Optimizing the Impact of Pragmatic Clinical Trials for Veteran and Military Populations: Lessons From the Pain Management Collaboratory

Pragmatic clinical trials (PCTs) are well-suited to address unmet healthcare needs, such as those arising from the dual public health crises of chronic pain and opioid misuse, recently exacerbated by the COVID-19 pandemic. These overlapping epidemics have complex, multifactorial etiologies, and PCTs can be used to investigate the effectiveness of integrated therapies that are currently available but underused. Yet individual pragmatic studies can be limited in their reach because of existing structural and cultural barriers to dissemination and implementation. The National Institutes of Health, Department of Defense, and Department of Veterans Affairs formed an interagency research partnership, the Pain Management Collaboratory. The partnership combines pragmatic trial design with collaborative tools and relationship building within a large network to advance the science and impact of nonpharmacological approaches and integrated models of care for the management of pain and common co-occurring conditions. The Pain Management Collaboratory team supports 11 large-scale, multisite PCTs in veteran and military health systems with a focus on team science with the shared aim that the "whole is greater than the sum of the parts." Herein, we describe this integrated approach and lessons learned, including incentivizing all parties; proactively offering frequent opportunities for problem-solving; engaging stakeholders during all stages of research; and navigating competing research priorities. We also articulate several specific strategies and their practical implications for advancing pain management in active clinical, "real-world," settings.

Military sexual trauma interacts with combat exposure to increase risk for posttraumatic stress symptomatology in female Iraq and Afghanistan veterans

OBJECTIVE

Sexual trauma during military service is increasingly recognized as a substantial public health problem and is associated with detrimental effects on veteran mental health. In this study, we examined associations between childhood trauma, military sexual trauma (MST), combat exposure, and military-related posttraumatic stress symptomatology (PTSS) in the Women Veterans Cohort Study (WVCS), a community-based sample of veterans who served in the recent conflicts in Iraq and Afghanistan.

METHOD

From July 2008 to December 2011, 365 female veterans completed a survey that assessed combat exposure, military sexual trauma, military-related PTSS (assessed using the PTSD [posttraumatic stress disorder] Checklist-Military Version), and demographic, life history, and other psychopathology variables.

RESULTS

High rates of childhood trauma (59.7%) and MST (sexual assault = 14.7%; sexual harassment = 34.8%) were observed in this sample. A hierarchical regression revealed that active duty status, childhood trauma, combat exposure, and MST were independently associated with increased severity of military-related PTSS (Ps < .05). Moreover, a significant interaction emerged between MST and combat exposure in predicting military-related PTSS (P = .030), suggesting that the relationship between combat exposure and PTSS was altered by MST status. Specifically, under conditions of high combat exposure, female veterans with MST had significantly higher PTSS compared to female veterans without MST.

CONCLUSIONS

Taken together, results suggest that exposure to multiple traumas during military service may have synergistic effects on posttraumatic stress symptoms in female veterans. Moreover, our findings highlight the importance of prevention efforts to protect female veterans from the detrimental effects of MST, particularly those who are exposed to high levels of combat.

Prescription headache medication in OEF/OIF veterans: results from the Women Veterans Cohort Study

OBJECTIVE

To examine differences in male and female veterans of Operations Enduring Freedom/Iraqi Freedom (OEF/OIF) period of service in taking prescription headache medication, and associations between taking prescription headache medication and mental health status, psychiatric symptoms, and rates of traumatic events.

BACKGROUND

Headaches are common among active service members and are associated with impairment in quality of life. Little is known about headaches in OEF/OIF veterans.

METHODS

Veterans participating in the Women Veterans Cohort Study responded to a cross-sectional survey to assess taking prescription headache medication, mental health status (Post Deployment Health Assessment), psychiatric symptoms (portions of the Brief Patient Health Questionnaire and the Posttraumatic Stress Disorder Checklist), and traumatic events (the Traumatic Life Events Questionnaire and queries regarding military trauma). Gender differences among taking prescription headache medication, health status, psychiatric symptoms, and traumatic events were examined. Regression analyses were used to examine the influence of gender on the associations between taking prescription headache medication and health status, psychiatric symptoms, and traumatic events.

RESULTS

139/551 (25.2%) participants reported taking prescription headache medication in the past year. A higher proportion of women veterans (29.1%) reported taking prescription medication for headache in the last year compared with men (19.7%). Taking prescription headache medication was associated with poorer perceived mental health status, higher anxiety and posttraumatic stress disorder symptoms, and higher rates of traumatic events. The association between prescription headache medication use and perceived mental health status, and with the association between prescription headache medication use and posttraumatic stress disorder symptoms, was stronger for men than for women.

CONCLUSIONS

Among OEF/OIF veterans, the prevalence of clinically relevant headache is high, particularly among women veterans. Taking prescription headache medication is associated with poor mental health status, higher rates of psychiatric symptoms, and higher rates of traumatic events; however, these variables did not appear to meaningfully account for gender differences in prevalence of taking prescription headache medication. Future research should endeavor to identify factors that might account for the observed differences.