 2 weeks to assess pain, activities of daily living (ADL), pain medication consumption, quality of life (QoL), mood, sleep, functional outcomes, and satisfaction.

RESULTS

463 individuals (372 males; 91 females) retuned the completed survey after 2 weeks of treatment. Pain and ADL scores significantly improved at follow-up compared with baseline (pain mean difference: 3.05; 95% confidence interval [CI]: 2.86, 3.24; ADL mean difference: 1.82; 95% CI: 1.60, 2.04). Corresponding improvements in QoL, sleep, mood, functional outcomes, and satisfaction were noted. On average, 8.00 ± 11.11 hours of pain relief were reported with 54% experiencing reductions in pain medication consumption. 98% would use the stimulation in the future.

CONCLUSION

Two weeks of noninvasive high-frequency peripheral nerve fiber stimulation appeared to confer positive effects in individuals with chronic pain. Future research employing a control group/arm is needed to establish the long-term impact of this bioelectric technique in specific pain cohorts.

Comorbid chronic pain and post-traumatic stress disorder in UK veterans: a lot of theory but not enough evidence

INTRODUCTION

Chronic pain and post-traumatic stress disorder (PTSD) are strongly correlated in military veteran populations. The aim of this article is to review what is known about the comorbidity of the two conditions.

METHODS

A literature search was carried out to establish evidence for current explanatory models of why the two conditions frequently co-occur, the most appropriate treatments and current UK service provision for veterans and to identify gaps in research.

RESULTS

Chronic pain and PTSD share a number of features, yet the mechanisms behind their comorbidity are not well understood, and while each condition alone has extensive literature, there is limited evidence to support specific care and treatment for the two conditions simultaneously. In addition, there is currently no UK data for veterans with comorbid chronic pain and PTSD so it is not possible to gauge the numbers affected or to predict the numbers who will be affected in the future, and there appear to be no co-located services within the United Kingdom for the management of the two conditions simultaneously in this population.

CONCLUSION

This review highlights a paucity of evidence in all areas of comorbid chronic pain and PTSD. Further work needs to consider fully the nature of the event that led to the development of the two conditions and examine further the possible mechanisms involved, and clinics need to establish routine and systematic evaluations of how any interventions work in practice.

Adapting to disruption of research during the COVID-19 pandemic while testing nonpharmacological approaches to pain management

The COVID-19 pandemic has slowed research progress, with particularly disruptive effects on investigations of addressing urgent public health challenges, such as chronic pain. The National Institutes of Health (NIH) Department of Defense (DoD) Department of Veterans Affairs (VA) Pain Management Collaboratory (PMC) supports 11 large-scale, multisite, embedded pragmatic clinical trials (PCTs) in military and veteran health systems. The PMC rapidly developed and enacted a plan to address key issues in response to the COVID-19 pandemic. The PMC tracked and collaborated in developing plans for addressing COVID-19 impacts across multiple domains and characterized the impact of COVID-19 on PCT operations, including delays in recruitment and revisions of study protocols. A harmonized participant questionnaire will facilitate later meta-analyses and cross-study comparisons of the impact of COVID-19 across all 11 PCTs. The pandemic has affected intervention delivery, outcomes, regulatory and ethics issues, participant recruitment, and study design. The PMC took concrete steps to ensure scientific rigor while encouraging flexibility in the PCTs, while paying close attention to minimizing the burden on research participants, investigators, and clinical care teams. Sudden changes in the delivery of pain management interventions will probably alter treatment effects measured via PMC PCTs. Through the use of harmonized instruments and surveys, we are capturing these changes and plan to monitor the impact on research practices, as well as on health outcomes. Analyses of patient-reported measures over time will inform potential relationships between chronic pain, mental health, and various socioeconomic stressors common among Americans during the COVID-19 pandemic.

Pain intensity and mental health quality of life in veterans with mental illnesses: the intermediary role of physical health and the ability to participate in activities

Purpose

The purpose of this study was to examine the intermediary role of physical health quality of life and ability to participate social roles and activities in the relationship between pain intensity and mental health quality of life in veterans with mental illnesses.

Methods

This is a cross-sectional correlational design study. Our participants are 156 veterans with self-reported mental illness (M_age = 37.85; SD_age = 10.74). Descriptive, correlation, and mediation analyses were conducted for the current study.

Results

Pain intensity was negatively correlated with physical health QOL, ability to participate in social roles and activities, and mental health QOL. Physical health QOL and ability to participate in social roles and activities were positively associated with mental health QOL, respectively. Physical health QOL was positively correlated with a ability to participate in social roles and activities. Study results indicate that the effect of pain intensity on mental health QOL can be explained by physical health QOL and ability to participate.

Conclusions

Specific recommendations for practitioners include implementing treatment goals that simultaneously focus on physical health and ability to participate in social roles and activities for clients who present with both physical pain and low mental health QOL.

Lower levels of bodily pain increase risk for non-medical use of prescription drugs among current US reserve soldiers

BACKGROUND

Military populations have a higher prevalence of pain compared to their civilian counterparts and are also at increased risk for substance use. The link between clinically significant pain and substance use has been established, but it is unclear if lower levels of pain relate to risk. The goal of this inquiry was to determine if level of bodily pain was associated with increased risk of current substance use over time among a community sample of U.S. Army Reserve/National Guard (USAR/NG) soldiers.

METHODS

Data were drawn from an ongoing study of USAR/NG soldiers. We used generalized estimating equations to examine the longitudinal impact of baseline bodily pain level (modeled in standard deviations from the mean pain score) on current drug use (illicit and non-medical use of prescription drugs [NMUPD]) among soldiers (n = 387) over two-years. Final models controlled for baseline post-traumatic stress disorder (PTSD), anxiety, and depression symptomatology, history of deployment (yes/no), years of military service, and substance use norms.

RESULTS

Bodily pain was longitudinally associated with increased odds of current NMUPD (AOR: 1.49, p < .05), but not with the current use of illicit drugs (AOR: 1.18, p > .05), controlling for symptoms of PTSD, anxiety, depression, deployment, years of service, and substance use norms.

CONCLUSIONS

Overall, our findings indicate that bodily pain is longitudinally associated with NMUPD among male soldiers, but not with illicit drugs. Significantly, our results stem from a non-clinical sample of soldiers with overall lower levels of pain. This indicates that pain may be important, even at lower levels, and underscores the importance of early non-pharmacologic interventions for pain.

The influence of prior opioid use on healthcare utilization and recurrence rates for non-surgical patients seeking initial care for patellofemoral pain

INTRODUCTION/OBJECTIVES

Prior opioid use can influence outcomes for patients with musculoskeletal disorders. The purpose of this study was to compare downstream medical utilization-based outcomes (costs, visits, recurrent episodes) after an initial diagnosis of patellofemoral pain based on pre-injury utilization of opioids.

METHOD

A total of 85,7880 consecutive patients were followed for a full 12 months before and 24 months after an initial diagnosis of patellofemoral pain (January 2009 to December 2013). Data were sourced from the Military Health System Data Repository, a single-payer closed government system. Opioid prescription fills were identified, and medical visits and costs were calculated for all knee-related medical care, to include recurrence rates in the 2-year surveillance period.

RESULTS

A relatively small number of individuals filled an opioid prescription in the year prior (n = 1746; 2.0%); however, these individuals had almost twice the mean costs of knee-related medical care ($1557 versus %802) and medical visits (8.4 versus 4.0). Patients with prior opioid use were more likely to have at least 1 recurrent episode of knee pain (relative risk 1.58, 95% CI 1.51, 1.65) with a higher mean number of episodes of knee pain (1.5 vs 1.8). The use of opioids with higher risk of misuse or dependency (Schedule II or III) resulted in greater medical costs (for any reason) and recurrent episodes of knee pain compared to the use of opioids in a lower risk category (Schedule IV).

CONCLUSIONS

Prior opioid utilization was associated with a greater number of recurrent episodes of knee pain and higher downstream medical costs compared with individuals without prior opioid use. For individuals with prior opioid utilization, opioids with higher risk of misuse or dependency (Schedule II or III) resulted in greater medical costs (for any reason) and recurrent episodes compared to the use of lower-risk opioids (Schedule IV). Key Points • Patients with prior opioid use had much greater knee-related medical costs compared to patients without prior opioid use. • Patients with prior opioid use were more likely to have additional episodes of knee pain in the following 2 years compared to patients without prior opioid use. • Prior opioid use has predicted higher costs and poor outcomes after surgery, but this is the first study to confirm similar findings in non-surgical patients.