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Van Houtven CH, Smith VA, Miller KEM, Berkowitz TSZ, Shepherd-Banigan M, Hein T, Penney LS, Allen KD, Kabat M, Jobin T, Hastings SN. Comprehensive Caregiver Supports and Ascertainment and Treatment of Veteran Pain. Med Care Res Rev 2024; 81:107-121. [PMID: 38062735 DOI: 10.1177/10775587231210026] [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: 03/09/2024]
Abstract
Disabled Veterans commonly experience pain. The Program of Comprehensive Assistance for Family Caregivers (PCAFC) provides training, a stipend, and services to family caregivers of eligible Veterans to support their caregiving role. We compared ascertainment of veteran pain and pain treatment through health care encounters and medications (pain indicators) of participants (treated group) and non-participants (comparison group) using inverse probability treatment weights. Modeled results show that the proportion of Veterans with a pain indicator in the first year post-application was higher than that pre-application for both groups. However, the proportion of Veterans with a pain indicator was substantially higher in the treatment group: 76.1% versus 63.9% in the comparison group (p < .001). Over time, the proportion of Veterans with any pain indicator fell and group differences lessened. However, differences persisted through 8 years post-application (p < .001). PCAFC caregivers appear to help Veterans engage in pain treatment at higher rates than caregivers not in PCAFC.
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Affiliation(s)
- Courtney H Van Houtven
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System
- Department of Population Health Sciences, Duke University School of Medicine
- Duke Margolis Center for Health Policy, Duke University
| | - Valerie A Smith
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System
- Department of Population Health Sciences, Duke University School of Medicine
- Department of General Internal Medicine, Duke University
| | - Katherine E M Miller
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System
- Department of Medical Ethics and Health Policy, University of Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania
| | - Theodore S Z Berkowitz
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System
| | - Megan Shepherd-Banigan
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System
- Department of Population Health Sciences, Duke University School of Medicine
| | - Tyler Hein
- Office of Mental Health and Suicide Prevention, Department of Veterans Affairs
| | - Lauren S Penney
- The Elizabeth Dole Center of Excellence for Veteran and Caregiver Research, South Texas Veterans Health Care System
- Department of Medicine, Division of Hospital Medicine, University of Texas Health San Antonio
| | - Kelli D Allen
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System
- Department of Medicine, University of North Carolina at Chapel Hill
| | - Margaret Kabat
- Office of the Secretary US Department of Veterans Affairs
| | - Timothy Jobin
- Caregiver Support Program, Veterans Health Administration, US Department of Veterans Affairs
| | - S Nicole Hastings
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System
- Department of Population Health Sciences, Duke University School of Medicine
- Department of Medicine, Division of Geriatrics, Duke University School of Medicine
- Center for the Study of Aging and Human Development, Duke University School of Medicine
- Geriatrics Research, Education and Clinical Center, Durham VA Health Care System
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2
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Knox PJ, Simon CB, Pohlig RT, Pugliese JM, Coyle PC, Sions JM, Hicks GE. Construct validity of movement-evoked pain operational definitions in older adults with chronic low back pain. PAIN MEDICINE (MALDEN, MASS.) 2023; 24:985-992. [PMID: 36944266 PMCID: PMC10391587 DOI: 10.1093/pm/pnad034] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 03/03/2023] [Accepted: 03/09/2023] [Indexed: 03/23/2023]
Abstract
OBJECTIVE Movement-evoked pain (MeP) may predispose the geriatric chronic low back pain (LBP) population to health decline. As there are differing operational definitions for MeP, the question remains as to whether these different definitions have similar associations with health outcomes in older adults with chronic LBP. DESIGN Cross-sectional analysis of an observational study. SETTING Clinical research laboratory. SUBJECTS 226 older adults with chronic LBP. METHODS This secondary analysis used baseline data from a prospective cohort study (n = 250). LBP intensity was collected before and after the repeated chair rise test, stair climbing test, and 6-minute walk test; MeP change scores (ie, sum of pretest pain subtracted from posttest pain) and aggregated posttest pain (ie, sum of posttest pain) variables were calculated. LBP-related disability and self-efficacy were measured by the Quebec Back Pain Disability Scale (QBPDS) and Low Back Activity Confidence Scale (LOBACS), respectively. Physical function was measured with the Health ABC Performance Battery. Robust regression with HC3 standard errors was used to evaluate adjusted associations between both MeP variables and disability, self-efficacy, and physical function. RESULTS Greater aggregated posttest MeP was independently associated with worse disability (b = 0.593, t = 2.913, P = .004), self-efficacy (b = -0.870, t = -3.110, P = .002), and physical function (b = -0.017, t = -2.007, P = .039). MeP change scores were not associated with any outcome (all P > .050). CONCLUSIONS Aggregate posttest MeP was linked to poorer health outcomes in older adults with chronic LBP, but MeP change scores were not. Future studies should consider that the construct validity of MeP paradigms partially depends on the chosen operational definition.
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Affiliation(s)
- Patrick J Knox
- Department of Physical Therapy, University of Delaware, Newark, DE 19713, United States
| | - Corey B Simon
- Department of Orthopaedic Surgery, Physical Therapy Division, Duke University, Durham, NC 27710, United States
| | - Ryan T Pohlig
- Department of Epidemiology, University of Delaware, Newark, DE 19713, United States
- Biostatistics Core, University of Delaware, Newark, DE 19713, United States
| | - Jenifer M Pugliese
- Department of Physical Therapy, University of Delaware, Newark, DE 19713, United States
| | - Peter C Coyle
- Department of Physical Therapy, University of Delaware, Newark, DE 19713, United States
| | - Jaclyn M Sions
- Department of Physical Therapy, University of Delaware, Newark, DE 19713, United States
| | - Gregory E Hicks
- Department of Physical Therapy, University of Delaware, Newark, DE 19713, United States
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Meerwijk EL, Adams RS, Larson MJ, Highland KB, Harris AHS. Dose of Exercise Therapy Among Active Duty Soldiers With Chronic Pain Is Associated With Lower Risk of Long-Term Adverse Outcomes After Linking to the Veterans Health Administration. Mil Med 2022; 188:usac074. [PMID: 35311994 PMCID: PMC10363012 DOI: 10.1093/milmed/usac074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 02/09/2022] [Accepted: 03/04/2022] [Indexed: 07/25/2023] Open
Abstract
INTRODUCTION Research in soldiers who had been deployed to Iraq or Afghanistan suggests that nonpharmacological treatments may be protective against adverse outcomes. However, the degree to which exercise therapy received in the U.S. Military Health System (MHS) among soldiers with chronic pain is associated with adverse outcomes after soldiers transition to the Veterans Health Administration (VHA) is unclear. The objective of this study was to determine if exercise therapy received in the MHS among soldiers with chronic pain is associated with long-term adverse outcomes after military separation and enrollment into the VHA and whether this association is moderated by prescription opioid use before starting exercise therapy. MATERIALS AND METHODS We conducted a longitudinal cohort study of electronic medical records of active duty Army soldiers with documented chronic pain after an index deployment to Iraq or Afghanistan (years 2008-2014) who subsequently enrolled in the VHA (N = 93,967). Coarsened exact matching matched 37,310 soldiers who received exercise therapy and 28,947 soldiers who did not receive exercise therapy in the MHS. Weighted multivariable Cox proportional hazard models tested for differences in adverse outcomes between groups with different exercise therapy exposure vs. no exercise therapy.Exercise therapy was identified by procedure codes on ambulatory records in the MHS and expressed as the number of exercise therapy visits in 1 year after the first diagnosis with a chronic pain condition. The number of visits was then stratified into seven dose groups.The primary outcomes were weighted proportional hazards for: (1) alcohol and drug disorders, (2) suicide ideation, (3) intentional self-injury, and (4) all-cause mortality. Outcomes were determined based on ICD-9 and ICD-10 diagnoses recorded in VHA healthcare records from enrollment till September 30, 2020. RESULTS Our main analysis indicated significantly lower hazard ratios (HRs) for all adverse outcomes except intentional self-injury, for soldiers with at least eight visits for exercise therapy, compared to soldiers who received no exercise therapy. In the proportional hazard model for any adverse outcome, the HR was 0.91 (95% CI 0.84-0.99) for soldiers with eight or nine exercise therapy visits and 0.91 (95% CI 0.86-0.96) for soldiers with more than nine visits. Significant exercise therapy × prior opioid prescription interactions were observed. In the group that was prescribed opioids before starting exercise therapy, significantly lower HRs were observed for soldiers with more than nine exercise therapy visits, compared to soldiers who received no exercise therapy, for alcohol and drug disorders (HR = 0.85, 95% CI 0.77-0.92), suicide ideation (HR = 0.77, 95% CI 0.66-0.91), and for self-injury (HR = 0.58, 95% CI 0.41-0.83). CONCLUSIONS Exercise therapy should be considered in the multimodal treatment of chronic pain, especially when pain is being managed with opioids, as it may lower the risk of serious adverse outcomes associated with chronic pain and opioid use. Our findings may generalize only to those active duty soldiers with chronic pain who enroll into VHA after separating from the military.
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Affiliation(s)
- Esther L Meerwijk
- VA Health Services Research & Development, Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA 94025, USA
| | - Rachel Sayko Adams
- Heller School for Social Policy and Management, Institute for Behavioral Health, Brandeis University, Waltham, MA 02453, USA
- Rocky Mountain Mental Illness Research Education and Clinical Center, Veterans Health Administration, Aurora, CO 80045, USA
| | - Mary Jo Larson
- Heller School for Social Policy and Management, Institute for Behavioral Health, Brandeis University, Waltham, MA 02453, USA
| | - Krista B Highland
- Department of Anesthesiology, Uniformed Services University, Bethe-sda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine Inc., Bethesda, MD 20817, USA
| | - Alex H S Harris
- VA Health Services Research & Development, Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA 94025, USA
- Department of Surgery, Stanford University, Stanford, CA 94305, USA
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Pagé MG, Gauvin L, Sylvestre MP, Nitulescu R, Dyachenko A, Choinière M. An Ecological Momentary Assessment Study of Pain Intensity Variability: Ascertaining Extent, Predictors, and Associations With Quality of Life, Interference and Health Care Utilization Among Individuals Living With Chronic Low Back Pain. THE JOURNAL OF PAIN 2022; 23:1151-1166. [PMID: 35074499 DOI: 10.1016/j.jpain.2022.01.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 01/13/2022] [Accepted: 01/13/2022] [Indexed: 11/16/2022]
Abstract
This ecological momentary assessment (EMA) study examined the extent of pain intensity variability among 140 individuals with chronic low back pain and explored predictors of such variability and psychosocial and health care utilization outcomes. Individuals completed momentary pain intensity reports (0-10 numeric rating scale) several times daily for two periods of seven consecutive days, one month apart. Participants also completed online questionnaires at baseline which tapped into pain characteristics, pain-related catastrophization, kinesiophobia, activity patterns, and depression and anxiety symptoms. Questionnaires assessing quality of life and health care utilization were administered online one month after completion of the last EMA report. Data were analyzed using linear hierarchical location-scale models. Results showed that pain intensity fluctuated over the course of a week as shown by an average standard deviation of 1.2. The extent of variability in pain intensity scores was heterogeneous across participants but stable over assessment periods. Patients' baseline characteristics along with psychosocial and health care utilization outcomes were not significantly associated with pain intensity variability. We conclude that pain intensity variability differs across patients yet correlates remain elusive. There is an important gap in our knowledge of what affects this variability. Future EMA studies should replicate and extend current findings. PERSPECTIVE: This study provides evidence indicating that there is substantial variability in momentary reports of pain intensity among individuals living with chronic low back pain. However, risk and protective factors for greater lability of pain are elusive as is evidence that greater pain intensity variability results in differential health care utilization.
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Affiliation(s)
- M Gabrielle Pagé
- Centre de recherche du Centre hospitalier de l'Université de Montréal & Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada.
| | - Lise Gauvin
- Centre de recherche du Centre hospitalier de l'Université de Montréal & Department of Social and Preventive Medicine, École de santé publique de l'Université de Montréal, Montreal, Quebec, Canada
| | - Marie-Pierre Sylvestre
- Centre de recherche du Centre hospitalier de l'Université de Montréal & Department of Social and Preventive Medicine, École de santé publique de l'Université de Montréal, Montreal, Quebec, Canada
| | - Roy Nitulescu
- Centre de recherche du Centre hospitalier de l'Université de Montréal & Centre d'intégration et d'analyse en données médicales du Centre hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Alina Dyachenko
- Centre de recherche du Centre hospitalier de l'Université de Montréal & Centre d'intégration et d'analyse en données médicales du Centre hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Manon Choinière
- Centre de recherche du Centre hospitalier de l'Université de Montréal & Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
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5
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Knox PJ, Simon CB, Pohlig RT, Pugliese JM, Coyle PC, Sions JM, Hicks GE. A Standardized Assessment of Movement-evoked Pain Ratings Is Associated With Functional Outcomes in Older Adults With Chronic Low Back Pain. Clin J Pain 2021; 38:241-249. [PMID: 34954729 PMCID: PMC8917081 DOI: 10.1097/ajp.0000000000001016] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 12/06/2021] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Despite high prevalence estimates, chronic low back pain (CLBP) remains poorly understood among older adults. Movement-evoked pain (MeP) is an understudied factor in this population that may importantly contribute to disability. This study investigated whether a novel MeP paradigm contributed to self-reported and performance-based function in older adults with CLBP. MATERIALS AND METHODS This secondary analysis includes baseline data from 230 older adults with CLBP in the context of a prospective cohort study. The Repeated Chair Rise Test, Six Minute Walk Test, and Stair Climbing Test were used to elicit pain posttest LBP ratings were aggregated to yield the MeP variable. Self-reported and performance-based function were measured by the Late Life Function and Disability Index (LLFDI) scaled function score and Timed Up-and-Go Test (TUG), respectively. Robust regression with HC3 standard errors was used to model adjusted associations between MeP and both functional outcomes; age, sex, body mass index, and pain characteristics (ie, intensity, quality, and duration) were utilized as covariates. RESULTS MeP was present in 81.3% of participants, with an average rating of 5.09 (SD=5.4). Greater aggregated posttest MeP was associated with decreased LLFDI scores (b=-0.30, t=-2.81, P=0.005) and poorer TUG performance (b=0.081, t=2.35, P=0.020), independent of covariates. LBP intensity, quality and duration were not associated with the LLFDI or TUG, (all P>0.05). DISCUSSION Aggregated posttest MeP independently contributed to worse self-reported and performance-based function among older adults with CLBP. To understand long-term consequences of MeP, future studies should examine longitudinal associations between MeP and function in this population.
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Affiliation(s)
- Patrick J. Knox
- Department of Physical Therapy, University of Delaware, Newark, DE
| | - Corey B. Simon
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC
| | - Ryan T. Pohlig
- Department of Epidemiology, University of Delaware, Newark, DE
- Biostatistics Core, University of Delaware, Newark, DE
| | | | - Peter C. Coyle
- Department of Physical Therapy, University of Delaware, Newark, DE
| | - Jaclyn M. Sions
- Department of Physical Therapy, University of Delaware, Newark, DE
| | - Gregory E. Hicks
- Department of Physical Therapy, University of Delaware, Newark, DE
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6
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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.
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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.
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7
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Hayes CJ, Krebs EE, Hudson T, Brown J, Li C, Martin BC. Impact of opioid dose escalation on pain intensity: a retrospective cohort study. Pain 2021; 161:979-988. [PMID: 31917775 DOI: 10.1097/j.pain.0000000000001784] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Prescribers are often confronted with the decision to escalate opioid doses to achieve adequate analgesia. Understanding the impact of dose escalation on pain intensity is warranted. Using a retrospective cohort study design, Veterans with chronic pain and chronic opioid therapy were identified. Opioid dose escalators (>20% increase in average morphine milligram equivalent daily dose) were compared with dose maintainers (±20% change in average morphine milligram equivalent daily dose) assessed over 2 consecutive 6-month windows. Pain intensity was measured by the Numeric Rating Scale. The primary analyses used linear repeated-measures models among a 1:1 matched sample of escalators and maintainers matched on propensity score and within ±180 days of the index date. Sensitivity analyses were conducted using adjusted linear repeated-measures models with and without incorporating stabilized inverse probability of treatment weighting. There were 32,420 dose maintainers and 20,767 dose escalators identified with 19,358 (93%) matched pairs. Pain scores were persistently higher among dose escalators at each 90-day period after the index date (0-90 days after index date: dose escalators: 4.68, 95% confidence interval [CI]: 4.64-4.72 dose maintainers: 4.32, 95% CI: 4.28-4.36, P < 0.0001; 91-180 days after index date: dose escalators: 4.53, 95% CI: 4.49-4.57; dose maintainers: 4.25, 95% CI: 4.22-4.29, P < 0.0001) but were not different in the 90 days before the index date (dose escalators: 4.64, 95% CI: 4.61-4.68; dose maintainers: 4.59, 95% CI: 4.55-4.63, P = 0.0551). Sensitivity analyses provided similar results as the primary analyses. Opioid dose escalation among patients with chronic pain is not associated with improvements in Numeric Rating Scale pain scores.
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Affiliation(s)
- Corey J Hayes
- Division of Health Services Research, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States.,Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, Little Rock, AR, United States
| | - Erin E Krebs
- Center for Care Delivery and Outcomes Research, Minneapolis VA Healthcare System, Minneapolis, MN, United States.,Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Teresa Hudson
- Division of Health Services Research, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States.,Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, Little Rock, AR, United States
| | - Joshua Brown
- Department of Pharmaceutical Outcomes and Policy, Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Chenghui Li
- Division of Pharmaceutical Evaluation and Policy, College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Bradley C Martin
- Division of Pharmaceutical Evaluation and Policy, College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR, United States
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8
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Wesolowicz DM, Bishop MD, Robinson ME. AN EXAMINATION OF DAY-TO-DAY AND INTRAINDIVIDUAL PAIN VARIABILITY IN LOW BACK PAIN. PAIN MEDICINE 2021; 22:2263-2275. [PMID: 33822203 DOI: 10.1093/pm/pnab119] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE This study aimed to capture day-to-day changes in pain intensity in individuals with low back pain (LBP), which may be indicative of patients' ability to modulate their pain levels. A secondary aim was to explore the presence of latent subgroups characterized by pain level, intraindividual pain variability, and change in pain over a 14-day period. SUBJECTS Participants were 54 adults with self-reported low back pain recruited from outpatient Physical Therapy clinics and the community. METHODS Over the course of 14 days, participants completed daily measures of pain intensity, catastrophizing, pain self-efficacy, and negative affect. Change in pain intensity as well as total amount of intraindividual pain variability were also calculated. RESULTS Daily increases in maladaptive coping and affective responses (i.e., higher catastrophizing, higher negative affect, lower pain self-efficacy) were associated with increases in pain intensity. A hierarchical cluster analysis revealed three subgroups: (1) moderate pain intensity, moderate pain variability, increase in pain over time; (2) low pain intensity, low pain variability, no change in pain over time; and (3) moderate pain intensity, high pain variability, decrease in pain over time. Cluster 2 demonstrated more adaptive coping and affective responses at baseline and during the 14-day period, and Cluster 1 and 3 did not differ in their coping nor affective responses. CONCLUSIONS These findings provide support that day-to-day changes in pain, coping and affective responses are meaningful and provide additional evidence of pain variability as a potential phenotypic characteristic.
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Affiliation(s)
- Danielle M Wesolowicz
- Center for Pain Research, and Behavioral Health.,Department of Clinical and Health Psychology, University of Florida
| | - Mark D Bishop
- Center for Pain Research, and Behavioral Health.,Department of Physical Therapy, University of Florida
| | - Michael E Robinson
- Center for Pain Research, and Behavioral Health.,Department of Clinical and Health Psychology, University of Florida
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9
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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.
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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
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Wang KH, McAvay G, Warren A, Miller ML, Pho A, Blosnich JR, Brandt CA, Goulet JL. Examining Health Care Mobility of Transgender Veterans Across the Veterans Health Administration. LGBT Health 2021; 8:143-151. [PMID: 33512276 DOI: 10.1089/lgbt.2020.0152] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Purpose: Transgender veterans are overrepresented in the Veterans Health Administration (VHA) compared with in the general population. Utilization of multiple different health care systems, or health care mobility, can affect care coordination and potentially affect outcomes, either positively or negatively. This study examines whether transgender veterans are more or less health care mobile than nontransgender veterans and compares the patterns of geographic mobility in these groups. Methods: Using an established cohort (n = 5,414,109), we identified 2890 transgender veterans from VHA electronic health records from 2000 to 2012. We compared transgender and nontransgender veterans on sociodemographic, clinical, and health care system-level measures and conducted conditional logistic regression models of mobility. Results: Transgender veterans were more likely to be younger, White, homeless, have depressive disorders, post-traumatic stress disorder (PTSD), and hepatitis C. Transgender veterans were more likely to have been health care mobile (9.9%) than nontransgender veterans (5.2%) (unadjusted odds ratio = 2.02, 95% confidence interval = 1.73-2.36). In a multivariable model, transgender status, being separated/divorced, receiving care in less-complex facilities, and diagnoses of depression, PTSD, or hepatitis C were associated with more mobility, whereas older age was associated with less mobility. For the top three health care systems utilized, a larger proportion of transgender veterans visited a second health care system in a different state (56.2%) than nontransgender veterans (37.5%). Conclusions: Transgender veterans were more likely to be health care mobile and more likely to travel out of state for health care services. They were also more likely to have complex chronic health conditions that require multidisciplinary care.
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Affiliation(s)
- Karen H Wang
- Department of Internal Medicine, Equity Research and Innovation Center, Yale School of Medicine, New Haven, Connecticut, USA
| | - Gail McAvay
- Department of Internal Medicine, Equity Research and Innovation Center, Yale School of Medicine, New Haven, Connecticut, USA.,Pain Research, Informatics, Multi-morbidities, and Education Center, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Allison Warren
- Department of Internal Medicine, Equity Research and Innovation Center, Yale School of Medicine, New Haven, Connecticut, USA.,Pain Research, Informatics, Multi-morbidities, and Education Center, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Mary L Miller
- Department of Internal Medicine, Equity Research and Innovation Center, Yale School of Medicine, New Haven, Connecticut, USA
| | - Anthony Pho
- Columbia University School of Nursing, New York, New York, USA
| | - John R Blosnich
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, California, USA.,Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Cynthia A Brandt
- Department of Internal Medicine, Equity Research and Innovation Center, Yale School of Medicine, New Haven, Connecticut, USA.,Pain Research, Informatics, Multi-morbidities, and Education Center, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Joseph L Goulet
- Department of Internal Medicine, Equity Research and Innovation Center, Yale School of Medicine, New Haven, Connecticut, USA.,Pain Research, Informatics, Multi-morbidities, and Education Center, VA Connecticut Healthcare System, West Haven, Connecticut, USA
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11
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Hill G, Hughes-Stricklett A. Patient outcomes following state-mandated opioid dose reductions. Am J Health Syst Pharm 2020; 77:S87-S92. [PMID: 33045722 DOI: 10.1093/ajhp/zxaa161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE Maine Public Law Chapter 488 required that all opioid doses be reduced to below 100 morphine milligram equivalent (MME) by July 1, 2017, and VA Maine Healthcare System implemented policies consistent with the state law. The purpose of this study was to assess self-reported pain scores over 2 years and overall utilization of alternative healthcare services for veterans who were using opioid doses in excess of 100 MME prior to the implementation of policies consistent with Maine PL Chapter 488 in the VA Maine Healthcare System. METHODS In this retrospective chart review, veterans were selected for inclusion if they were receiving chronic opioid therapy at the VA Maine Healthcare System of at least 100 MME daily in March 2016 according to the opioid therapy risk report (OTRR). Self-reported pain scores and use of alternative healthcare services were evaluated using VA Computerized Patient Record System (CPRS) data. RESULTS Of the 147 patients evaluated per protocol, 75 patients (51%) did not have a clinically significant change in self-reported pain scores, and the self-reported pain scores of 29 patients (20%) improved from March 2016 to March 2018 (P = 0.054). CONCLUSION We found that mandatory dose reductions of chronic opioid medications did not result in a clinically or statistically significant worsening of self-reported pain scores. Our study suggests that opioid dose reductions may not negatively impact a patient's functioning and pain intensity and calls into question the use of long-term opioid therapy for pain given the safety implications.
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12
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Meerwijk EL, Larson MJ, Schmidt EM, Adams RS, Bauer MR, Ritter GA, Buckenmaier C, Harris AHS. Nonpharmacological Treatment of Army Service Members with Chronic Pain Is Associated with Fewer Adverse Outcomes After Transition to the Veterans Health Administration. J Gen Intern Med 2020; 35:775-783. [PMID: 31659663 PMCID: PMC7080907 DOI: 10.1007/s11606-019-05450-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 09/26/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Potential protective effects of nonpharmacological treatments (NPT) against long-term pain-related adverse outcomes have not been examined. OBJECTIVE To compare active duty U.S. Army service members with chronic pain who did/did not receive NPT in the Military Health System (MHS) and describe the association between receiving NPT and adverse outcomes after transitioning to the Veterans Health Administration (VHA). DESIGN AND PARTICIPANTS A longitudinal cohort study of active duty Army service members whose MHS healthcare records indicated presence of chronic pain after an index deployment to Iraq or Afghanistan in the years 2008-2014 (N = 142,539). Propensity score-weighted multivariable Cox proportional hazard models tested for differences in adverse outcomes between the NPT group and No-NPT group. EXPOSURES NPT received in the MHS included acupuncture/dry needling, biofeedback, chiropractic care, massage, exercise therapy, cold laser therapy, osteopathic spinal manipulation, transcutaneous electrical nerve stimulation and other electrical manipulation, ultrasonography, superficial heat treatment, traction, and lumbar supports. MAIN MEASURES Primary outcomes were propensity score-weighted proportional hazards for the following adverse outcomes: (a) diagnoses of alcohol and/or drug disorders; (b) poisoning with opioids, related narcotics, barbiturates, or sedatives; (c) suicide ideation; and (d) self-inflicted injuries including suicide attempts. Outcomes were determined based on ICD-9 and ICD-10 diagnoses recorded in VHA healthcare records from the start of utilization until fiscal year 2018. KEY RESULTS The propensity score-weighted proportional hazards for the NPT group compared to the No-NPT group were 0.92 (95% CI 0.90-0.94, P < 0.001) for alcohol and/or drug use disorders; 0.65 (95% CI 0.51-0.83, P < 0.001) for accidental poisoning with opioids, related narcotics, barbiturates, or sedatives; 0.88 (95% CI 0.84-0.91, P < 0.001) for suicide ideation; and 0.83 (95% CI 0.77-0.90, P < 0.001) for self-inflicted injuries including suicide attempts. CONCLUSIONS NPT provided in the MHS to service members with chronic pain may reduce risk of long-term adverse outcomes.
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Affiliation(s)
- Esther L Meerwijk
- VA Health Services Research & Development, Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA.
| | - Mary Jo Larson
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA
| | - Eric M Schmidt
- Program Evaluation and Resource Center, VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - Rachel Sayko Adams
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA
| | - Mark R Bauer
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA
| | - Grant A Ritter
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA
| | - Chester Buckenmaier
- Defense and Veterans Center for Integrative Pain Management, Uniformed Services University, Rockville, MD, USA
| | - Alex H S Harris
- VA Health Services Research & Development, Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA
- Department of Surgery, Stanford University, Stanford, CA, USA
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13
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Nakad L, Booker S, Gilbertson-White S, Shaw C, Chi NC, Herr K. Pain and Multimorbidity in Late Life. CURR EPIDEMIOL REP 2020. [DOI: 10.1007/s40471-020-00225-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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14
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Wang WY, Chu CM, Wu YS, Sung CS, Ho ST, Pan HH, Wang KY. Evaluation of the pain intensity differences among hospitalized cancer patients based on a nursing information system. PLoS One 2019; 14:e0222516. [PMID: 31553746 PMCID: PMC6760775 DOI: 10.1371/journal.pone.0222516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 08/30/2019] [Indexed: 11/19/2022] Open
Abstract
Evaluating the absolute difference in pain intensity and the percentage difference in pain intensity could facilitate an understanding of pain reduction among cancer patients during repeated hospitalizations. Examinations of the absolute differences in pain intensity and the percentage differences in pain intensity according to the worst pain intensity and last evaluated pain intensity before discharge are lacking. The aim of this study was to evaluate the absolute and percentage difference in pain intensities among cancer patients with moderate or severe pain from their 1st to 18th hospitalizations from 2011–2013. A population-based retrospective cohort study was conducted. Pain intensity was assessed using scales and was recorded in a nursing information system. The absolute and percentage difference in pain intensities were examined via the one-sample Kolmogorov-Smirnov test, and group differences in moderate or severe pain were evaluated with the Mann-Whitney U test. For moderate pain patients, the mean absolute difference in pain intensity was 1.52, and the percentage difference in pain intensity was 29.0%; both these values were significant. More significant changes in the absolute and percentage difference in pain intensities were associated with severe pain patients. Both the average absolute difference in pain intensity (3.09) and the percentage difference in pain intensity (38.5%) in patients with severe pain were significantly higher than the average absolute difference in pain intensity (1.52) and the percentage difference in pain intensity (29.0%) in patients with moderate pain. Cancer patients with moderate and severe pain experienced pain reductions of approximately 30% and 40%, respectively. Early pain management intervention in patients with severe pain is necessary to achieve an obvious analgesic effect, and the formula of the percentage difference in pain intensity should be incorporated into the nursing information system to alert clinicians for early detection of the effectiveness of cancer pain management.
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Affiliation(s)
- Wei-Yun Wang
- Department of Nursing, Tri-Service General Hospital, Taipei, Taiwan
- School of Nursing, National Defense Medical Center, Taipei, Taiwan
| | - Chi-Ming Chu
- School of Public Health, National Defense Medical Center, Taipei, Taiwan
| | - Yi-Syuan Wu
- Graduate Institute of Life Science, National Defense Medical Center, Taipei, Taiwan
| | - Chun-Sung Sung
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Shung-Tai Ho
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hsueh-Hsing Pan
- School of Nursing, National Defense Medical Center, Taipei, Taiwan
| | - Kwua-Yun Wang
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Nursing, National Defense Medical Center, Taipei, Taiwan
- * E-mail:
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15
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Abstract
Abstract
Editor’s Perspective
What We Already Know about This Topic
What This Article Tells Us That Is New
Background
The Opioid Safety Initiative decreased high-dose prescriptions across the Veterans Health Administration. This study sought to examine the impact of this intervention (i.e., the Opioid Safety Initiative) on pain scores and opioid prescriptions in patients undergoing total knee arthroplasty.
Methods
This was an ecological study of group-level data among 700 to 850 patients per month over 72 consecutive months (January 2010 to December 2015). The authors examined characteristics of cohorts treated before versus after rollout of the Opioid Safety Initiative (October 2013). Each month, the authors aggregated at the group-level the differences between mean postoperative and preoperative pain scores for each patient (averaged over 6-month periods), and measured proportions of patients (per 1,000) with opioid (and nonopioid) prescriptions for more than 3 months in 6-month periods, preoperatively and postoperatively. The authors compared postintervention trends versus trends forecasted based on preintervention measures.
Results
After the Opioid Safety Initiative, patients were slightly older and sicker, but had lower mortality rates (postintervention n = 28,509 vs. preintervention n = 31,547). Postoperative pain scores were slightly higher and the decrease in opioid use was statistically significant, i.e., 871 (95% CI, 474 to 1,268) fewer patients with chronic postoperative prescriptions. In time series analyses, mean postoperative minus preoperative pain scores had increased from 0.65 to 0.81, by 0.16 points (95% CI, 0.05 to 0.27). Proportions of patients with chronic postoperative and chronic preoperative opioid prescriptions had declined by 20% (n = 3,355 vs. expected n = 4,226) and by 13% (n = 5,861 vs. expected n = 6,724), respectively. Nonopioid analgesia had increased. Sensitivity analyses confirmed all findings.
Conclusions
A system-wide initiative combining guideline dissemination with audit and feedback was effective in significantly decreasing opioid prescriptions in populations undergoing total knee arthroplasty, while minimally impacting pain scores.
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16
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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.
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Silverstein RP, VanderVos M, Welch H, Long A, Kaboré CD, Hootman JM. Self-Directed Walk With Ease Workplace Wellness Program - Montana, 2015-2017. MMWR-MORBIDITY AND MORTALITY WEEKLY REPORT 2018; 67:1295-1299. [PMID: 30462629 PMCID: PMC6289078 DOI: 10.15585/mmwr.mm6746a3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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18
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Chui PW, Bastian LA, DeRycke E, Brandt CA, Becker WC, Goulet JL. Dual Use of Department of Veterans Affairs and Medicare Benefits on High-Risk Opioid Prescriptions in Veterans Aged 65 Years and Older: Insights from the VA Musculoskeletal Disorders Cohort. Health Serv Res 2018; 53 Suppl 3:5402-5418. [PMID: 30298672 DOI: 10.1111/1475-6773.13060] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE To examine the association of dual use of both Veterans Health Administration (VHA) and Medicare benefits with high-risk opioid prescriptions among Veterans aged 65 years and older with a musculoskeletal disorder diagnosis. DATA SOURCES/STUDY SETTING Data were obtained from the VA Musculoskeletal Disorder (MSD) cohort and national Medicare claims data from 2008 to 2010. STUDY DESIGN We conducted a retrospective analysis of Veterans enrolled in Medicare to examine the association of dual use with long-term opioid use (>90 days of prescription opioids/year) and overlapping opioid prescriptions. Multivariable logistic regression was performed adjusting for demographic and clinical characteristics. DATA COLLECTION/EXTRACTION METHODS We identified 21,111 Veterans enrolled in Medicare who entered the MSD cohort in 2008 and received an opioid prescription in 2010. We linked VHA data with Medicare claims data to identify opioid prescriptions for these Veterans in 2010. PRINCIPAL FINDINGS As compared to Veterans who used only VHA or Medicare, Veterans with dual use of VHA and Medicare were significantly more likely to be prescribed long-term opioid therapy (OR = 4.61 (95 percent CI 4.05-5.25) and were also found to have higher median number of opioid prescriptions and higher odds of overlapping opioid prescriptions in 1 year. Patients reporting moderate-to-severe pain, non-white-race/ethnicity, and higher scoring on the Charlson comorbidity index had significantly higher odds of long-term opioid prescriptions. CONCLUSIONS Among Veterans aged 65 years or older, dual use of both VHA and Medicare was associated with higher odds of long-term opioid therapy. Our findings suggest there may be benefit to combining VHA and non-VHA electronic health record data to minimize exposure to high-risk opioid prescribing.
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Affiliation(s)
- Philip W Chui
- Pain, Research, Informatics, Medical Comorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT.,Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Lori A Bastian
- Pain, Research, Informatics, Medical Comorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT.,Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Eric DeRycke
- Pain, Research, Informatics, Medical Comorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT
| | - Cynthia A Brandt
- Pain, Research, Informatics, Medical Comorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT.,Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - William C Becker
- Pain, Research, Informatics, Medical Comorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT.,Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Joseph L Goulet
- Pain, Research, Informatics, Medical Comorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT
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Berg JM, Malte CA, Reger MA, Hawkins EJ. Medical Records Flag for Suicide Risk: Predictors and Subsequent Use of Care Among Veterans With Substance Use Disorders. Psychiatr Serv 2018; 69:993-1000. [PMID: 29879873 PMCID: PMC6196077 DOI: 10.1176/appi.ps.201700545] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The U.S. Department of Veterans Affairs (VA) health care system established policies to include patient record flags (PRFs) for high suicide risk in the electronic medical record to alert providers and to increase health care contacts. This study identified predictors of new PRFs and described health care utilization before and after PRF initiation among VA patients with substance use disorders. METHODS The sample included patients ages ≥18 who received a substance use disorder diagnosis in 2012 (N=474,946). Demographic, clinical, and utilization predictors of PRFs were identified by multivariable logistic regression. Changes in short-term (three months) and longer-term (12 months) health care utilization before and after PRF initiation were compared by negative binomial regression. RESULTS A total of 8,913 patients received PRFs. Demographic predictors of PRF initiation included being younger than 35, white, and homeless. Clinical predictors were cocaine, opioid, and sedative use disorders; posttraumatic stress, psychotic, bipolar, and depressive disorders; and diagnosis of a suicide attempt. Patients with PRFs averaged 1.33 (95% confidence interval [CI]=1.29-1.38) times more primary care visits, 2.29 (CI=2.24-2.34) times more mental health visits, 4.10 (CI=3.80-4.42) times more substance use visits, and fewer (incidence rate ratio=.55, CI=.53-.58) emergency department visits in the three months following compared with the three months before PRF initiation. Modest increases in mental health- and substance use--related days hospitalized were observed. CONCLUSIONS Veterans received significantly more health care services after PRF initiation. Further research is warranted on the effects of PRFs on clinical outcomes, such as suicide behaviors.
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Affiliation(s)
- Joanna M Berg
- Dr. Berg is with the Evidence-Based Treatment Centers of Seattle. Ms. Malte and Dr. Hawkins are with the U.S. Department of Veterans Affairs (VA) Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care System Seattle. Dr. Hawkins is also with the Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, where Dr. Reger is affiliated. Dr. Reger is also with the Department of Mental Health Services, VA Puget Sound Health Care System
| | - Carol A Malte
- Dr. Berg is with the Evidence-Based Treatment Centers of Seattle. Ms. Malte and Dr. Hawkins are with the U.S. Department of Veterans Affairs (VA) Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care System Seattle. Dr. Hawkins is also with the Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, where Dr. Reger is affiliated. Dr. Reger is also with the Department of Mental Health Services, VA Puget Sound Health Care System
| | - Mark A Reger
- Dr. Berg is with the Evidence-Based Treatment Centers of Seattle. Ms. Malte and Dr. Hawkins are with the U.S. Department of Veterans Affairs (VA) Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care System Seattle. Dr. Hawkins is also with the Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, where Dr. Reger is affiliated. Dr. Reger is also with the Department of Mental Health Services, VA Puget Sound Health Care System
| | - Eric J Hawkins
- Dr. Berg is with the Evidence-Based Treatment Centers of Seattle. Ms. Malte and Dr. Hawkins are with the U.S. Department of Veterans Affairs (VA) Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care System Seattle. Dr. Hawkins is also with the Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, where Dr. Reger is affiliated. Dr. Reger is also with the Department of Mental Health Services, VA Puget Sound Health Care System
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20
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Haverfield MC, Giannitrapani K, Timko C, Lorenz K. Patient-Centered Pain Management Communication from the Patient Perspective. J Gen Intern Med 2018; 33:1374-1380. [PMID: 29845465 PMCID: PMC6082206 DOI: 10.1007/s11606-018-4490-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 04/17/2018] [Accepted: 04/27/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND Pain management discussions between patient and provider can be stressful to navigate and greatly impact the care received. Because of the complexity, emotional color, and sensitivity of pain management, such discussions require a high degree of skill. OBJECTIVE To identify patients' perspectives of patient-centered care communication within the context of pain management discussions. DESIGN We conducted semi-structured interviews (25-65 min) with patients regarding their experiences with pain assessment and management. PARTICIPANTS 36 patients (29 males, 7 females), from 3 Veteran Affairs healthcare locations. Participant age ranged from 28 to 94 with pain intensity ranging from 0 to 10, based on the "pain now" numeric rating scale report gathered at the time of the interview. APPROACH Interview transcript analysis was conducted using the constant comparison method to produce mutually agreed upon themes. KEY RESULTS Elements of patient-centered care communication described by participants include judgment, openness, listening, trust, preferences, solution-oriented, customization, and longevity. Patients perceive provider reciprocation in openness and trust as drivers of the patient-provider relationship, thereby enhancing positive, associated themes. CONCLUSIONS Findings highlight the importance of the patient-provider relationship in patient-centered care and offer patient-centered care communication tools for practitioners to utilize, such as solution-oriented messages and communicating trust, especially when interacting with patients about pain.
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Affiliation(s)
- Marie C Haverfield
- Veteran Affairs Palo Alto Health Care System, Center for Innovation to Implementation (Ci2i), 152-MPD, 795 Willow Road, Menlo Park, California, 94025, USA.
- Stanford University School of Medicine, Palo Alto, California, USA.
| | - Karleen Giannitrapani
- Veteran Affairs Palo Alto Health Care System, Center for Innovation to Implementation (Ci2i), 152-MPD, 795 Willow Road, Menlo Park, California, 94025, USA
- Stanford University School of Medicine, Palo Alto, California, USA
| | - Christine Timko
- Veteran Affairs Palo Alto Health Care System, Center for Innovation to Implementation (Ci2i), 152-MPD, 795 Willow Road, Menlo Park, California, 94025, USA
- Stanford University School of Medicine, Palo Alto, California, USA
| | - Karl Lorenz
- Veteran Affairs Palo Alto Health Care System, Center for Innovation to Implementation (Ci2i), 152-MPD, 795 Willow Road, Menlo Park, California, 94025, USA
- Stanford University School of Medicine, Palo Alto, California, USA
- RAND Corporation, Santa Monica, California, USA
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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.
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Electronic Medical Record Alert Associated With Reduced Opioid and Benzodiazepine Coprescribing in High-risk Veteran Patients. Med Care 2018; 56:171-178. [DOI: 10.1097/mlr.0000000000000861] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Scherrer JF, Salas J, Sullivan MD, Ahmedani BK, Copeland LA, Bucholz KK, Burroughs T, Schneider FD, Lustman PJ. Impact of adherence to antidepressants on long-term prescription opioid use cessation. Br J Psychiatry 2018; 212:103-111. [PMID: 29436331 PMCID: PMC6655534 DOI: 10.1192/bjp.2017.25] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Depression contributes to persistent opioid analgesic use (OAU). Treating depression may increase opioid cessation. Aims To determine if adherence to antidepressant medications (ADMs) v. non-adherence was associated with opioid cessation in patients with a new depression episode after >90 days of OAU. METHOD Patients with non-cancer, non-HIV pain (n = 2821), with a new episode of depression following >90 days of OAU, were eligible if they received ≥1 ADM prescription from 2002 to 2012. ADM adherence was defined as >80% of days covered. Opioid cessation was defined as ≥182 days without a prescription refill. Confounding was controlled by inverse probability of treatment weighting. RESULTS In weighted data, the incidence rate of opioid cessation was significantly (P = 0.007) greater in patients who adhered v. did not adhered to taking antidepressants (57.2/1000 v. 45.0/1000 person-years). ADM adherence was significantly associated with opioid cessation (odds ratio (OR) = 1.24, 95% CI 1.05-1.46). CONCLUSIONS ADM adherence, compared with non-adherence, is associated with opioid cessation in non-cancer pain. Opioid taper and cessation may be more successful when depression is treated to remission. Declaration of interest None.
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Affiliation(s)
- Jeffrey F. Scherrer
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis, Missouri and Harry S. Truman Veterans Administration Medical Center, Columbia, Missouri
| | - Joanne Salas
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis, Missouri and Harry S. Truman Veterans Administration Medical Center, Columbia, Missouri
| | - Mark D. Sullivan
- Department of Psychiatry and Behavioral Health, University of Washington School of Medicine, Seattle, Washington
| | - Brian K. Ahmedani
- Henry Ford Health System, Center for Health Policy and Health Services Research, Detroit, Michigan
| | - Laurel A. Copeland
- VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts, Center for Applied Health Research, Baylor Scott & White Health, Temple, Texas and UT Health San Antonio, San Antonio, Texas
| | - Kathleen K. Bucholz
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri
| | - Thomas Burroughs
- Saint Louis University Center for Outcomes Research, St. Louis, Missouri
| | - F. David Schneider
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis, Missouri
| | - Patrick J. Lustman
- The Bell Street Clinic, VA St. Louis Health Care System – John Cochran Division, St. Louis and Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA
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Abstract
Recent studies suggest that longer durations of opioid use, independent of maximum morphine equivalent dose (MED) achieved, is associated with increased risk of new-onset depression (NOD). Conversely, other studies, not accounting for duration, found that higher MED increased probability of depressive symptoms. To determine whether rate of MED increase is associated with NOD, a retrospective cohort analysis of Veterans Health Administration data (2000-2012) was conducted. Eligible patients were new, chronic (>90 days) opioid users, aged 18 to 80, and without depression diagnoses for 2 years before start of follow-up (n = 7051). Mixed regression models of MED across follow-up defined 4 rate of dose change categories: stable, decrease, slow increase, and rapid increase. Cox proportional hazard models assessed the relationship of rate of dose change and NOD, controlling for pain, duration of use, maximum MED, and other confounders using inverse probability of treatment-weighted propensity scores. Incidence rate for NOD was 14.1/1000PY (person-years) in stable rate, 13.0/1000PY in decreasing, 19.3/1000PY in slow increasing, and 27.5/1000PY in rapid increasing dose. Compared with stable rate, risk of NOD increased incrementally for slow (hazard ratio = 1.22; 95% confidence interval: 1.05-1.42) and rapid (hazard ratio = 1.58; 95% confidence interval: 1.30-1.93) rate of dose increase. Faster rates of MED escalation contribute to NOD, independent of maximum dose, pain, and total opioid duration. Dose escalation may be a proxy for loss of control or undetected abuse known to be associated with depression. Clinicians should avoid rapid dose increase when possible and discuss risk of depression with patients if dose increase is warranted for pain.
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Painter JM, Malte CA, Rubinsky AD, Campellone TR, Gilmore AK, Baer JS, Hawkins EJ. High inpatient utilization among Veterans Health Administration patients with substance-use disorders and co-occurring mental health conditions. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2017; 44:386-394. [PMID: 29095057 DOI: 10.1080/00952990.2017.1381701] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Substance-use disorders (SUDs) are common and costly conditions. Understanding high inpatient utilization (HIU) among patients with SUD can inform the development of treatment approaches designed to reduce healthcare expenditures and improve service quality. OBJECTIVES To examine the prevalence, type, and predictors of HIU among patients with SUD and co-occurring mental health conditions. METHODS Service utilization and demographic and clinical variables were extracted from a national sample of Veterans Health Administration (VA) patients with SUD-only [n = 148,960 (98.3% male)], SUD plus serious mental illness ([i.e. schizophrenia- and/or bipolar-spectrum disorders; SUD/SMI; n = 75,913 (91.6% male)], and SUD plus other mental illness [SUD/MI; n = 245,675 (94.6% male)]. Regression models were used to examine HIU during a follow-up year. RESULTS Prevalence of HIU among the SUD-only group was 6.2% (95% confidence interval (CI): 6.1%-6.3%) compared with 22.7% (95% CI: 22.4%-23.0%) and 9.7% (95% CI: 9.6%-9.8%) among the SUD/SMI and SUD/MI groups, respectively. Patients with SUD/MI represented nearly half of the HIU sample. Primary type of inpatient service use varied by comorbidity: SUD-only = medicine; SUD/SMI = psychiatric; SUD/MI similar use of psychiatric, SUD-related, and medicine. Predictors of HIU were generally similar across groups: older age, unmarried, homelessness, suicide risk, pain diagnosis, alcohol/opioid/sedative-use disorders, and prior-year emergency department/inpatient utilization. CONCLUSIONS Substantial reductions in HIU among an SUD population will likely require treatment approaches that target patients with less-severe mental health conditions in addition to SMI. Cross-service collaborations (e.g., integration of medical providers in SUD care) and interventions designed to target issues and/or conditions that lead to HIU (e.g., homeless care services) may be critical to reducing HIU in this population.
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Affiliation(s)
- Janelle M Painter
- a VA Puget Sound Health Care System , Seattle Division , Seattle , WA , USA
| | - Carol A Malte
- b Health Services Research & Development (HSR&D) Seattle Center of Innovation for Veteran Centered and Value-Driven Care , VA Puget Sound Health Care System , Seattle , WA , USA.,c Center of Excellence for Substance Abuse Treatment and Education (CESATE) , VA Puget Sound Health Care System , Seattle , WA , USA
| | - Anna D Rubinsky
- b Health Services Research & Development (HSR&D) Seattle Center of Innovation for Veteran Centered and Value-Driven Care , VA Puget Sound Health Care System , Seattle , WA , USA.,c Center of Excellence for Substance Abuse Treatment and Education (CESATE) , VA Puget Sound Health Care System , Seattle , WA , USA.,d Kidney Health Research Collaborative (KHRC), Department of Medicine , University of California, San Francisco, and VA San Francisco Health Care System , San Francisco , CA , USA
| | - Timothy R Campellone
- a VA Puget Sound Health Care System , Seattle Division , Seattle , WA , USA.,e Department of Psychology , University of California , Berkeley, Berkeley , CA , USA
| | - Amanda K Gilmore
- f Department of Psychiatry & Behavioral Science, Medical University of South Carolina, National Crime Victims Research and Treatment Center , Charleston , SC , USA
| | - John S Baer
- b Health Services Research & Development (HSR&D) Seattle Center of Innovation for Veteran Centered and Value-Driven Care , VA Puget Sound Health Care System , Seattle , WA , USA.,c Center of Excellence for Substance Abuse Treatment and Education (CESATE) , VA Puget Sound Health Care System , Seattle , WA , USA.,g Department of Psychology , University of Washington , Seattle , WA , USA
| | - Eric J Hawkins
- b Health Services Research & Development (HSR&D) Seattle Center of Innovation for Veteran Centered and Value-Driven Care , VA Puget Sound Health Care System , Seattle , WA , USA.,c Center of Excellence for Substance Abuse Treatment and Education (CESATE) , VA Puget Sound Health Care System , Seattle , WA , USA.,h Department of Psychiatry & Behavioral Sciences , University of Washington , Seattle , WA , USA
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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.
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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
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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.
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Pain Induced during Both the Acquisition and Retention Phases of Locomotor Adaptation Does Not Interfere with Improvements in Motor Performance. Neural Plast 2016; 2016:8539096. [PMID: 28053789 PMCID: PMC5178857 DOI: 10.1155/2016/8539096] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 11/06/2016] [Indexed: 12/12/2022] Open
Abstract
Cutaneous pain experienced during locomotor training was previously reported to interfere with retention assessed in pain-free conditions. To determine whether this interference reflects consolidation deficits or a difficulty to transfer motor skills acquired in the presence of pain to a pain-free context, this study evaluated the effect of pain induced during both the acquisition and retention phases of locomotor learning. Healthy participants performed a locomotor adaptation task (robotized orthosis perturbing ankle movements during swing) on two consecutive days. Capsaicin cream was applied around participants' ankle on both days for the Pain group, while the Control group was always pain-free. Changes in movement errors caused by the perturbation were measured to assess global motor performance; temporal distribution of errors and electromyographic activity were used to characterize motor strategies. Pain did not interfere with global performance during the acquisition or the retention phases but was associated with a shift in movement error center of gravity to later in the swing phase, suggesting a reduction in anticipatory strategy. Therefore, previously reported retention deficits could be explained by contextual changes between acquisition and retention tests. This difficulty in transferring skills from one context to another could be due to pain-related changes in motor strategy.
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Dobscha SK, Lovejoy TI, Morasco BJ, Kovas AE, Peters DM, Hart K, Williams JL, McFarland BH. Predictors of Improvements in Pain Intensity in a National Cohort of Older Veterans With Chronic Pain. THE JOURNAL OF PAIN 2016; 17:824-35. [PMID: 27058162 DOI: 10.1016/j.jpain.2016.03.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Revised: 03/21/2016] [Accepted: 03/24/2016] [Indexed: 12/25/2022]
Abstract
UNLABELLED Little is known about the factors associated with pain-related outcomes in older adults. In this observational study, we sought to identify patient factors associated with improvements in pain intensity in a national cohort of older veterans with chronic pain. We included 12,924 veterans receiving treatment from the Veterans Health Administration with persistently elevated numeric rating scale scores in 2010 who had not been prescribed opioids in the previous 12 months. We examined: 1) percentage decrease over 12 months in average pain intensity scores relative to average baseline pain intensity score; and 2) time to sustained improvement in average pain intensity scores, defined as a 30% reduction in 3-month scores compared with baseline. Average relative improvement in pain intensity scores from baseline ranged from 25% to 29%; almost two-thirds met criteria for sustained improvement during the 12-month follow-up period. In models, higher baseline pain intensity and older age were associated with greater likelihood of improvement in pain intensity, whereas Veterans Affairs service-connected disability, mental health, and certain pain-related diagnoses were associated with lower likelihood of improvement. Opioid prescription initiation during follow-up was associated with lower likelihood of sustained improvement. The findings call for further characterization of heterogeneity in pain outcomes in older adults as well as further analysis of the relationship between prescription opioids and treatment outcomes. PERSPECTIVE This study identified factors associated with improvements in pain intensity in a national cohort of older veterans with chronic pain. We found that older veterans frequently show improvements in pain intensity over time, and that opioid prescriptions, mental health, and certain pain diagnoses are associated with lower likelihood of improvement.
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Affiliation(s)
- Steven K Dobscha
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon; Department of Psychiatry, Oregon Health and Science University, Portland, Oregon.
| | - Travis I Lovejoy
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon; Department of Psychiatry, Oregon Health and Science University, Portland, Oregon
| | - Benjamin J Morasco
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon; Department of Psychiatry, Oregon Health and Science University, Portland, Oregon
| | - Anne E Kovas
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon
| | - Dawn M Peters
- Department of Public Health and Preventive Medicine, Oregon Health and Science University, Portland, Oregon
| | - Kyle Hart
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon
| | - J Lucas Williams
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon
| | - Bentson H McFarland
- Department of Psychiatry, Oregon Health and Science University, Portland, Oregon; Department of Public Health and Preventive Medicine, Oregon Health and Science University, Portland, Oregon
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Wang WY, Chu CM, Sung CS, Ho ST, Wu YS, Liang CY, Wang KY. Using a New Measurement to Evaluate Pain Relief Among Cancer Inpatients with Clinically Significant Pain Based on a Nursing Information System: A Three-Year Hospital-Based Study. PAIN MEDICINE 2016; 17:2067-2075. [PMID: 26995798 DOI: 10.1093/pm/pnw026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE Developing a new measurement index is the first step in evaluating pain relief outcomes. Although the percentage difference in pain intensity (%PID) is the most popular indicator, this indicator does not take into account the goal of pain relief. Therefore, the aims of this study were to develop a pain relief index (PRI) for outcome evaluation and to examine the index using demographic characteristics of cancer inpatients with clinically significant pain. DESIGN Retrospective cohort study. SETTING A national hospital. SUBJECTS All cancer inpatients. METHODS Pain intensity was assessed using a numerical rating scale, a faces pain scale or the Face, Legs, Activity, Cry, Consolability (FLACC) Behavioral Tool. Using a nursing information system, a pain score database containing data from 2011 through 2013 was analyzed. RESULTS Cancer patients representing 93,812 hospitalizations were considered in this study. We focused on cancer patients for whom the worst pain intensity (WPI) was ≥ 4 points. PRI values of -62.02% to -72.55% were observed in the WPI ≥ 7 and 4 ≤ WPI ≤ 6 groups. Significant (P < 0.05) effects on PRI values were observed among patients who were > 65 years old, those who were admitted to the medicine or gynecology and those who had a hospital stay > 30 days. CONCLUSION This hospital-based study demonstrated that the PRI is an effective and valid measure for evaluating outcome data using an electronic nursing information system. We will further define the meaningful range of percentage difference in PRI from various perspectives.
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Affiliation(s)
- Wei-Yun Wang
- *Graduate Institute of Medical Sciences, National Defense Medical Center and Department of Nursing, Tri-Service General Hospital, Taipei, Taiwan
| | - Chi-Ming Chu
- School of Public Health, National Defense Medical Center, Taipei, Taiwan
| | - Chun-Sung Sung
- Department of Anesthesiology, Taipei Veterans General Hospital and School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Shung-Tai Ho
- Hospital Division, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yi-Syuan Wu
- School of Public Health, National Defense Medical Center, Taipei, Taiwan
| | - Chun-Yu Liang
- Graduate Institute of Medical Sciences, and School of Nursing, National Defense Medical Center, Taipei, Taiwan
| | - Kwua-Yun Wang
- Department of Nursing, Taipei Veterans General Hospital and Graduate Institute of Medical Sciences, and School of Nursing, National Defense Medical Center, Taipei, Taiwan
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Morasco BJ, Peters D, Krebs EE, Kovas AE, Hart K, Dobscha SK. Predictors of urine drug testing for patients with chronic pain: Results from a national cohort of U.S. veterans. Subst Abus 2015; 37:82-7. [PMID: 26516794 DOI: 10.1080/08897077.2015.1110742] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Urine drug testing (UDT) is recommended for all patients who initiate chronic opioid therapy (COT) for the treatment of chronic pain; however, it is infrequently utilized. Some prior research has identified factors that may predict UDT, but studies have been limited. The purpose of this study is to examine the rate and predictors of UDT among a national sample of patients with chronic pain who had new initiations of COT. METHODS Administrative data were examined for all veterans receiving medical care at Department of Veterans Affairs medical facilities who had new initiations of chronic opioid therapy (COT) during fiscal year 2011. RESULTS Nineteen percent of patients who had new initiations of COT for chronic noncancer pain received UDT within 90 days of starting opioids. In adjusted analyses, patient-level factors that predicted increased likelihood of UDT included male gender (risk ratio [RR] = 1.23, 95% confidence interval [CI] = 1.02-1.49), Black race (RR = 1.20, 95% CI = 1.06-1.37), divorced/separated marital status (RR = 1.13, 95% CI = 1.02-1.25), higher pain intensity (RR = 1.03, 95% CI = 1.01-1.05), comorbid substance use disorder (RR = 1.42, 95% CI = 1.27-1.60), posttraumatic stress disorder (PTSD) (RR = 1.14, 95% CI = 1.01-1.29), bipolar disorder or schizophrenia (RR = 1.29, 95% CI = 1.08-1.53), having received UDT prior to initiating opioid therapy (RR = 1.43, 95% CI = 1.26-1.62), and a higher baseline opioid dose (RR = 1.38-1.81, 95% CIs = 1.20-1.58, 1.57-2.09). Age was also associated with UDT, in a nonlinear manner. Several factors were associated with lower likelihood of UDT, including living in a highly rural setting (RR = 0.62, 95% CI = 0.29-0.99), having a VA service-connected disability (RR = 0.85-0.89, 95% CIs = 0.75-0.97, 0.79-0.99), and having a nurse practitioner or physician assistant as one's primary care clinician (RR = 0.72, 95% CI = 0.61-0.85). CONCLUSIONS Urine drug testing was conducted with 19% of patients who had new initiations of COT. Factors that predicted UDT were multifaceted and included patient and clinician variables. Multidimensional system-level interventions may be needed to facilitate widespread implementation of UDT.
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Affiliation(s)
- Benjamin J Morasco
- a Center to Improve Veteran Involvement in Care , VA Portland Health Care System , Portland , Oregon , USA.,b Department of Psychiatry , Oregon Health & Science University , Portland , Oregon , USA
| | - Dawn Peters
- c Department of Public Health & Preventive Medicine , Oregon Health & Science University , Portland , Oregon , USA
| | - Erin E Krebs
- d Center for Chronic Disease Outcomes Research , Minneapolis VA Health Care System , University of Minnesota Medical School , Minneapolis , Minnesota , USA
| | - Anne E Kovas
- a Center to Improve Veteran Involvement in Care , VA Portland Health Care System , Portland , Oregon , USA
| | - Kyle Hart
- a Center to Improve Veteran Involvement in Care , VA Portland Health Care System , Portland , Oregon , USA
| | - Steven K Dobscha
- a Center to Improve Veteran Involvement in Care , VA Portland Health Care System , Portland , Oregon , USA.,b Department of Psychiatry , Oregon Health & Science University , Portland , Oregon , USA
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