- Veterans Reveal Positive Aspects of Routine VA Pain Screening
Using data from a study that evaluated a strategy to improve the use of the “5th Vital Sign” of pain in primary care, investigators identified 36 Veterans from five primary care clinics and three VA healthcare systems who were interviewed about pain screening. Generally, Veterans believed that routine pain screening is positive. Findings revealed five themes that summarize Veterans’ experience and preferences of being screened for pain: 1) Pain screening can determine the tone and guide the focus of the visit; 2) Screening can initiate communication about pain, which is important because some Veterans feel that discussing pain indicates weakness; 3) Screening can facilitate patient recall and reflection, allowing the patient to bring up symptoms that may have been overlooked in the past or would have gone unmentioned; 4) Screening can help identify under-reported psychological pain, mental distress, and suicidality that might not come up without provider probing; and 5) Screening allows patients to offer recommendations to improve screening for pain; e.g., Veterans emphasized that screening language and specific word choices matter. Results indicate that Veterans perceive meaningful, positive impacts of routine pain screening, specifically, routine screening for pain may help capture mental health concerns that may otherwise not emerge
Date: March 6, 2020
- Integrated Pain Team Programs Improve Outcomes for Chronic Pain and May Reduce Reliance on High-Risk Opioid Therapy
This study examined changes in self-reported chronic pain-, opioid-, and treatment-related outcomes among Veterans with chronic pain following the implementation of a primary care-based biopsychosocial Integrated Pain Team (IPT) model within the San Francisco VA Health Care System. Findings showed that Veterans with chronic pain who engaged in the IPT program reported improvement in several outcomes related to pain-related distress and disability, and opioid misuse. While patients did not report a significant change in pain severity from baseline to follow-up, they did report significantly reduced pain interference in daily functioning. Pain catastrophizing also showed significant reduction, driven by decreases in pain-related magnification and helplessness. Regarding patients prescribed opioids at both baseline and follow-up, opioid misuse decreased significantly. For example, there was a significant reduction in the frequency of opioid misuse behaviors. At follow-up versus baseline, patients reported increased use of integrative (e.g., acupuncture) and active pain management strategies (e.g., exercise), and were less likely to use only pharmacological pain management strategies. Findings suggest that primary care-based IPT programs may improve patient-centered outcomes for individuals with chronic pain and reduce reliance on potentially high-risk opioid therapy.
Date: February 25, 2020
- Increases in Opioid Dosing of 20% or Greater were Not Associated with Improvements in Pain among Veterans
This study examined the influence of opioid dose escalation on pain scores recorded in the VA electronic medical record among patients on chronic opioid therapy for chronic non-cancer pain. Findings showed that increases in opioid dose of 20% or greater were not associated with improvements in pain scores. In the follow-up period, dose escalators had higher average morphine milligram equivalents (MME) when compared to dose maintainers and were more likely to use long-acting opioids in combination with a short-acting opioid (18% vs. 8%, respectively). Clinicians should carefully evaluate increasing opioid doses, regardless of the current dose. When determining whether to escalate the dose, considerations should focus less on the potential benefit to improve pain intensity and more on the balance of other potential benefits and harms.
Date: January 7, 2020
- Health is the Main Concern of Newly Separated Veterans
This large study is the first in-depth investigation of U.S. Veterans’ health and well-being as they leave military service. Findings showed that health concerns were the most salient for newly separated Veterans, with many reporting that they had chronic physical (53%) or mental (33%) health conditions – and that they were less satisfied with their health than either their work or social relationships. Chronic pain, sleep problems, anxiety, and depression were most commonly reported by Veterans. Men were more likely to report a hearing condition, high blood pressure, and high cholesterol, while women were more likely to report anxiety and depression at both survey timepoints. Compared with officers, enlisted personnel reported consistently poorer health, vocational, and social outcomes, and deployed Veterans reported poorer health than non-deployed Veterans. Veterans’ work functioning declined in the first year after leaving military service. Findings suggest several important directions for future prevention and early intervention efforts (i.e., health concerns such as chronic pain, sleep, and anxiety), which, if implemented, have the potential to put Veterans on the path to more successful and fulfilling post-military lives.
Date: December 28, 2019
- History of Military Sexual Trauma Common among Older Women Veterans
This study sought to determine the prevalence of military sexual trauma (MST) among older women Veterans – and investigate associations between MST and medical and mental health diagnoses. Findings showed that a history of MST was common among older women Veterans. Positive MST screens were observed in nearly 1 in 5 women aged 55-64, and 1 in 10 aged 65-74. [This is similar to the 23% prevalence found in previous studies in women younger than age 55. Accounting for demographic risk factors, MST was associated with increased odds of a range of medical and mental health diagnoses. Most notably, MST was associated with 7.25 times the odds of PTSD and over two-fold odds of depression and suicidal ideation, as well as increased odds of anxiety, alcohol use disorder, substance use disorder, opioid use disorder, sleep disorders, and chronic pain. Thus, older women Veterans remain at risk for the effects of potentially remote MST. Findings call attention to the need for additional research in this understudied population, and the importance of trauma-informed care approaches for women across the lifespan.
Date: November 11, 2019
- Strategies VA Clinicians Use to Structure Difficult Conversations Regarding Opioid Prescribing
This study aimed to identify and describe clinicians’ strategies for managing prescription opioid misuse and aberrant behaviors among patients prescribed long-term opioid therapy (LTOT) for chronic pain. Interview results identified challenges faced by clinicians in navigating conversations about opioid management, stemming from patient dissatisfaction and clinician ambivalence about enacting guideline-recommended changes. To manage difficult conversations, clinicians shared “verbal heuristics” – essentially a pre-packaged response or conversational short-cut – to more quickly and efficiently guide and defuse challenging, emotional conversations. Four varieties of heuristics were identified and include: safety (i.e., “I don’t feel comfortable prescribing for you anymore because you’re using in a way that’s unsafe.”); setting expectations (i.e., “no early refills even for legitimate reasons”); following orders (i.e., “we’re following the rules…and have no choice”), and standardization (i.e., “I do this for all my patients.”).
Date: July 1, 2019
- Opioid Prescribing Safety Initiative Effective in Decreasing Rates of Opioid Prescribing for Older Veterans with Osteoarthritis
Investigators in this study examined national trends in opioid and non-opioid analgesic prescribing before and after implementation of VA’s Opioid Safety Initiative (OSI). Findings showed that before OSI implementation, total analgesic prescriptions showed a steady rise, which abruptly decreased to a flat trajectory after the OSI was implemented. This trend was primarily due to a decrease in opioid prescribing after OSI, as well as a significant modest rise in acetaminophen prescriptions post-OSI. Among Veterans reporting pain, the intensity of pain remained unchanged over the study period. Thus, changes in analgesic prescribing trends were not accompanied by changes in reported pain intensity for older Veterans with osteoarthritis. No changes in non-steroidal anti-inflammatory drug prescribing were observed. Thus, over the period 2012-2016, VA’s successful efforts to reduce opioid prescribing did not result in worsening pain among patients with osteoarthritis.
Date: June 1, 2019
- Substantial Variation in Opioid Prescribing Rates among ED Providers in the Same VA Healthcare Facility
The study team examined the extent to which variation in individual ED physicians’ opioid prescribing was independently associated with long-term opioid use in Veterans. Using VA data, investigators identified Veterans with an index ED visit at any VA facility in 2012 – and who were opioid naïve (without opioid prescriptions in the prior 6 months). Findings showed that there was a three-fold variation in the rates of opioid prescribing by ED physicians within the same VA facility (21% vs. 6%), regardless of patients’ severity of pain or primary diagnosis. The frequency of long-term opioid use was higher among opioid-naïve Veterans treated by high vs. low-quartile ED prescribers, though above the threshold for statistical significance (1.39% vs. 1.26%). Though the increase in long-term opioid use among Veterans treated by the highest-prescribing ED providers was not significant in the overall sample, it was significant among important patient subgroups, including those with back pain, musculoskeletal pain, or depression. High-intensity prescribers were more likely to prescribe opioids across the spectrum of pain intensity, while low-intensity prescribers were less likely to prescribe opioids across the spectrum.
Date: May 29, 2019
- Rural and Western Region Veterans Prescribed More Opioids Than Urban, Other Regions
This study sought to characterize regional variation in opioid prescribing across VA and examine prescribing differences between rural and urban Veterans. Findings showed substantial rural-urban variation in VA opioid prescribing, with rural Veterans receiving over 30% more opioids than their urban counterparts, with most of the difference attributable to long-term use. Utilization was lowest in the Northeast and highest in the West. Mean days’ supply dispensed at initiation was higher for rural veterans (15 vs. 13) and the proportion prescribed an initial 30 days’ supply was 23% for rural vs. 19% for urban Veterans. The prescribing gap between urban and rural Veterans in the South was 33% vs. 13% in the Northeast, and similar in the West and Midwest. Higher rates of opioid prescribing among rural compared to urban Veterans are driven mostly by higher rates of long-term use, indicating a need for interventions to improve access to non-pharmacologic treatment for chronic pain among rural Veterans.
Date: May 21, 2019
- Many VA Patients Use and are Interested in Learning More about Complementary and Integrated Health Options
In part to guide the expansion of evidence-based complementary and integrative health (CIH), VA leaders sought current information on Veterans’ interest in and use of various CIH approaches, both inside and outside the VA healthcare system. Thus, investigators in this study analyzed survey results from a large sample of Veterans on their interest in, use of, and satisfactions with 26 CIH approaches. Findings showed that in the past year, 52% of Veterans in this study used any CIH approach, with 44% using massage therapy, 37% using chiropractic, 34% using mindfulness, 24% using other meditation, and 25% using yoga. Pain, stress reduction/relaxation, and improving overall health and well-being were the top three reasons for using 9 of the 26 CIH approaches. Overall, 84% of Veterans in this study stated an interest in trying/learning more about at least one CIH approach, with about half being interested in six individual approaches (massage therapy, chiropractic, acupuncture, acupressure, reflexology, and progressive relaxation). Veterans appeared to be much more likely to use each CIH approach outside vs. within VA.
Date: April 22, 2019
- Links Between Opioid Use and Suicide
This review describes what is known about the links between suicide and overdoses, with a focus on pathways through opioid use, issues of intent, risk factors, prevention strategies, and unresolved issues. Many factors promote the initiation and persistence of opioid use, but several specific pathways toward vulnerability to overdose and suicide are highlighted. Interventions that address shared causes and risk factors, such as programs to improve the quality of pain care, expanding access to psychotherapy, and increasing access to medication-assisted treatment for opioid use disorders, have the potential to be high-value investments by addressing both problems.
Date: January 3, 2019
- Link between Length of Prescription for Initial Exposure to Opioids and Long-Term Use
This study examined the association between initial opioid exposure and subsequent long-term use in two national VA cohorts from 2011 and 2016. Findings showed a strong relationship between initial opioid exposure and the future likelihood for long-term use. Cumulative days’ supply of prescription opioids emerged as the strongest predictor of long-term opioid use, which occurred in only 2% of Veterans dispensed 7 days’ or less supply, and in 28% of patients dispensed greater than 30 days’ supply. Comparing 2011 and 2016 data, the association between day’s supply and long-term use persisted, even as the overall rate of long-term opioid use decreased. Findings suggest that limiting initial opioid exposure may reduce risk for long-term opioid use. Moreover, examination of early opioid exposure may offer an opportunity to recognize when a patient is in the process of starting long-term opioid use.
Date: November 5, 2018
- Veterans Receiving Prescriptions Through Both VA and Medicare Are More Likely to Be Taking Opioids and Benzodiazepines
This study sought to assess the association between receiving medications from both VA and Medicare Part D (dual use) and the receipt of overlapping opioid and benzodiazepine prescriptions. Findings showed that receiving prescription medications from both VA and Medicare Part D was associated with a 27% increased risk of overlapping opioids and benzodiazepines – and more than twice the risk of overlapping high-dose opioids with benzodiazepines – compared to receiving prescriptions from VA alone. Receipt of prescriptions from both VA and Medicare also was associated with a greater risk of opioid/benzodiazepine overlap compared to Medicare alone, although the difference was smaller. Receipt of medications from more than one healthcare system is a key risk factor for unsafe prescribing practices, highlighting the need to enhance coordination of care across healthcare systems to optimize the quality and safety of prescribing.
Date: October 9, 2018
- Battlefield Acupuncture Proves Highly Effective in Treating Chronic Pain among Veterans
Battlefield acupuncture (BFA) involves a small needle inserted into parts of the ear that have a “central effect” on the nervous system and an area of the brain that processes pain. This study examined the use and effectiveness of BFA for pain in group and individual sessions at a large VA medical center. Findings showed that BFA was highly efficacious in immediately reducing pain for a significant majority of Veterans in this study, whether BFA was done individually or in group clinics. Of 753 total patient encounters, a decrease in self-reported pain occurred in 82%, no change occurred in 10%, and an increase occurred in 8%. Absolute levels of pain reduction were greater in Veterans with the highest self-reported pain and did not seem to decrease in those who underwent repeated procedures.
Date: September 5, 2018
- Women Veterans with Pain More Likely to Use Complementary and Integrative Therapies
This study sought to examine complementary and integrative health (CIH) therapy use by gender among Veterans with chronic musculoskeletal pain, and variations in gender differences by race/ethnicity and age. Findings showed that of Veterans with chronic musculoskeletal pain, more women than men used CIH therapies (36% vs. 26%). Black women, regardless of age, were least likely to use CIH therapies compared to other women. Among men, White and Black Veterans were less likely to use CIH therapies, irrespective of age, than men of Hispanic or other race/ethnicities. Among both women and men, CIH therapies were least likely to be used by younger Black or White Veterans. Given the disparities in CIH therapy use, tailoring CIH therapy engagement to gender, race/ethnicity, and age may increase CIH therapy use among Veterans.
Date: September 1, 2018
- Pain Medicine Supplement Features Articles by VA Researchers
This Pain Medicine Supplement highlights health services research conducted by HSR&D investigators at the Pain Research, Informatics, Multimorbidities and Education (PRIME) Center of Innovation in West Haven, CT, as well as other pain researchers. Serving as the only federally funded national pain center, PRIME played a leadership role in the HSR&D-sponsored state-of-the-art conference “Non-pharmacological Approaches to Chronic Musculoskeletal Pain Management. Investigators in this Supplement focused on four Health Federal Pain Research Strategy goals: 1) Define the Epidemiology of Pain; 2) Develop, Evaluate, and Improve Pain Management; 3) Determine the Relationship between Pain and Common Comorbidities, and 4) Determine Optimal Self-Management Strategies for Chronic Pain.
Date: September 1, 2018
- Pain Intensity Following Discontinuation of Long-Term Opioid Therapy Does Not, on Average, Worsen for Patients
This study sought to characterize pain intensity over 12 months following opioid discontinuation. Findings showed that average pain intensity did not significantly worsen in the 12 months after Veterans discontinued opioid therapy; for some patients, pain intensity improved. Mean estimated pain at the time of opioid discontinuation was 4.9 on a scale from 0-10. Changes in pain following discontinuation were characterized by slight but statistically non-significant declines in pain intensity over 12 months post-discontinuation. Veterans in the mild (average pain = 3.9) and moderate (average pain = 6.3) pain categories experienced the greatest pain reductions post-discontinuation. Of this study cohort, 87% of Veterans were diagnosed with chronic musculoskeletal pain, 6% with neuropathic pain, and 11% with headache pain (including migraine). Study findings can aid clinicians during discussions with patients about opioid discontinuation.
Date: June 13, 2018
- Opioids Do Not Result in Better Pain-Related Function or Pain Intensity Compared to Non-Opioid Drugs in Veterans with Chronic Pain
This randomized trial compared opioid therapy versus non-opioid medication therapy over 12 months for primary care patients with chronic back pain or hip or knee osteoarthritis pain. Findings showed that the use of opioid therapy compared with non-opioid medication therapy did not result in significantly better pain-related function over 12 months. Opioid therapy compared with non-opioid medication therapy resulted in significantly worse pain intensity over 12 months, but the importance of this is unclear because the magnitude was small. Opioids caused significantly more medication-related adverse symptoms than non-opioid medications. Overall, opioids did not demonstrate any advantage over non-opioid medications that could potentially outweigh their greater risk of overdose and other serious harms. Results do not support initiation of opioid therapy for moderate to severe chronic back pain or hip/knee osteoarthritis pain.
Date: March 6, 2018
- Racial/Ethnic and Gender Variations in Veteran Satisfaction with VA Healthcare
This study of Veterans’ satisfaction with outpatient, inpatient, and specialist care in a diverse sample of Veterans from predominantly minority-serving VAMCs sought to better understand racial/ethnic and gender variations in healthcare satisfaction. Findings showed generally high levels of healthcare satisfaction across 16 domains, with 83% of respondents somewhat or very satisfied with VA healthcare overall. The highest satisfaction ratings were reported for costs, outpatient facilities, and pharmacy services (74% to 76% were very satisfied); the lowest ratings were reported for access to care, pain management, and mental healthcare (21% to 24% were less than satisfied). Contrary to previous studies, there was little evidence of racial, ethnic, or gender disparities in satisfaction with care at minority serving VAMCs.
Date: March 1, 2018
- Medical Record Alert Associated with Reduced Opioid and Benzodiazepine Co-prescribing
This implementation project evaluated the effectiveness of an advanced medication alert designed to reduce opioid and benzodiazepine co-prescribing among Veterans with high-risk conditions (substance use disorder, sleep apnea, suicide risk, and age =65) at one VA healthcare system (VA Puget Sound). Findings showed that the proportions of patients with concurrent prescriptions decreased significantly post-alert launch among Veterans with substance use (25%), sleep apnea (39%), and suicide risk (62%), with greater decreases at the alert site relative to the comparison site in sleep apnea and suicide-risk cohorts. Significant decreases in benzodiazepine prescribing were observed at the alert site only.
Date: December 28, 2017
- Effects of Cannabis among Adults with Chronic Pain
This systematic review assesses the efficacy of cannabis for treating chronic pain, and provides a broad overview of the short- and long-term physical and mental health effects of cannabis use in chronic pain and general patient populations. Overall, investigators found low-strength evidence that cannabis may improve pain in some patients with neuropathic pain and insufficient evidence to characterize the effects of cannabis on pain in patients with multiple sclerosis. Moderate-strength evidence suggests that light to moderate cannabis smoking does not adversely impact lung function over about 20 years, however, the limited evidence examining the effects of heavy use suggests a possible deleterious effect on lung function over time. There is a consistent association between cannabis use and the development of psychotic symptoms over the short and long term, and cannabis appears to be associated with at least small, short-term deleterious effects on cognition in active users.
Date: August 5, 2017
- Systematic Review: Patient Outcomes in Dose Reduction or Discontinuation of Long-term Opioid Therapy Suggest Utility of Multimodal Care
Investigators examined the evidence on the effectiveness of strategies to reduce or discontinue long-term opioid therapy (LTOT) prescribed for chronic pain – and the effect of dose reduction or discontinuation on important patient outcomes, including pain severity and pain-related function. Findings showed that there are multiple strategies to reduce or discontinue long-term opioid treatment for chronic pain, however the quality of the evidence for effectiveness was very low. In 3 good-quality trials of behavioral interventions and 11 fair-quality studies of interdisciplinary pain programs, patients received multimodal care that emphasized non-pharmacologic and self-management strategies. Sixteen fair-quality studies reported improvement in pain severity (8/8 studies), function (5/5 studies), and quality of life (3/3 studies) following opioid dose reduction. However, few studies examined the potential risks of opioid dose reduction such as adverse events (i.e., opioid overdose), illicit substance abuse, or suicide.
Date: July 18, 2017
- A Positive Psychological Intervention Improves Outcomes for Veterans with Knee or Hip Osteoarthritis
This study sought to determine whether patients randomized to a program designed to boost positive affect and develop positive psychological skills (e.g., gratitude and kindness) would report greater improvements over time in osteoarthritis (OA) symptom severity and measures of psychosocial well-being compared with patients randomized to a neutral control program. Findings showed that the 6-week positive psychological intervention produced large reductions in OA symptom severity, decreased negative affect, and increased life satisfaction compared to a robust control program among Veterans with knee or hip osteoarthritis. Retention through both 6-week programs was high, with 79% of participants completing at least 5 of 6 weekly calls and 64% reporting that they completed 80% or more of their weekly activities. Participants rated the activities as highly beneficial, highly enjoyable, and low in difficulty. Results indicate the potential of a non-pharmacological therapy to improve symptom management in this population with moderate to severe pain and suggest that using positive activities as part of an overall treatment program for patients with OA could have a large impact.
Date: June 27, 2017
- Managing Chronic Pain in the Wake of the Opioid Backlash
This JAMA Viewpoint commentary discusses several options for managing pain, as well as the overuse of the term “opioid epidemic.” Authors warn that imperfect treatments do not justify therapeutic distrust, and suggest that there is a broad menu of partially effective treatment options that can maximize the chances of achieving at least partial amelioration of patients’ chronic pain.
Date: June 20, 2017
- Systematic Review on the Benefits and Harms of Spinal Manipulative Therapy for Acute Low Back Pain
This systematic review was conducted to provide updated estimates of the effectiveness and harms associated with spinal manipulative therapy (SMT) compared with other non-manipulative therapies for adults with acute low back pain. Findings showed that spinal manipulative therapy was associated with statistically significant benefits in both pain (15 randomized controlled trials [RCTs] with moderate quality evidence) and function (12 RCTs with moderate quality evidence) – of an average modest magnitude at up to six weeks. Minor transient adverse events (i.e., increased pain, muscle stiffness, and headache) were reported in more than half of the patients (67%) in the large case series.
Date: April 11, 2017
- Self-Management Intervention for Chronic Pain
Interactive voice response (IVR) – automated telephonic technology that allows patients to report symptoms, functioning, and pain coping skill use and to receive pre-recorded information and feedback – may improve access to cognitive behavioral therapy (CBT) for chronic pain. This randomized trial assessed the efficacy of interactive voice response-based CBT (IVR-CBT) as compared to in-person CBT among 125 Veterans who received treatment for chronic back pain in the VA Connecticut Healthcare System from June 2012 through July 2015. Findings showed that Veterans in both the IVR-CBT and in-person CBT groups experienced statistically significant reductions in average pain intensity at 3 and 6 months post-baseline, but not at 9 months. Veterans in both groups also experienced statistically significant improvements in physical functioning, sleep, and physical quality of life at 3 months relative to baseline, with no advantage for either group. The treatment dropout rate was lower among Veterans in the IVR-CBT group, with patients completing an average 2.3 more sessions. IVR-CBT is a low-burden alternative that can increase access to CBT for patients with chronic pain; it also shows promise as a non-pharmacologic treatment option for chronic pain.
Date: April 3, 2017
- Opioid Use among Afghanistan and Iraq War Veterans
This study sought to understand current opioid use in OEF/OIF/OND Veterans who are regular users of VA care and did not have a cancer diagnosis at the time of this study. Findings showed that opioid use among OEF/OIF/OND Veterans is characterized by moderate doses that are used over relatively long periods of time by a minority of Veterans. Approximately 23% of all OEF/OIF/OND Veterans received opioids, with 7-8% receiving them chronically. The prevalence of high-dose opioids, concurrent use of multiple opioids, and use of long-acting opioids was fairly low. Diagnoses of PTSD, major depressive disorder, and tobacco use disorder were strongly associated with chronic opioid use. Back pain also was strongly associated with chronic use. Findings suggest that the use of opioids is less common among OEF/OIF/OND Veterans compared with Veterans as a whole, and provide a strong baseline for evaluating the impact of recently implemented opioid-related policies.
Date: March 25, 2017
- Gender and Smoking Impact Severity of Musculoskeletal Pain among OEF/OIF Veterans
This study sought to examine gender differences in the association between cigarette smoking and moderate to severe musculoskeletal pain in Veterans of the wars in Afghanistan and Iraq. Findings showed that both gender and current smoking status were significantly associated with increased odds of moderate to severe musculoskeletal pain. Male Veteran non-smokers were more likely than female Veteran non-smokers to report moderate to severe pain; however, there were no gender differences in moderate to severe pain among Veteran smokers. Relative to female non-smokers, female Veteran smokers had increased odds of reporting moderate to severe musculoskeletal pain.
Date: March 14, 2017
- Addressing the Opioid Epidemic: Lessons Learned from VA
This article describes VA’s efforts to address the opioid epidemic, and lessons learned that can inform other healthcare systems planning comprehensive action to reduce the risks associated with opioid therapy.
Date: March 13, 2017
- Discontinuation of Long-Term Opioid Therapy among Veterans is Overwhelmingly Initiated by VA Clinicians
The aim of this study was to compare reasons for discontinuation of long-term opioid therapy (LTOT) between Veterans with and without substance use disorder (SUD) receiving care within the VA healthcare system in the years following release of 2009 and 2010 clinical practice guidelines. Findings showed that the majority of Veterans (85%) discontinued opioid use because their clinician stopped prescribing, rather than the patients deciding to stop. For patients whose clinicians initiated discontinuation, 75% were discontinued due to opioid-related aberrant behaviors (i.e., suspected substance abuse, aberrant urine drug test). Veterans with SUD diagnoses were more likely to discontinue LTOT due to aberrant behaviors, particularly abuse of alcohol or other substances, compared to Veterans without SUD. High proportions of patients received diagnoses for mental health disorders in the year prior to discontinuation of LTOT, including PTSD, anxiety disorders other than PTSD, and depressive disorders (25%). Increasing rates of opioid discontinuation are likely to occur due to policies and programs that encourage close monitoring of Veterans on LTOT for opioid misuse behaviors. Integrating non-opioid pain therapies and SUD treatment into multiple settings such as primary care and specialty SUD care is one possible approach to enhance their care.
Date: March 1, 2017
- VA Opioid Safety Initiative Decreases Potentially Risky Opioid Prescriptions among Veterans
This study examined changes associated with Opioid Safety Initiative (OSI) implementation among all adult VA patients who filled outpatient opioid prescriptions from October 2012 through September 2014 in any of 141 VA facilities. Findings showed that during the two-year study period there was a decrease in the number of VA patients receiving risky opioid regimens, with an overall reduction of 16% among Veterans receiving >100 morphine-equivalent milligrams (mEq) daily dosages and 24% among Veterans receiving >200 mEq. There was a 21% reduction in Veterans receiving benzodiazepines concurrently with opioids. Implementation of the OSI dashboard tool was associated with a significant decrease in all three outcomes (>100 mEq, >200 mEq and concurrent opioid/benzodiazepine prescribing). The implementation of the OSI dashboard tool was associated with a significant decrease in risky opioid prescribing across the VA healthcare system, which highlights the possibility of system-wide approaches to address high-risk opioid prescribing. However, a large number of VA patients remained on these regimens at the end of the study period, which emphasizes the challenges of making significant changes in healthcare systems that treat a large population of complex patients.
Date: January 4, 2017
- Safety Risk for Veterans Receiving Overlapping Buprenorphine, Opioid, and Benzodiazepine Prescriptions from VA and Medicare Part D
Ensuring safe buprenorphine prescribing is especially challenging for VA, which treats a substantial number of Veterans with chronic pain and opioid use disorder, as well as an increasing number of patients who receive concurrent care in the private sector (i.e., Medicare Part D). This study identified Veterans dually enrolled in VA and Medicare Part D who filled a buprenorphine prescription in 2012 from either healthcare system and identified the proportion of Veterans with overlapping prescriptions from either system. Findings showed that more than one in four Veterans who received a VA prescription for buprenorphine – and one in five Veterans who received a Medicare prescription for buprenorphine – also received overlapping prescriptions for opioids from a different healthcare system. Among Veterans receiving buprenorphine from VA, 1% received an overlapping benzodiazepine prescription from Medicare, while among those receiving buprenorphine from Medicare, 16% received an overlapping benzodiazepine prescription from VA. Among VA and Part D buprenorphine recipients who had cross-system opioid overlap, 25% and 35%, respectively, had >90 days of overlap. Findings indicate a previously undocumented safety risk for Veterans dually enrolled in VA and Medicare who are receiving prescriptions for buprenorphine and overlapping prescriptions for opioids and/or benzodiazepines.
Date: December 7, 2016
- OEF/OIF/OND Veterans that Currently Smoke More Likely to Receive Opioid Prescription than Non-Smokers
This study sought to determine if smoking status is associated with the receipt of opioids among OEF/OIF/OND Veterans – and to examine important covariates of smoking (i.e., current pain intensity, gender, and mental health diagnoses) and receipt of opioids. Findings showed that compared to non-smokers, OEF/OIF/OND Veterans who were current smokers were more likely to receive an opioid prescription, even after controlling for covariates including: pain intensity, age, gender, service-connection, substance use disorder, mood disorders, and anxiety disorders. Veterans who reported a higher current pain intensity and those with pain diagnoses also were more likely to receive an opioid prescription. Among this young cohort of Veterans (mean age=30 years), more than one-third (34%) reported moderate to severe current pain intensity within +/-30 days of smoking status, with approximately 8% receiving at least one opioid prescription.
Date: September 21, 2016
- Barriers to Implementing Choosing Wisely® Recommendations
This study sought to determine whether particular Choosing Wisely® (CW) recommendations are perceived by primary care providers as difficult to follow, difficult for patients to accept, or both. Findings showed that while PCPs found many Choosing Wisely® recommendations easy to follow, they felt that some, especially those for symptomatic conditions, would be difficult for patients to accept. For 4 recommendations about not screening or testing in asymptomatic patients, e.g., avoiding colorectal screening for 10 years in patients with negative colonoscopy, less than 20% of PCPs found the CW recommendations difficult to accept (7%-17%) or difficult for patients to follow (12%-19%). For 5 recommendations about testing or treatment for symptomatic conditions, e.g., limiting the use of antibiotics for sinusitis, avoiding imaging tests for low back pain within the first six weeks, however, there was both variation in reported difficulty to follow (10%-32%) and a high level of reported difficulty for patients to accept (36%-87%). The most frequently reported barriers to reducing overuse included malpractice concern, patient requests for services, lack of time for shared decision-making, and the number of tests recommended by specialists.
Date: September 6, 2016
- Prescription Opioids Associated with Lower Likelihood of Sustained Improvement in Pain among Older Veterans
This study sought to identify patient factors associated with improvements in pain intensity in a national cohort of Veterans 65 years or older with chronic pain. Findings showed that on average, Veterans prescribed an opioid were less likely to demonstrate sustained improvement in pain intensity scores compared to Veterans who were not prescribed opioids. Overall, average relative improvement in pain intensity scores from baseline ranged from 25% to 29%; almost two-thirds of Veterans met criteria for sustained improvement during follow-up. Findings call for further characterization of heterogeneity in pain outcomes in older adults, as well as further analysis of the relationships between prescription opioids and treatment outcomes.
Date: July 1, 2016
- Prescription Opioid Use among Patients with Recent History of Depression Increases Risk of Recurrence
This study examined whether patients in depression remission who were prescribed opioids for non-cancer pain had an increased risk of depression recurrence. Investigators analyzed two patient populations: Veterans treated in the VA healthcare system, and patients treated by a non-profit integrated healthcare system located in Texas. Findings showed that prescription opioid use among patients with a recent history of depression increased the chance of depression recurrence, and this effect was independent of pain diagnoses and pain intensity scores. Patients with remitted depression who were exposed to opioid analgesics at any point during the follow-up period were 77% to 117% more likely to experience a recurrence of depression than those who remained opioid free, after controlling for other factors. Among VA patients with depression remission, those who received opioids during follow-up were younger, had more psychiatric comorbidities, and had more painful conditions and higher pain scores than those who didn’t receive opioids.
Date: April 1, 2016
- Prescription Use of Codeine Associated with Greater Risk of New Onset Depression among Veterans
This study sought to determine whether the hazard of new depression diagnosis differs among VA patients prescribed only codeine, only hydrocodone, or only oxycodone. Findings showed that Veterans prescribed only codeine for 30 days or longer had a 29% increased risk of a new diagnosis of depression compared to Veterans prescribed only hydrocodone for 30 days or longer. Those prescribed only oxycodone for 30 days or longer were not significantly more likely to develop a new depression diagnosis compared to patients prescribed hydrocodone only. Opioid use of 30-90 days was most common among oxycodone users, and opioid use of more than 90 days was most common among hydrocodone users. The distribution of individual comorbid conditions did not significantly differ across the three types of opioids.
Date: March 22, 2016
- The Gerontologist Supplement Highlights VA Research on Health Issues Affecting Older Women Veterans
This Supplement includes 13 articles that highlight findings on a range of topics related to women Veterans and aging, such as, menopause, diabetes, cardiovascular disease, chronic pain, and substance use.
Date: February 1, 2016
- Increased Dose of Prescription Opioids Raises Risk of Suicide among Veterans with Chronic Non-Cancer Pain
This study examined the association between prescribed opioid dose and suicide in a national sample of VA patients with a chronic non-cancer pain condition who received opioid therapy. Findings showed that increased dose of opioids was found to be a marker of increased suicide risk, even when relevant demographic and clinical factors were statistically controlled. Type of opioid dosing schedule (i.e., regularly scheduled, as needed, or both) did not significantly affect suicide risk after accounting for other factors. Similar to the U.S. population and other large studies of VA patients, the vast majority of suicides involved firearms (64%), with overdose accounting for 20% of all suicides.
Date: January 5, 2016
- Receipt of Opioid Analgesics and Benzodiazepines Associated with Increased Risk of Death Due to Drug Overdose
This study sought to describe the relationship between the receipt of concurrent benzodiazepines and opioid analgesics and death due to drug overdose in patients receiving prescription opioids for acute, chronic, and non-terminal cancer pain. Findings showed that during the study period, 27% of Veterans who received opioid analgesics also received benzodiazepines. Among those receiving opioid analgesics, receipt of benzodiazepines was associated with an increased risk of death due to drug overdose. About half of the overdose deaths occurred when Veterans were concurrently prescribed benzodiazepines and opioids. Patients who were prescribed concurrent opioids and benzodiazepines –and then stopped receiving benzodiazepines had higher rates of overdose than those patients who had only received opioids. Veterans who received benzodiazepines were more likely to be female, middle-aged, white, and to reside in wealthier areas. Veterans who received benzodiazepines were also more likely to have had a recent mental health or substance use disorder-related hospitalization, a diagnosis of a substance use disorder, or a number of psychiatric disorders (i.e., PTSD, depression, anxiety). These findings provide empirical support for the goal of the VA Opioid Safety Initiative (OSI) to reduce unnecessary co-prescribing of opioids and benzodiazepines, for which there had been limited evidence prior to this study.
Date: June 10, 2015
- Gender Differences in Chronic Pain among Veterans
This study examined a) gender differences in trauma, social support, and family conflict among OEF/OIF/OND Veterans with chronic pain, and b) whether these variables were differentially associated with pain severity, functioning, and depressive symptom severity as a function of gender. Findings showed that 69% of Veterans in the study reported experiencing pain for 3 months or longer (67% of men and 71% of women); 75% stated pain had been present for more than one year. The most problematic sites of pain were: back (37%), joint (33%), headache (12%), and neck (9%). Men and women Veterans did not differ significantly in terms of pain severity, pain interference with function, depressive symptom severity, or use of prescription opioids. Relative to men, women Veterans reporting chronic pain evidenced higher rates of childhood interpersonal trauma (51% vs. 34%) and military sexual trauma (54% vs 3%), as well as lower levels of combat exposure. Being married was associated with greater pain-related functional difficulty for women and lower difficulty for men. Combat exposure was associated with pain-related functional difficulty for women but was unrelated for men. Childhood interpersonal trauma was more strongly associated with pain-related functioning among men. Family conflict was associated with greater pain-related functional difficulty and depressive symptoms for men, but was unrelated for women. Thus, gender may be a salient target of investigation when examining development of and/or adaptation to chronic pain, and is an important consideration in tailoring treatment programs to meet the needs of Veterans with chronic pain.
Date: June 1, 2015
- Stepped Care Intervention Benefits Veterans with Chronic Pain
This randomized controlled trial tested the Evaluation of Stepped Care for Chronic Pain (ESCAPE) intervention in primary care settings that included 12 weeks of analgesic treatment (i.e., acetaminophen, topical analgesics, opioids) coupled with pain self-management strategies (i.e., goal setting, positive self-talk), which was followed by 12 weeks of cognitive behavioral therapy. Findings showed that the stepped-care intervention resulted in statistically significant reductions in pain-related disability, pain interference, and pain severity in Veterans with chronic musculoskeletal pain compared to usual care.
Date: March 9, 2015
- Differences between Men and Women Veterans Undergoing Cardiac Catheterization in VA
This study sought to determine whether there were gender differences in clinical characteristics and comorbidities, coronary anatomy and treatment, and procedural complications and long-term outcomes after diagnostic catheterization. Findings showed that female Veterans were younger (57 vs 63 years), with fewer traditional cardiovascular risk factors, but had more obesity, depression, and PTSD than male Veterans. Compared to male Veterans, female Veterans had lower rates of obstructive coronary artery disease (CAD) (23% vs 53%), similar or lower rates of procedural complications, and lower rates of all-cause rehospitalization. Women Veterans had lower mortality at one year, even when adjusted for age, presence of obstructive disease, and multiple comorbidities. Findings suggest that a significant portion of women Veterans treated in VA catheterization labs have chest pain not related to obstructive CAD. This may represent a complex interplay of psychological stressors and somatic disease, but further research is needed.
Date: March 1, 2015
- VA Primary Care Intervention Decreases High-Dose Opioid Prescription for Veterans with Non-Cancer Pain
In October 2013, VA initiated a nationwide Opioid Safety Initiative (OSI) that includes goals of decreasing high-risk opioid prescribing practices, including prescribing of high-dose opioids. Prior to this national initiative, the Minneapolis VA Health Care System implemented a primary care population-based OSI aimed primarily at reducing high-dose opioid prescribing. This study evaluated the Minneapolis initiative. Findings showed that the number of Veterans prescribed daily high-dose opioids decreased from 342 to 65. Overall, the number of unique pharmacy patients who received at least one opioid prescription within 90 days decreased 14%. The number of Veterans receiving oxycodone SA decreased from 292 to 3 over the study time period. The number of Veterans receiving other long-acting opioids, as well as hydrocodone-acetaminophen, hydromorphone, and oxycodone/acetaminophen also decreased. The proportion of primary care providers who agreed that it was reasonable for the medical center to set a dosage limit was 76% at baseline and 87% at follow-up. The two most commonly endorsed barriers to lowering doses were patients becoming upset (62% baseline and 64% follow-up) and pressure from patient service representatives or the administration (59% baseline and 22% follow-up).
Date: February 3, 2015
- Characteristics Associated with Suicide among Male Veterans Treated in VA Primary Care
This study sought to identify characteristics of Veterans who received VA primary care in the six months prior to suicide (in 2009) – and compare these to control patients who also received primary care at the same 41 VA facilities in 11 geographically diverse states. Findings showed that compared to controls, Veterans who died by suicide were significantly more likely to be unmarried, white, and to have major depression, bipolar disorder, anxiety disorder other than PTSD, and/or an alcohol or other substance use disorder diagnosis. Veterans who died by suicide also were more likely to have documented functional decline, sleep disturbance, expressions of anger, and suicidal ideation. The odds of dying by suicide were greatest among Veterans with anxiety disorder diagnoses and functional decline. A diagnosis of PTSD was not significantly associated with suicide, nor was a pain diagnosis or general medical comorbidity. Also, non-white race and a VA service-connected disability rating were associated with decreased odds of suicide. The assessment of anxiety disorders and functional decline, in particular, may be important for determining suicide risk among Veterans. The authors suggest continued development of interventions that support identifying and addressing these conditions in primary care.
Date: December 1, 2014
- Study Highlights Mental Health Services Important to Women Veterans
Investigators in this study identified a subset of women Veteran primary care users who were potential stakeholders for mental health services, and then quantified their priorities for these services. Treatment for depression, pain management, coping with chronic conditions, sleep problems, weight management, and PTSD emerged as the top six mental healthcare priorities for women. The majority of women Veterans in this study (98%) selected at least one of these services as important, and 80% selected at least three of these six services as important. The majority of women who prioritized each of these six services reported that they had either used this type of service in the past year or were quite a bit or extremely likely to use the service within the next six months, ranging from 62% for weight management to 96% for chronic conditions. Findings suggest that women’s primary care clinics, which are available at many VA healthcare facilities, are a strategic setting to enhance the implementation of women’s health services through primary care-mental health integration.
Date: November 17, 2014
- Providers’ Endorsement of Stigma Regarding Mental Illness Is Related to Patient Treatment Options
This study examined provider response to two treatment options that might be offered to a male patient with schizophrenia who was seeking help for low back pain due to arthritis: 1) referral for specialist consult, or 2) refilling the patient’s prescription for Naproxen. Findings showed that healthcare providers who endorsed more stigmatizing attitudes about mental illness were likely to be more pessimistic about the patient’s adherence to treatment. Stigmatizing attitudes were greater among those providers who were relatively less comfortable with using mental health services themselves. Greater perceived treatment adherence was positively associated with both health decisions: referrals and prescription refill. Thus, poor perceived adherence was partly a proxy for stigmatizing attitudes providers held about people with mental illness, which in turn led to different treatment decisions in patients with serious mental illness. Providers from mental health backgrounds showed no difference in expectations about treatment response than primary care professionals, suggesting that both primary care and mental health providers should be targets of interventions aimed at decreasing disparities in clinical care.
Date: August 15, 2014
- Risk Factors for Suicide-Related Behavior among OEF/OIF Veterans with “Polytrauma Clinical Triad”
The co-occurrence of PTSD, TBI, and chronic pain is known as the “Polytrauma Clinical Triad” (PCT). This study examined the association of these conditions, independently and in interaction with other conditions, with the risk of suicide-related behavior (SRB) among OEF/OIF Veterans. Findings showed that the PCT was a moderate predictor of suicide-related behavior, but did not appear to increase risk for SRB above that associated with PTSD, depression, or substance abuse alone. Moreover, PTSD comorbid with either depression or substance abuse significantly increased risk for suicidal ideation. Veterans with a diagnosis of bipolar disorder, anxiety, substance abuse, schizophrenia, depression, or PTSD were significantly more likely to be diagnosed with all three categories of SRB. Female Veterans were less likely than male Veterans to exhibit suicidal ideation, which contradicts prior research and may suggest that females are less comfortable reporting ideation within VA. Risk for SRB was highest in the 18-25 year old age group.
Date: July 17, 2014
- Efficacy of Routine Screening Pelvic Examination in Asymptomatic Average-Risk Women
This systematic review evaluated the benefits and harms of the routine screening pelvic examination in asymptomatic, non-pregnant, adult women for indications other than sexually transmitted infection screening, provision of hormonal contraception, and cervical cancer screening. No data supported the use of the routine pelvic examination (excluding cervical cytology) for reduction in morbidity or mortality from any condition. The percentage of women endorsing pain or discomfort during the pelvic exam ranged from 11% to 60% and the percentage of women endorsing fear, embarrassment, or anxiety ranged from 10% to 80%. No studies evaluated mortality or morbidity outcomes of the screening pelvic examination for the diagnosis of other malignancies or other benign gynecologic conditions (i.e., pelvic inflammatory disease).
Date: July 1, 2014
- Prevalence of “Polytrauma Triad” among Iraq and Afghanistan War Veterans
This study sought to determine the prevalence of TBI, PTSD, and pain among Veterans from the OEF/OIF/OND wars, who received VA healthcare. Findings showed that large and increasing numbers of OEF/OIF/OND Veterans accessed the VA healthcare system over the three-year study period. Of these Veterans, about 10% were diagnosed with TBI, 30% with PTSD, and 40% with pain. Approximately 6% had all three diagnoses — or the polytrauma triad. Overall, while the absolute number of OEF/OIF/OND Veterans increased by more than 40% from FY09 through FY11, the relative proportion of Veterans diagnosed with TBI, and the high rate of comorbid PTSD and pain in this population have remained stable.
Date: January 1, 2014
- Gaps in Quality of Supportive VA Cancer Care for Veterans
This study evaluated non-hospice supportive VA cancer care in a nationally representative sample of Veterans with stage IV metastatic lung, colorectal, and prostate cancers who were diagnosed in 2008. Quality of care was measured using the Cancer Quality-Assessing Symptoms and Side Effects of Supportive Treatment (ASSIST) quality indicators. Findings showed that, overall, Veterans received only about half (49%) of recommended care as measured by ASSIST quality indicators. Gaps in quality of cancer care included: inpatient pain screening was common (96%) but lacking for outpatients (58%); few Veterans had timely dyspnea evaluation (16%) or treatment (11%); only 4% of Veterans had a new diagnosis of depression identified; of patients at high risk for diarrhea from chemotherapy, 24% were offered antidiarrheals; only 18% of Veterans had their goals of care addressed in the month after a diagnosis of advanced cancer; and 64% of patients had timely discussion of goals ICU admission. Most Veterans who died (86%) were referred to palliative care or hospice before death and 72% had an advanced directive or surrogate decision maker documented in the medical record.
Date: December 9, 2013
- OEF/OIF Veterans with PTSD Experience More Pain Complaints than Veterans without PTSD
This study sought to extend previous work by evaluating the association among PTSD, major depressive disorder (MDD), and pain among Iraq and Afghanistan war era Veterans. Findings showed that Veterans with PTSD reported pain-related complaints at greater rates than Veterans without PTSD. PTSD – with or without MDD – was associated with increased risk of back, muscle, or headache pain. The highest rate of pain complaints was found in Veterans with comorbid PTSD and MDD. Women Veterans were more likely to report back pain, muscle aches, and headaches, but the relationship between psychiatric diagnsoses and pain did not differ in men and women. Veterans with PTSD/MDD were less likely to be employed, more likely to be receiving disability compensation, and more likely to report combat-related injury than Veterans without either disorder. Observed associations of PTSD and MDD with pain complaints suggest that integrated, multidisciplinary treatment may be beneficial, particularly for Veterans with multiple mental health comorbities and pain.
Date: August 7, 2013
- Musculoskeletal Conditions, Injuries, and Pain More Prevalent among Patients Using Statins
This study sought to determine whether statin use was associated with musculoskeletal conditions, including arthropathy (joint disease) and injury. Findings showed that musculoskeletal conditions, injuries, and pain were more common among statin users than similar non-users. In addition, arthropathy was found to be more common among statin users than non-users. Authors note that these findings are concerning, since starting statins at a young age for primary prevention of cardiovascular diseases has been widely advocated.
Date: July 22, 2013
- Non-Cancer Pain Associated with Suicide
This study evaluated associations between non-cancer, pain-related clinical diagnoses (arthritis, back pain, migraine, tension headache or headache symptom, psychogenic pain, neuropathy, fibromyalgia) and suicide. Findings showed that, after controlling for demographics, most clincial diagnoses of non-cancer pain conditions were associated with risk of suicide in this large national cohort of Veterans. After further controlling for co-occuring psychiatric conditions, the associations between pain conditions and suicide death were reduced; however, significant associations remained for back pain, migraine, and psychogenic pain. In Veterans with a pain condition who died by suicide, the two most common methods of suicide were firearms (68%) and poisoning (17%). There was no relationship between the number of pain conditions and suicide risk. The authors suggest that there is a need for increased awareness of suicide risk among Veterans with back pain, migraine, and psychogenic pain, which may not be fully explained by comorbid psychiatric diagnoses.
Date: July 1, 2013
- Opioid Prescribing for Veterans with Chronic Non-Cancer Pain
This study sought to describe patterns of prescription opioid initiation, identify correlates of opioid initiation, and examine correlates of receipt of chronic opioid therapy (COT) among Veterans with persistent non-cancer pain. Findings showed that the initiation of opioid drug therapy is common among Veterans with persistent pain, but most Veterans are not prescribed opioids long-term. During the study year, 35% of Veterans in the sample received an opioid prescription: 30% were prescribed opioids on a short-term basis (<90 days), and 5% received chronic opioid therapy (>90 days). Clinical factors associated with initiating COT include increased pain intensity, nicotine dependence, substance use disorders, and major depression diagnoses. Nearly one-quarter of Veterans prescribed COT also received prescriptions for benzodiazepine medications, which is a concern given that overdose deaths have been linked to the use of multiple sedating medications. Two-thirds of opioid prescriptions resulting in COT were initiated by primary care clinicians. The authors suggest that this supports the development of guidelines geared toward primary care practice. It also supports the provision of interventions and structures in primary care that facilitate proactive planning around opioid use and its monitoring.
Date: February 1, 2013
- Equitable Rates of Pain Assessment among African American and White Veterans
This study sought to determine whether African American Veterans were less likely to be screened for pain than their White counterparts – and to determine the factors associated with differences in screening rates. Findings showed that VA’s mandate for pain screening has resulted in high and relatively equitable rates of pain assessment among both African American and White Veterans. Although rates of pain screening were lower among African Americans compared to Whites (78% vs.82%), this disparity was reduced by half after controlling for prior healthcare use, in which African American Veterans had a greater number of outpatient visits, which was associated with lower rates of pain screening at the index visit. Overall, Veterans were less likely to be screened for pain if they were African American, female, and married; if they had a diagnosis of deficiency anemia; if they had a greater number of outpatient visits; and if they were an established (vs. new) patient. Veterans were more likely to be screened if they had prior diagnoses of chronic joint, neck, or back pain; opioid abuse, anemia, and pulmonary circulation disorders; and if they had a non-opioid analgesic prescription and/or greater number of inpatient admissions in the previous two years.
Date: November 21, 2012
- Post-deployment Health Outcomes Associated with Multiple Deployment-Related Factors
This study examined the unique contributions of various deployment-related exposures and injuries to current post-deployment physical, psychological, and general health outcomes in National Guard members. Findings showed that various deployment-related experiences increased the risk for post-deployment adverse mental and physical health outcomes, individually and in combination. Most adverse outcomes had associations with multiple deployment-related factors. Deployment-related mild traumatic brain injury (TBI) was associated with post-deployment depression, anxiety, PTSD, and post-concussive symptoms such as headaches and dizziness. Combat exposures with and without physical injury were associated not only with PTSD, but also with numerous post-concussive and non-post-concussive symptoms (e.g., chest pain, indigestion). Associations between blast exposure and abdominal pain, pain on deep breathing, shortness of breath, hearing loss, and tinnitus suggested residual barotrauma. The experience of seeing others wounded or killed, or experiencing the death of a buddy or leader, was associated with indigestion and headaches, but not with depression, anxiety, or PTSD. Findings indicate that an integrated interdisciplinary healthcare approach would be beneficial for Veterans with multiple deployment-related health issues. Such a system of care is currently being used within the VA Polytrauma programs.
Date: November 1, 2012
- Association between Several Common Antiepileptic Drugs and Suicide-Related Behavior in Older Veterans
This retrospective study examined the relationship between antiepileptic drugs (AEDs) and suicide-related behaviors among Veterans aged 65 years and older who received VA healthcare. Findings showed that, within the study sample of 2 million older Veterans, there were 332 cases of suicide-related behavior (SRB). Exposure to antiepileptic drugs was significantly associated with suicide-related behavior, even after controlling for psychiatric comorbidity and prior SRB. Individuals who received AEDs were significantly more likely to have prior diagnoses of suicide-related behavior, depression, anxiety, bipolar disorder, PTSD, schizophrenia, substance abuse/dependence, conditions associated with chronic pain, and dementia. Veterans who received prescriptions for several specific AEDs – valproate, gabapentin, lamotrigine, levetiracetam, phenytoin, and topiramate – were at greater risk of diagnosed suicide-related behavior than Veterans with no AED exposure. Findings indicated that suicide-related behavior may occur as early as one week following AED use.
Date: October 30, 2012
- Factors Associated with Increased Aggression in Veterans with Dementia
This study sought to examine the factors predicting the development of aggression among Veterans with dementia. Findings show that potentially mutable factors were associated with the development of aggression in Veterans with newly diagnosed dementia. Mutable factors that predicted increased risk of aggression included: higher levels of baseline caregiver burden, worst patient pain, declining patient-caregiver relationship, and increasing non-aggressive physical agitation. Baseline dementia severity and depression were indirectly related to the onset of aggression.
Date: October 26, 2012
- Rape and Sex Partnership Adversely Associated with Lower Physical Functioning in Women Veterans
This study sought to determine whether current physical health status in women Veterans is associated with rape in military (RIM) and same-sex partnering. Findings showed that women Veterans who reported a history of rape (during childhood or adolescence, in-military or post-military) and those with same-sex sexual partners at some point in their lives had significantly lower current physical health status compared to women without such histories. Of the participants in the study, 11% reported having women as sex partners (WSW). Women with same-sex partners reported significantly higher lifetime substance use disorder (SUD) and higher rates of rape, both lifetime and in separate time periods, compared to women who reported having sex with men exclusively. Three-quarters (74%) of WSW reported lifetime rape and one-third (35%) reported RIM compared to 48% and 23% in women with men as partners only. Physical health status was lowest for women with a history of chronic pain. Other factors significantly associated with lower physical health status were depression, PTSD, and not having a current SUD.
Date: October 15, 2012
- Higher Rates of Reproductive and Physical Health Problems in OEF/OIF Women Veterans with Mental Illness
OEF/OIF women Veterans with any mental health diagnoses had significantly higher prevalence of nearly all categories of reproductive and physical disease diagnoses compared to women Veterans without mental health diagnoses. Women with mental health diagnoses had approximately two to four times the odds of receiving diagnoses of sexually transmitted infections, cervical dysplasia, dysmenorrhea, and gynecologic pain syndromes, as well as other reproductive and gynecologic health conditions, with prevalence being highest in women with comorbid PTSD and depression. The most striking difference was in sexual dysfunction (a relatively rare outcome), in which women Veterans diagnosed with mental health disorders had 6 to 10 times the odds of receiving this diagnosis than women without mental disorders.
Findings were similar after adjusting for demographics, military service characteristics, and distance to/type of nearest VAMC. The magnitude of the associations of mental and physical health diagnoses were reduced after adjusting for primary care utilization, but most remained significant.
Date: September 1, 2012
- Pain and PTSD Common Comorbidities among OEF/OIF Veterans with Spinal Cord Injury Undergoing Inpatient Rehabilitation
Pain and PTSD were more likely to manifest as comorbidities than as isolated conditions during inpatient rehabilitation for spinal cord injury. Comorbid pain and PTSD symptoms were more common than either condition alone, and nearly as common as not having either condition. Veterans with pain at the beginning of rehabilitation showed declines in pain ratings over the course of rehabilitation. In contrast, Veterans in the “PTSD Alone” group showed increasing pain over the course of rehabilitation. Factors not associated with pain and PTSD status were: demographic and SCI characteristics, number of comorbid traumatic injuries, and the prevalence of individual comorbid injuries.
Date: August 1, 2012
- Mental Health Diagnoses Associated with Opioid Prescription, High-Risk Use, and Adverse Outcomes among OEF/OIF Veterans
Among OEF/OIF Veterans with pain, mental health diagnoses, especially PTSD, were associated with an increased risk of receiving opioids, high-risk opioid use, and adverse clinical outcomes. Compared to those without mental health diagnoses, Veterans with PTSD who were prescribed opioids were more likely to receive higher-dose opioids (16% vs. 23%), receive two or more opioids concurrently (11% vs. 20%), receive sedative hypnotics concurrently (8% vs. 41%), and to obtain early opioid refills (20% vs. 34%). Receiving prescription opioids (vs. not) increased risk for serious adverse clinical outcomes for Veterans (10% vs. 4%) across all mental health categories and was most pronounced in Veterans with PTSD. Of the 141,029 Veterans with pain diagnoses, 15,676 (11%) received prescription opioids for = 20 consecutive days; 77% of which were prescribed by VA primary care providers. Veterans with PTSD and mental health diagnoses excluding PTSD were significantly more likely to receive opioids for pain (18% and 12%) compared to Veterans without mental health diagnoses (7%).
Date: March 7, 2012
- Veterans that Use Cigarette Smoking to Cope with Chronic Pain Experience Worse Pain-Related Outcomes
Veterans who reported smoking as a coping strategy for chronic pain scored significantly worse compared to Veterans who did not smoke and those who denied using cigarettes to cope with pain on the majority of measures of pain-related outcomes. After controlling for demographics and clinical factors, smoking as a coping strategy for pain was significantly and positively associated with pain intensity, pain interference, and fear of pain. There were no significant differences between the three groups on current symptoms of depression or anxiety, indicating that comorbid psychopathology likely did not contribute to poorer pain-related outcomes in the group who used cigarettes to cope with pain. The two smoking groups did not differ with respect to the frequency or severity of nicotine dependence, use of opioid medications, or on other clinical factors, suggesting that impairment in pain-related variables may be due to reliance on cigarettes as a coping strategy for chronic pain.
Date: March 1, 2012
- Publicly Reported Quality Ratings have Small but Positive Effect on Patient Choice of Nursing Home for Post-Acute Care
Patients were more likely to choose facilities with higher reported post-acute care quality related to resident pain control after public reporting was initiated; however, the magnitude of the effect was small. No changes in nursing home choice related to report card scores were seen in facilities not exposed to public reporting. A better pain score (less pain experienced by the patient) was associated with an increase in consumer demand after public reporting was initiated; for delirium, there was no significant effect, and for improved walking, the effect was unexpectedly negative. There was a differential response across patients by education level, which raises the possibility that the format and distribution of this information matters. Authors suggest that this information may be more influential if it is delivered to consumers in a more user-friendly format, or if it is delivered to patient advocates or surrogate decision-makers.
Date: January 10, 2012
- Majority of OEF/OIF Veterans with Traumatic Brain Injury also Diagnosed with Mental Illness and Head, Neck or Back Pain
This study examined the prevalence and VA healthcare costs of TBI with and without comorbid psychiatric illness and pain among OEF/OIF Veterans who used VA healthcare services (inpatient or outpatient) during FY09. Findings showed that 7% of the Veterans who used VA healthcare received a diagnosis of TBI. Among this patient subgroup, the vast majority (89%) also had a psychiatric diagnosis (most frequently PTSD: 73%), and 70% had a diagnosis of head, neck or back pain. More than half had both PTSD and pain (54%). Overall, depression was the second most common (45%) mental health diagnosis. Annual costs for OEF/OIF Veterans with TBI were four times greater than for those without TBI ($5,831 vs. $1,547), and costs increased as clinical complexity increased. For example, Veterans with TBI, PTSD, and pain demonstrated the highest median cost per patient ($7,974).
Date: January 4, 2012
- Complementary and Alternative Medicine Options for Veterans with Chronic Pain
As part of the “Study of the Effectiveness of a Collaborative Approach to Pain,” investigators surveyed Veterans with chronic (non-cancer) pain about their prior use of, and their willingness to try four complementary/alternative medicine (CAM) treatments: massage, chiropractic care, herbal medicines, and acupuncture. Investigators also examined whether demographic characteristics, VA treatment satisfaction, common pain-related characteristics (i.e., pain intensity, disability, depression), or overall disease burden distinguished CAM users from non-users. Findings showed that 82% of Veterans reported previously trying CAM therapy, and nearly all were willing to try one or more of the four CAM treatment options in the study survey. Chiropractic care was the least preferred CAM therapy, whereas massage was the most preferred option. Compared to Veterans who did not use CAM therapy, CAM users were less likely to have service-connected disabilities, and reported having spent a larger percentage of their lives in pain. Investigators detected few differences between Veterans who had tried CAM therapy and those who had not, suggesting CAM may have broad appeal among Veterans with chronic pain. Moreover, study results did not show differences in treatment satisfaction or pain treatment effectiveness ratings between the two groups. This suggests that Veteran patients with chronic pain may use CAM as an additional tool in pain management, rather than as a reaction to perceived inadequacies of conventional care.
Date: December 1, 2011
- Article Recommends Role of “Patient Safety Professional” to Increase Patient Safety
This article recommends consideration of a new type of clinical role in the hospital setting – the Patient Safety Professional (PSP) – to ensure that each patient receives individualized prevention strategies to minimize the hazards of hospitalization. Authors suggest the PSP be an advanced practice registered nurse, who would: 1) assess assigned patients for hospital-acquired complications (e.g., pressure ulcers, falls, pain) following explicit protocols relevant to a short list of safety targets; 2) prioritize identified complications based on morbidity, mortality, and hospital costs; and 3) develop and implement plans to decrease hospital-acquired complications, in consultation with physicians and staff nurses. The PSP might also provide additional benefits to the organization, i.e., he/she could serve as an educational resource or consultant to other clinicians and take responsibility for staying up to date on new advances and recommendations in the area of patient safety.
Date: September 8, 2011
- Majority of OEF/OIF Veterans with Chronic Non-Cancer Pain are Prescribed Opioids by VA Outpatient Providers
This study sought to describe the prevalence of prescription opioid use, types and doses of opioids received, as well as factors associated with the prescription of opioids among OEF/OIF Veterans. Findings showed that about two-thirds of OEF/OIF Veterans with chronic non-cancer pain were prescribed opioids over a one-year timeframe. Of Veterans prescribed any opioids, 59% were prescribed opioids ‘short-term’ compared to 41% prescribed opioids ‘long-term’ (more than 90 days). The mean duration of opioid prescription was 61 days for Veterans in the short-term group and 285 days for Veterans in the long-term group. Several findings suggest a need for improvement in adherence to pain and opioid treatment guidelines. For example, among long-term opioid users, 51% were prescribed short-acting opioids only (guidelines recommend transitioning to long-acting opioids); only 31% were administered one or more urine drug screens (guidelines suggest more frequent drug screening); and 33% were also prescribed sedative-hypnotic medications (monitoring by prescribing physicians is recommended to prevent possible overdose or death). Diagnoses associated with an increased likelihood of receiving an opioid prescription included: low back pain, migraine headache, PTSD, and nicotine use disorder.
Date: September 7, 2011
- Painful Musculoskeletal Conditions More Prevalent among Female Compared to Male OEF/OIF Veterans
This study sought to describe gender differences in the prevalence of painful musculoskeletal conditions in male and female OEF/OIF Veterans. Findings showed that the prevalence of back pain, musculoskeletal conditions, and joint disorders increased significantly in years 1-7 after deployment among both female and male Veterans using VA care. Moreover, the odds of having back pain, a musculoskeletal condition, or a joint disorder was higher for female compared to male Veterans and increased over time.
Date: June 14, 2011
- Veterans Receiving Higher-Dose Opioid Prescriptions for Pain at Increased Risk of Death from Overdose
This study examined the association of maximum prescribed daily opioid dose and dosing schedule (“as needed,” regularly scheduled, or both) with risk of opioid overdose death among Veterans with cancer, chronic pain, acute pain, and substance use disorders. Findings showed that among Veterans receiving opioid prescriptions for pain, higher opioid doses were associated with increased risk of death from opioid overdose. The frequency of fatal overdose among Veterans treated with opioids was rare – estimated to be 0.04% - and was directly related to the maximum prescribed daily dose of opioid medication. There was no significant increased risk of opioid overdose among Veterans who were treated with both “as-needed” and regularly scheduled opioids – a strategy for treating pain exacerbations – after adjusting for maximum daily dose and patient characteristics. Veterans who died from opioid overdose were significantly more likely to have chronic or acute pain, substance use disorders, and other psychiatric disorders, but they were less likely to have cancer. This study highlights the importance of implementing strategies for reducing opioid overdose among patients being treated for pain, for example, ascertaining history of substance abuse, using treatment contracts, and scheduling frequent follow-up visits and toxicological screens for patients at special risk.
Date: April 6, 2011
- Overuse of Diagnostic Imaging for Chronic Low Back Pain
This article discusses evidence-based recommendations for the use of imaging tests in patients with low back pain, factors that promote the overuse of imaging, as well as how physicians can reduce overuse. The American College of Physicians and the American Pain Society call for imaging only for patients with low back pain who have severe or progressive neurologic deficits – or signs or symptoms that suggest a serious or specific underlying condition. Patient expectations and preferences about diagnostic testing can affect clinical decisions, e.g., wanting diagnostic testing is a frequent reason for repeated office visits for chronic back pain. The number of MRI scanners in the U.S. tripled from 2000 to 2005, and studies suggest that greater availability of imaging resources correlates with their increased use. To be most effective, efforts to reduce the use of diagnostic imaging should be multi-focal and should address clinician behaviors, patient expectations, and financial incentives.
Date: February 1, 2011
- Telephone-Based Self-Management Program Improves Pain among Veterans with Osteoarthritis
This study examined the effectiveness of a one-year, telephone-based self-management support intervention for 461 Veterans with symptomatic hip and/or knee osteoarthritis who received VA primary care at the Durham VAMC. Findings show that the telephone-based self-management program produced moderate improvements in pain among Veterans with osteoarthritis, particularly compared with a general health education intervention. The self-management group also had greater improvement on the walking and bending subscale measure.
Date: November 2, 2010
- Pain Screening Implementation for Veterans Falls Short
This study included surveys of Veteran outpatients and nursing staff who screened for pain during normal vital sign intake. Investigators compared pain levels documented by the nursing staff with those reported by Veterans during the study survey. Findings show that despite a longstanding mandate, pain screening implementation falls short, and informal screening is common. Although pain was evaluated in all patient encounters, less than half of the Veterans reported that the nursing staff formally rated their pain. However, the majority of the time the nursing staff’s pain documentation matched the Veteran’s subsequent report within one point on the rating scale. When differences did occur, the nursing staff under-estimated pain in 25% of the cases, and overestimated pain in 7% of the cases. Veterans with PTSD or another anxiety disorder were almost twice as likely to report higher pain levels than those documented by the nursing staff. Additionally, nursing staff were less likely to underestimate pain when the patient self-reported excellent, very good, or good health status (relative to fair or poor health status).
Date: August 6, 2010
- Inappropriate Non-Steroidal Anti-Inflammatory Drug Use is Prevalent among Veterans
This study examined the prevalence of inappropriate non-steroidal anti-inflammatory drug (NSAID) use among Veterans– and identified patient and clinical characteristics associated with inappropriate use. The inappropriate use of NSAIDs was prevalent and was associated with more GI symptoms and higher levels of pain. Of the 1,250 Veterans who reported NSAID use, approximately 32% used NSAIDs inappropriately, including taking two or more NSAIDs, exceeding the highest daily recommended dosage, or both. Veterans classified as using NSAIDs inappropriately were more likely to be non-white and were more likely to have an income of less than $20,000.
Date: June 1, 2010
- Communication Regarding Health-Related Quality of Life between Cancer Patients and Providers
Health-related quality of life (HRQOL) discussions between oncologists and patients were common, but the emphasis was often on treatment (e.g., side effects) and symptoms (e.g., pain), even in patients with advanced disease. All provider/patient encounters included some talk of HRQOL, ranging from 3% to 75% of the total conversation, with the average HRQOL discussion taking up 25% of the conversation. An analysis of topics showed that 56% concerned treatment, 14% concerned disease, and 3% concerned testing. Talk of emotions, mental health, and psychological HRQOL was introduced into the conversations more frequently by patients than providers and occurred in only 9% of the audio segments studied. Spiritual HRQOL also was introduced into the conversations more frequently by patients than providers, and was discussed in only 1% of all audio segments. The authors suggest that given the often intense emotional experience of patients with advanced cancer, oncologists may need to pay more attention to psychological, social, and spiritual HRQOL concerns.
Date: May 1, 2010
- Article Helps Identify Patients Prone to Persistent and Disabling Low Back Pain
Findings show that the most helpful components for predicting persistent, disabling low back pain were maladaptive pain coping behaviors (e.g., avoidance of work), nonorganic signs (e.g., suggests strong psychological component of pain), functional impairment, general health status, and presence of psychiatric comorbidities. In addition, baseline functional impairment showed an increasing likelihood of poor outcomes at three to six months and at one year. However, patients’ age, sex, education level, smoking status, and overweight status consistently failed to predict worse outcomes.
Date: April 7, 2010
- Affective Disorders Strongest Predictor of Suicidal Behavior in Elderly Veterans Receiving Anti-Epileptic Medication
In January 2008, the FDA issued an alert indicating that anti-epileptic drug (AED) treatment is associated with increased risk for suicidal ideation, attempt, and completion. This study sought to assess variation in suicide-related behaviors in a population not well-represented by the data used for the FDA analysis – individuals 66 years and older with new exposure to AEDs. Findings show that in older Veterans who were started on AED monotherapy, the strongest reliable predictor of suicide-related behaviors was the diagnosis of an affective disorder prior to AED treatment. Increased suicide-related behaviors were not associated with individual AEDs. However, while most Veterans in this study received AED prescriptions for gabapentin (76.8%), a trend for increased suicide-related behaviors was found among those prescribed levetiracetam or lamotrigine, but interpretation was difficult since few Veterans received either drug (0.6%). The associations between suicide-related behaviors and chronic pain or chronic disease burden were not statistically significant, but dementia was significantly associated with suicide-related behaviors (42.2% with dementia vs. 25.8% without).
Date: January 11, 2010
- Cost/Benefit of Collaborative Care Intervention for Veterans with Chronic Pain and Depression
This study reports on the incremental benefit (pain disability-free days – PDFDs) and incremental health services costs of the Study of the Effectiveness of a Collaborative Approach to Pain (SEACAP) intervention from a VA healthcare perspective. Findings show that the collaborative care intervention resulted in more pain-free days for Veterans with chronic pain and depression, but was more expensive than usual care. Veterans in the intervention group experienced an average of 16 additional PDFDs over the 12 month follow-up period compared to Veterans in the treatment as usual group, with a cost per PDFD of $364 (overall, about $2300 per patient during the study year). Study results also show that important predictors of costs were baseline medical comorbidities, depression severity, and prior year treatment costs.
Date: January 1, 2010
- Ethnic Disparities in Treatment for Chronic Pain
This study sought to identify racial and ethnic differences in patient-reported rates of treatment for chronic pain and ratings of pain-treatment effectiveness among 255,522 Veterans who were treated at more than 800 VA healthcare facilities in FY05. Findings show that 35% of male Veterans and 44% of female Veterans reported receiving treatment for chronic pain. Male and female Veterans who were Hispanic or non-Hispanic black were more likely to report receiving treatment for chronic pain compared to non-Hispanic white Veterans. Among the Veterans who received treatment for chronic pain, non-Hispanic black men were one-fifth less likely to rate pain treatment effectiveness as very good or excellent compared to non-Hispanic white male Veterans.
Date: October 1, 2009
- Special Issue of Pain Medicine Highlights VA Research on Pain among OEF/OIF Veterans
This publication is in follow-up to a Pain Research Summit held in September 2007 by VA’s Rehabilitation R&D Service and VA/HSR&D’s Polytrauma and Blast-Related Injury Quality Enhancement Research Initiative (PT/BRI-QUERI). This Special Issue begins with four articles that build on the growing epidemiological literature on the prevalence and correlates of pain among OEF/OIF Veterans, and considers the evidence for the assessment and management of pain in this population. The Issue also includes several original articles that provide a sample of the relatively large and growing body of research on pain, including research that focuses on the most prevalent and challenging of pain conditions observed among OEF/OIF Veterans, such as neuropathic pain, chronic widespread pain, musculoskeletal/joint pain, and pain secondary to spinal cord injury.
Date: October 1, 2009
- Primary Care-Based Collaborative Care for Chronic Pain May Be More Effective than Usual Care
A primary care-based collaborative care intervention for chronic pain was significantly more effective than usual care across a variety of outcome measures, including pain disability and intensity. However, these improvements were generally modest. Depression severity and pain disability and intensity improved among Veterans in the intervention group who reported both chronic pain and depression. Greater use of adjunctive pain medications and long-term opioids among the intervention group suggested that the intervention contributed to the delivery of guideline-concordant care.
Date: March 25, 2009
- Racial Differences in Coping with Chronic Osteoarthritis Pain
Compared to white veterans, African American veterans were much more likely to perceive prayer as helpful (85% vs. 66%) and were more likely to have tried it for hip or knee pain (73% vs. 55%). Race was not associated with arthritis pain self-efficacy, arthritis function self-efficacy, or any other coping strategies.
Date: December 1, 2008
- Pain among Veterans with Spinal Cord Injury
Veterans reported higher rates of pain-related catastrophizing (exaggerated negative interpretations of pain, e.g., “my pain is unbearable and will never get better”). Authors suggest that in clinical settings it may be important to assess and manage catastrophizing as a factor important to the experience of pain and especially the impact of pain on functioning.
Date: October 1, 2008