Giving Veterans an Active Voice in Creating a Chronic Pain Research Agenda

Veterans’ Perspectives highlights research conducted by HSR&D and/or QUERI investigators, showcasing the importance of research for Veterans – and the importance of Veterans for research.

In the September-October 2023 Issue:

• Introduction: Despite the risk of addiction, many Veterans receive opioids for chronic pain.
• Project: This project sought to develop a national Veteran-centered chronic pain research agenda that included Veterans’ recommendations for chronic pain research priorities and their preferred pain management and treatment options.
• Findings: Veterans’ most frequently cited need for chronic pain management and treatment was better access to care. Some Veterans perceived that many providers overprescribed opioids as a “quick fix,” many Veterans wanted to be offered a range of choices for pain management, and many would like to see more studies on care coordination, mental health support, structural support, and the efficacy of non-traditional therapies.
• Implications: The project’s outcomes promote a Veteran-centered focus for researchers, clinicians, healthcare providers, healthcare system managers, and policy makers, and the VAL 2.0 methodology can be implemented with other historically marginalized populations to address healthcare topics that are most important to the chosen community.

Introduction

Chronic pain is a leading cause of disability among U.S. Veterans, affecting the lives of up to 70% of former military members.[1][2] Although rates of initiating opioid treatment for pain have fallen in VA, many Veterans still receive opioids for pain. Opioids are highly addictive, and their use for chronic pain control has contributed to a national public health crisis with devastating consequences.[3] Every day, approximately 220 Americans die after overdosing on opioids.[4]

In considering alternatives to opioids for Veterans who have chronic pain, it is important to recognize the unique factors specific to the Veteran population, as well as to understand pain's effects on Veterans' mental and physical well-being, and Veterans’ preferred pain management and treatment options.

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This Project

Veterans Action League (VAL) 2.0 was a two-year (2019–2021) Engagement Award funded by the Patient-Centered Outcomes Research Institute that sought to develop a national Veteran-centered chronic pain patient-centered outcomes research/comparative effectiveness research agenda that included Veterans’ recommendations for chronic pain research priorities. A total of 21 community meetings were held in Florida, Georgia, Illinois, North Carolina, and Virginia with 129 attendees, including Veterans (n = 111) and community stakeholders (n = 18), of which 84 were men, 41 were women, and four did not disclose their gender. Attendees shared opinions and challenges faced by Veterans and clinicians when managing and treating chronic pain, as well as strategies for improving chronic pain management and treatment options.

Project Participants

Each community meeting was co-led by a local Veteran with strong ties to the Veteran community and a nurse scientist with a Veteran-focused research program or clinical practice. Meeting leaders were trained as facilitators, and meeting invitations were extended to Veterans and key community stakeholders such as family members and friends of Veterans, healthcare providers who were working with Veterans, and representatives from Veteran advocacy organizations. Up to eight Veterans and stakeholders attended each meeting.

Findings

The personal interactions and camaraderie—as well as the presence of Veteran unit leaders—engendered comfort and trust among the diverse groups of Veterans at community meetings, and promoted open, honest, and meaningful conversations about pain management experiences and concerns. Veterans were very articulate in voicing their recommendations related to (a) what they need from the healthcare system to improve their chronic pain, (b) the chronic pain management techniques that they have found to be effective, and (c) their priorities related to chronic pain research.

• Veterans’ most frequently cited need for chronic pain management and treatment was better access to care, with easier appointment booking and shorter wait times.
• Veterans requested improved coordination among providers, and more thorough, holistic assessments for identifying contributors to their chronic pain.
• Some Veterans perceived that many providers overprescribed opioids as a "quick fix," while other Veterans were concerned that the anti-opioid pendulum had swung too far. Veterans across states strongly agreed that they wanted to be offered choices for chronic pain management, with their options clearly outlined and their preferences sought.
• Veterans’ preferred approaches for managing chronic pain were wide-ranging and included acupuncture, an anti-inflammatory diet, and epidural injections.
• Many Veterans said that they would like to see more studies on care coordination, mental health support, and structural support (access to care, including telehealth) for chronic pain management, as well as studies on the efficacy of non-traditional therapies, including cannabis, chiropractic treatments, and therapeutic massage.

Veterans shared their personal experiences with pain management and negotiating the healthcare system while experiencing chronic pain. One Veteran commented:

“Doctors see similar patterns with similar symptoms and assume you have whatever everyone else has. I wish doctors would listen more—take the time to investigate. I am worried I might have something more—like cancer.”

Many Veterans said they wanted alternatives to opioids, steroids, and other common pharmaceutical pain treatments; they wanted to treat the source of the pain rather than the pain symptom, and they were willing to try nontraditional methods to treat their pain. One Veteran said:

“People might say that you are just trying to get government to pay for your massage, but it really does help. Not a spa treatment. Massages really helped. Also acupuncture helps. Doctors chuckle when I ask about massage.”

David Hibler, a former U.S. Army sergeant, served as a military consultant to the project. He noted the challenges related to helping Veterans who have chronic pain, including a “significant gap in cultural understanding and language.” He explained:

“Many terms and phrases used by researchers and clinicians did not fully or correctly translate to many of the Veterans, and many of the researchers and clinicians were caught by surprise when learning about elements of the Veterans’ culture and how that played into their medical treatments.”

Mr. Hibler believed that this highlights the need for Veterans and research communities to educate each other, and for Veterans to be included on research teams.

Veterans’ Preferred Approaches to Chronic Pain Management

Implications

The outcomes of this Engagement Award project can be used by researchers, clinicians, healthcare providers, healthcare system managers, and policy makers to engage in activities that are Veteran-centered.

• Researchers interested in other healthcare needs among Veterans should consider engaging Veterans as this project did, using teams around the country to capture a sense of the Veteran community as a whole, while also providing details about specific regions and locations.
• Healthcare providers should consider integrating a patient-centered focus in primary and specialized care visits with Veterans.
• Policy makers should ensure that policies integrate Veterans’ needs and care preferences, and address care coordination barriers, especially those related to community providers.
• The VAL 2.0 methodology can be implemented with other historically marginalized populations to address healthcare topics that are most important to the chosen community.

Frances Weaver, PhD, MA, is an HSR&D Research Career Scientist and is part of HSR&D's Center of Innovation for Complex Chronic Healthcare in Hines, IL. She and HSR&D colleagues assisted lead investigator Cheryl A. Krause-Parello, PhD, RN, FAAN, on this project. Dr. Krause-Parello is director of Canines Providing Assistance to Wounded Warriors.

Study Publication

Krause-Parello CA, Flynn L, Pratt BA, and Weaver FM, et al. Veterans Action League 2.0: Creating a Veteran-Centered Chronic Pain Research Agenda. Journal of Community Engagement and Scholarship. March 23, 2023;15(2).

References

[1] Veterans Action League 2.0: Creating a Veteran-Centered Chronic Pain Research Agenda - Journal of Community Engagement and Scholarship (ua.edu)

[2] Chronic Pain - Whole Health Library (va.gov)

[3] Current perspectives on the opioid crisis in the US healthcare system - PMC (nih.gov)

[4] Benzodiazepines and Opioids | National Institute on Drug Abuse (NIDA) (nih.gov)

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