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Understanding Pain and Pain Treatment for Veterans: Responding to the Federal Pain Research Strategy

Year: 2018

Type: article

Abstract: The Veterans Health Administration (VHA) is the largest integrated health system in the United States, providing care for some 9 million veterans annually at more than 1,700 sites across all 50 states, Puerto Rico, and other territories. With a research appropriation of $722 million in 2018 and over 20 years of electronic health record data, the VHA serves as critical laboratory for studying and improving care for common health conditions. One of the most important of these is chronic pain, both for its effect on function and disability and for its contributions to an epidemic of opioid use in the United States. Chronic pain is reported by more than one-third of veterans in our care [1]. This and other factors have made the VHA a fertile ground for pain research: a national opioid safety initiative has reduced overall opioid use; the VHA is ahead of other systems in offering nonopioid alternatives for pain; with a global budget, it can support new models for pain care without worrying about reimbursement patterns; and the VHA is part of an interagency federal strategy for pain research. The objectives of this supplement are to raise awareness of and disseminate new health services research findings from recent research about pain and pain management for veterans. We solicited submissions to this supplement that provide insight for clinicians, educators, researchers, administrators, and policy-makers related to the care of veterans. Given the important role that the VHA has played in the development of innovative practice and policy initiatives and research in this area, this supplement contributes important findings for addressing pain care in America and around the world. This supplement highlights health services research conducted by interdisciplinary investigative teams at the Pain Research, Informatics, Multimorbidities and Education (PRIME) Center of Innovation, located at the VA Connecticut Healthcare System and supported by the VHA’s Health Service Research and Development (HSR&D) program. The overarching goals of the PRIME Center are to align our health services research with clinical priority goals, to conduct rapid and efficient studies, and to leverage existing data to evaluate innovations and best practices. Thus, the PRIME Center focuses on impacting clinical practice and veterans’ health. The PRIME Center’s strategic goals have been adopted from the Federal Pain Research Strategy (FPRS), a strategic plan created by a federal advisory committee of pain experts and designed to advance research in pain and pain management [2]. Briefly, key areas of the FPRS include prevention of acute and chronic pain, acute pain management, the transition from acute to chronic pain, chronic pain management, and disparities in care. The PRIME Center plays a leadership role in pain and pain management within the VHA. Serving as the only federally funded national pain center, multiple PRIME investigators played leadership roles in the VHA’s HSR&D-sponsored State-of-the-Art Conference on nonpharmacological treatments for chronic musculoskeletal pain [3]. The PRIME Center also contributes to the FPRS goal of forming a national research network for pain within the VHA. Dr. Heapy chairs the national Pain Research Working Group, a network of approximately 80 VA-affiliated pain researchers with the objective to increase pain-relevant research in the VHA. In this supplement, we focused on four FPRS goals and solicited manuscripts that address these goals. The Women Veteran’s Cohort Study (WVCS) was initially funded in 2007 and focuses on women veterans and gender differences in utilization, costs, and outcomes after combat exposure in more than 1 million veterans from recent wars. Numerous empirical reports on pain, reproductive health, and mental health conditions have been published [4]. Several studies in this supplement have utilized WVCS to examine pain among disparate veteran populations. Dr. Lynch and colleagues used WVCS to examine the impact of cigarette smoking status on pain intensity among veterans with and without hepatitis C virus (HCV) [5]. Tobacco smoking is an independent risk factor for high pain intensity among veterans [6]. Lynch et al. found that while the association between pain and smoking was significant and positive for veterans with and without an HCV diagnosis, the association was significantly higher for patients with an HCV diagnosis than those without. Investigations are needed to promote smoking cessation and pain management in veterans with HCV. Dr. Leapman and colleagues used WVCS to examine variation in opioid prescribing following surgery for kidney stones [7]. Long-term opioid therapy may begin in the acute postoperative setting, where little guidance exists regarding optimal prescribing practices, or the impact of initial exposure on subsequent use. Among the predominantly male surgical sample, the authors identified significant variability in opioid prescribing patterns. Although type of surgical intervention did not impact opioid prescribing, veterans with a diagnosis of PTSD were more likely to receive higher doses. This work can inform efforts to improve the safety and efficacy of postoperative opioid prescribing. Dr. Driscoll and colleagues conducted a qualitative study to examine gender differences in veteran perceptions of VHA chronic pain care [8]. In the 10 focus groups, both men and women described frustration with the use of trainees in the medical center that frequently resulted in a lack of continuity. They also noted challenges accessing pharmacologic and nonpharmacologic modalities. Notably, tensions between patient expectations and the guidelines governing provider prescribing behavior emerged suggesting that improved patient education and better provider communication may optimize care. Women veterans were particularly appreciative of the integrative health care options in the VHA such as acupuncture and yoga. Four papers in this supplement address this goal. Dr. Edmond and colleagues examined the Stepped Care Model for Pain Management, the single standard of pain care for the VHA, which prioritizes the role of primary care providers in optimizing pharmacological management and timely and equitable access to patient-centered, evidence-based nonpharmacological approaches [9,10]. Findings suggest that engagement of interdisciplinary teams and partnerships to promote organizational improvements is a useful strategy to increase the use of integrated, multimodal pain care. Dr. Oldfield and colleagues examined the impact of a novel clinical program designed to address unsafe use of opioids prescribed for pain—the Opioid Reassessment Clinic (ORC)—to inform practice and health system improvement [11,12]. The ORC is a multidisciplinary clinic in a primary care setting designed to perform longitudinal treatment of patients with high-risk use of opioids prescribed for pain, including tapering or rotating to the partial opioid agonist buprenorphine. Results suggest the ORC is effective in reducing total prescribed opioid doses and in transitioning patients to partial agonist therapy, but primary care adoption strategies are needed. Dr. Midboe and colleagues examined the implementation facilitation of academic detailing to decrease risky opioid prescribing and increase nonpharmacological pain treatments among veterans [13]. Semistructured interviews at seven VHA health care systems in the Sierra Pacific region included current and former academic detailers and VHA providers with varying exposure to academic detailing. Key lessons identified by academic detailers and providers coalesced around modes of communication and tracking performance that are likely critical to facilitating uptake of evidence-based interventions addressing the opioid epidemic. Dr. Lisi and colleagues examined patient characteristics associated with opioid use among veterans who received chiropractic care and explored the relationship between timing of chiropractic visit and receipt of opioid prescription [14]. Overall, 31% of veterans with at least one chiropractic visit received one or more opioid prescriptions. The percentage of veterans receiving opioid prescriptions was lower in each of the three 30-day time frames assessed after the index chiropractic visit than before, suggesting that use of chiropractic care may have an impact on opioid use in this population. Dr. Fenton and colleagues examined the co-occurrence of painful conditions and mental health diagnoses in veterans with temporomandibular disorder (TMD) [15]. The authors developed an observational cohort of 5.2 million veterans having at least one musculoskeletal disorder (MSD) [16]. Those with TMD, relative to the cohort as a whole, were younger and more likely to be women. Non-MSD comorbidities (e.g., irritable bowel syndrome, mental health conditions, and headaches) were significantly associated with TMD in both men and women veterans. Veterans with back pain, nontraumatic joint disorder, or osteoarthritis had more MSD multimorbidity than those with TMD. Complex patterns of multimorbidity of MSD and non-MSD conditions in TMD cases may indicate different underlying mechanisms of association in subgroups of cases, suggesting multiple potential targets to improve TMD. Obstructive sleep apnea (OSA) and pain are highly prevalent conditions in veterans [17]. The specific link between OSA and pain is unknown, but it has been hypothesized that OSA patients are hyperalgesic because of fragmented sleep and hypoxemia, which enhance sensitivity to pain, promote inflammation, and increase spontaneous pain [18]. Dr. Charokopos and colleagues conducted a systematic review of the literature assessing whether OSA is a risk factor for subjective pain intensity and experimental pain tolerance [19]. Twelve manuscripts met study inclusion criteria. Whereas several studies found a positive association between OSA and higher pain intensity and lower tolerance, there was considerable variability among study outcomes. Several studies also reported that receipt of continuous positive airway pressure (CPAP) reduced pain intensity. Further research is needed to identify the differential effects of nocturnal hypoxemia and fragmented sleep on pain intensity and whether patients with chronic pain and OSA might benefit from CPAP in terms of improved pain management. Cognitive behavioral therapy (CBT) for chronic pain is a skills-based approach designed to help individuals identify and decrease negative and maladaptive thoughts, feelings, and behaviors and increase adaptive and consistent behaviors that contribute to the reduction of physical and psychological distress in the context of chronic pain [20]. Dr. Higgins examined predictors of enrollment in a noninferiority trial of in-person vs technology-based CBT for patients with chronic low back pain [21]. Among eligible patients, a slight majority declined enrollment due to lack of interest. Patients not receiving opioids were more likely to enroll, perhaps reflecting a preference for nonpharmacological approaches. Identifying predictors of enrollment in CBT may help increase recruitment efficiency and assist in targeting patients who may benefit but are not currently interested in treatment. Dr. Driscoll and colleagues report on an innovative integrated treatment program for smoking cessation among smokers with chronic pain [22]. Individuals who smoke and have chronic pain report lower self-efficacy to quit smoking and are less successful in their quit attempts [23]. The authors assess the feasibility of a five-session telephone-delivered intervention designed to integrate evidence-based smoking cessation and pain management components in a way that allows veterans to understand the interplay between the two while attempting to have them build off each other and develop coping skills to address both concerns. Pilot data support the feasibility of a combined intervention. A randomized controlled trial to test its effectiveness on smoking and pain outcomes is underway. The FPRS provides a useful framework for characterizing advances in the VHA’s pain-relevant research agenda and products. The VHA’s pain research includes a national network of researchers, including collaborators on some of these articles. The range of articles included in this supplement highlights the contributions a coordinated research strategy can make to address important knowledge gaps and clinical and policy priorities. With the goal of accelerating implementation of evidence-based care for pain, researchers should continue to engage in effective partnerships within the VHA to ensure that research continues to positively impact patient care. Funding sources: This supplement was supported by the Veterans Health Administration (VHA) Health Services Research and Development (HSR&D) Service, Office of Research and Development, and the Pain Research, Informatics, Multimorbidities and Education (PRIME) Center of Innovation (CIN 13-407). Disclosure: The views expressed in this article are those of the authors and do not necessarily represent the position or policy of the Department of Veterans Affairs or the United States Government. Conflicts of Interest: There are no conflicts to disclose.

Source: Pain Medicine

DOI: 10.1093/pm/pny143

Authors: Lori A Bastian, Alicia Heapy, William C Becker, Friedhelm Sandbrink, David Atkins, Robert D Kerns