Spotlight on Chronic Pain and Pain Awareness
Veterans experience chronic pain at rates higher than those of the general population and are about 40% more likely to have severe pain1. Seventy-seven percent of Veterans report pain control as among their top three priorities in primary care2. VA has strived to increase pain awareness, notably via its 1990’s era “Pain as the 5th Vital Sign” initiative3 in which providers had Veterans rate pain on a scale of 1-10 at every visit. Since that time however, a nationwide opioid crisis has resulted in higher levels of addiction, and more than 200,000 opioid-related overdose deaths4.
Current VA pain management strategies include non-pharmacological modalities, promotion of self-efficacy, and team-based care, as well as emphasis on safe opioid prescribing and usage5.
The October 2018 web feature highlights several HSR&D studies on chronic pain awareness and treatment as part of VA’s commitment to continued improvement of pain care for Veterans.
Painful musculoskeletal disorders (MSD), including back conditions and osteoarthritis, are highly prevalent and costly among Veterans. Yet, little is known about the characteristics of Veterans with MSD, the development and persistence of pain, variation in pain management, associated medical and mental health conditions, and treatment outcomes and costs. Investigators created a longitudinal cohort of Veterans with MSD from national VA electronic clinical and administrative data and studied variation in pain, pain treatment, comorbidities, and outcomes, by patient and facility characteristics.
- Over 50% (N=5.2 million) of Veterans who received VHA care between 2000 and 2014 had one or more MSD diagnoses.
- Women Veterans constituted an increasing proportion of MSD patients (6% in 2001 vs. 9% in 2014).
- More recently diagnosed Veterans reported higher pain scores, with nearly 50% reporting moderate to severe pain, and they were more likely to have multiple concurrent MSD, depressive disorder diagnoses, and PTSD.
- Veterans with housing instability and MSD were more likely to report high levels of pain, have high rates of medical and mental health comorbid conditions, but less likely to receive an opioid medication.
- Black Veterans diagnosed with osteoarthritis were less likely to undergo Total Knee Arthroplasty (TKA) than White Veterans; in contrast, Hispanics and Whites received TKA at similar rates, and these differences remained relatively stable over time.
Implications: This study identified needs for integrated pain, mental health, and medical care across a range of comorbid conditions. This information will guide VA Clinical Operations in their efforts to reduce variation in care access and process quality across VA.
This study resulted in the following publication(s):
Goulet JL, Kerns RD, Bair M, et al. . The musculoskeletal diagnosis cohort: examining pain and pain care among veterans. Pain. 2016 Aug 1; 157(8):1696-703.
Hausmann LRM, Brandt CA, Carroll CM, et al. et al. . Racial and Ethnic Differences in Total Knee Arthroplasty in the Veterans Affairs Health Care System, 2001-2013. Arthritis care & research. 2017 Aug 1; 69(8):1171-1178.
Higgins DM, Fenton BT, Driscoll MA, et al. Gender Differences in Demographic and Clinical Correlates among Veterans with Musculoskeletal Disorders. Women's health issues: official publication of the Jacobs Institute of Women's Health. 2017 Jul 1; 27(4):463-470.
Wang KH, Goulet JL, Carroll CM, et al. Estimating healthcare mobility in the Veterans Affairs Healthcare System. BMC health services research. 2016 Oct 21; 16(1):609.
Benin AL, Fodeh SJ, Lee K, et al. Electronic approaches to making sense of the text in the adverse event reporting system. Journal of healthcare risk management: the journal of the American Society for Healthcare Risk Management. 2016 Aug 1; 36(2):10-20.
Fenton BT, Goulet JL, Bair MJ, et al. Relationships between Temporomandibular disorders, MSD conditions, and mental health comorbidities: Findings from the Veterans Musculoskeletal Disorders Cohort. Pain Medicine, 2018 Sep 01; 19(suppl_1), S30-S37.
Chui PW, Bastian LA, DeRycke EC, et al. Association of Dual use of Department of Veterans Affairs and Medicare benefits on opioid prescriptions: Insights from the VA Musculoskeletal Disorder Cohort. Health Services Research. DOI:10.1111/1475-6773.13060 (in press)
Principal Investigators: Joseph Lucien Goulet PhD, MS and Cynthia A. Brandt, MD, MPH. VA Connecticut Healthcare System, West Haven, CT.
In the 1990s, chronic pain was considered a disease that warranted aggressive and humane treatment, including the use of opioids, but by 2016, opioid overuse had reached epidemic status. VA is ideally suited to develop an integrated approach to the treatment of chronic pain. To this end, HSR&D held a state-of-the-art conference (SOTA) titled “Non-pharmacological Approaches to Chronic Musculoskeletal Pain Management” in 2016, which included researchers, clinical experts, and various stakeholders from the VA, DoD, National Institutes of Health, and academia. That SOTA produced a Journal of General Internal Medicine (JGIM) supplement, featuring several original papers selected from manuscripts submitted in response to a Call for Papers following the SOTA conference. Articles included:
- Peterson and colleagues conducted the first evidence review to evaluate the effectiveness of models to improve multimodal chronic pain care delivery in the primary care setting. Investigators found five models that coupled a decision-support component (i.e., stepped care) with proactive ongoing treatment monitoring as having the best evidence from good-quality randomized trials. They suggest wider implementation of one or more of these models, with a plan for further evidence development to address shortcomings of previous research.
- Edmond and colleagues examined non-pharmacological pain treatment strategies among 460 OEF/OIF/OND Veterans with chronic pain. Study results show that while one in five Veterans reported past-week opioid use, the majority (72%) used a non-opioid medication. In addition, some differences were observed in the use of non-pharmacological treatment based on demographic and clinical characteristics, which may indicate differences in Veteran treatment preferences or provider referral patterns.
- Lovejoy and colleagues compared rates of non-opioid analgesic pharmacotherapy and clinician referrals for non-pharmacologic pain treatment, complementary and integrative pain therapies, and specialty mental health and substance use disorder treatment between patients discontinued from opioid therapy due to aberrant behaviors versus other reasons. Patients discontinued due to aberrant behaviors, relative to patients discontinued for other reasons, were more likely to receive opioid tapers, new non-opioid analgesic medications, or dose changes to an existing non-opioid analgesic medication – or to be referred for specialty substance use disorder treatment. Findings highlight the variability in referral rates for different types of non-opioid pain treatments and challenges accessing specific types of pain care.
- Lozier and colleagues examined the frequency and correlates of use and self-rated helpfulness of non-pharmacologic treatments (NPTs) for chronic pain among 517 patients who were prescribed long term-opioid therapy. Findings show that 71% of patients used one or more NPTs for pain in the past six months, with clinician-directed NPT higher than self-directed NPT. More than half of the patients (range 51% to 79%) rated the use of NPTs assessed as helpful or very helpful.
- An editorial by Kerns, Krebs, and Atkins discusses the path forward – both clinical and research recommendations that focus on effective non-opioid therapies and integrated programs.
CITATION: Journal of General Internal Medicine. May 2018, Supplement;33(1)
As part of VA’s patient-centered approach to care, awareness of pain and efforts to improve pain management are VA's '5th Vital Sign' - a policy and practice wherein nursing staff routinely screen for 'pain now' at every health encounter using a 0-10 Numeric Rating Scale (NRS). Alternatives such as the NRS with a one-week lookback and a three-item scale (PEG) may improve the sensitivity and specificity of screening for chronic pain. This study evaluated such alternatives for use in primary care and patient aligned care teams (PACT’s).
In the development phase, investigators conducted interviews and focus groups with primary care staff and Veterans, to understand what patient-reported pain assessment data are most useful for clinical decision-making and how this pain information can best be integrated into primary care team processes. With those data investigators designed the enhanced pain screening approaches used in the second phase, a randomized controlled trial (RCT). In the setting of a primary care clinic, investigators evaluated three arms - a nurse documented NRS now, a tablet computer-based NRS one week, and a tablet computer-based PEG. Findings were:
- Multi-disciplinary team-based approaches to screening and managing pain in primary care should incorporate members of the extended PACT team including pharmacy, mental and behavioral health, and social work.
- Current approaches to screening and pain management in PACT may overemphasize pharmacologic approaches to the detriment of self-care and multidisciplinary approaches.
- Expanding the scope of PACT pharmacists to include pain-specific training may help relieve the burden of managing patients with chronic pain.
Implications: This project evaluated VA clinician and patient views of pain management processes as well as considerations for how improved screening could improve chronic pain management. Study findings have implications for continued research in PACT team structure, chronic pain management policies, clinical uses of automated pain screening tools, and sufficient access to non-pharmacological care.
This study resulted in the following publication(s):
Giannitrapani KF, Glassman PA, Vang D et al. Expanding the role of clinical pharmacists on interdisciplinary primary care teams for chronic pain and opioid management. BMC family practice. 2018 Jul 3; 19(1):107.
Giannitrapani KF, Ahluwalia SC, Day RT, et al. Challenges to teaming for pain in primary care. Healthcare (Amsterdam, Netherlands). 2018 Mar 1; 6(1):23-27.
Principal Investigator: Karl A. Lorenz MD, MSHS. VA Palo Alto Health Care System, Palo Alto, CA.
Chronic musculoskeletal pain is highly prevalent among Veterans and costly to treat. Complementary and integrative health practices (CIH) such as yoga, acupuncture, and chiropractic care appear to be effective non-pharmacological options for treating some types of chronic musculoskeletal pain or its comorbid conditions. As such, providing CIH practices are a VA-wide priority, but their cost effectiveness is unclear. This study sought to examine the cost effectiveness of CIH practices in reducing Veterans’ chronic musculoskeletal pain and its comorbidities. Researchers examined the use of nine CIH practices: acupuncture, biofeedback, guided imagery, therapeutic massage, meditation, tai chi, yoga, hypnosis, and chiropractic care among a cohort of 530,216 OEF/OIF/OND Veterans with chronic musculoskeletal pain. Specific aims were to determine the extent of Veterans' use of CIH practices, the cost of that CIH use, and the cost effectiveness of adjunctive CIH use compared to usual care alone. An advisory board of key VA stakeholders facilitated integration of results into recommendations.
- Of Veterans with chronic musculoskeletal pain, 16% used meditation, 7% used yoga, 6% used acupuncture, 4% used guided imagery, 4% used chiropractic, 3% used biofeedback, 2% used tai chi, 2% used massage, and 2% use hypnosis, with 27% using any of these.
- Those more likely to use any CIH practices included: female, White, or single patients; patients with back or neck pain, fibromyalgia, or temporo-mandibular disorder; or patients with symptoms of anxiety, depression, substance use disorder, sleep disturbance, or traumatic brain injury.
- Those using CIH practices differed from those not using CIH practices, even when controlling for demographic characteristics and comorbidities.
- On average, use of any CIH had a small, observable reduction on pain, healthcare costs (approximately $400/year), and opioid use.
Implications: This is the first widespread study of the overall impact of CIH use on healthcare utilization and health care cost in VA. The results of this cost-effectiveness study will help VA and other healthcare systems determine the extent to which particular CIH practices can provide a cost-effective non-pharmacological approach to reducing chronic musculoskeletal pain and its co-morbid conditions.
View study abstract.
This study resulted in the following publication(s):
Evans E, Herman P, Washington D, et al. Gender Differences in Use of Complementary and Integrative Health by U.S. Military Veterans with Chronic Musculoskeletal Pain. Women’s Health Issues. August 30, 2018;epub ahead of print.
Principal Investigator: Stephanie L Taylor PhD, MPH. VA Greater Los Angeles Healthcare System, Sepulveda, CA