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Yarns BC, Jackson NJ, Alas A, Melrose RJ, Lumley MA, Sultzer DL. Emotional Awareness and Expression Therapy vs Cognitive Behavioral Therapy for Chronic Pain in Older Veterans: A Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2415842. [PMID: 38869899 DOI: 10.1001/jamanetworkopen.2024.15842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/14/2024] Open
Abstract
Importance Chronic pain is common and disabling in older adults, and psychological interventions are indicated. However, the gold standard approach, cognitive-behavioral therapy (CBT), produces only modest benefits, and more powerful options are needed. Objectives To evaluate whether emotional awareness and expression therapy (EAET) is superior to CBT for treatment of chronic pain among predominantly male older veterans and whether higher baseline depression, anxiety, or posttraumatic stress disorder (PTSD) symptoms-key targets of EAET-moderate treatment response. Design, Setting, and Participants This 2-arm randomized clinical trial was conducted from May 16, 2019, to September 14, 2023, in the US Department of Veterans Affairs Greater Los Angeles Healthcare System. The trial included a racially and ethnically diverse group of veterans aged 60 to 95 years with at least 3 months of musculoskeletal pain. Interventions Emotional awareness and expression therapy or CBT, conducted concurrently, each presented as one 90-minute individual session followed by eight 90-minute group sessions. Main Outcomes and Measures The primary outcome was Brief Pain Inventory pain severity (range, 0 to 10) from baseline to posttreatment (week 10, primary end point) and 6-month follow-up. Secondary outcomes included Patient Reported Outcomes Institute Measurement System Anxiety, Depression, Fatigue, General Life Satisfaction (NIH Toolbox), Pain Interference, and Sleep Disturbance Short Forms, Patient Global Impression of Change (PGIC), and Satisfaction with Therapy and Therapist Scale-Revised. A subset of participants completed the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition). All analyses were for the intention-to-treat population and included all randomized participants. Results Among 126 randomized participants (66 in the EAET group and 60 in the CBT group; mean [SD] age, 71.9 [5.9] years; 116 [92%] male), 111 (88%) completed posttreatment, and 104 (82%) completed the 6-month follow-up. The EAET was superior to CBT for the primary outcome of reduction in pain severity at posttreatment (estimate, -1.59 [95% CI, -2.35 to -0.83]; P < .001) and follow-up (estimate, -1.01 [95% CI, -1.78 to -0.24]; P = .01). A greater percentage of participants in EAET vs CBT had clinically significant (at least 30%) pain reduction (63% vs 17%; odds ratio, 21.54 [95% CI, 4.66-99.56]; P < .001) at posttreatment. In addition, EAET was superior to CBT on 50% pain reduction (35% vs 7%; odds ratio, 11.77 [95% CI, 2.38-58.25]; P = .002), anxiety (estimate, -2.49 [95% CI, -4.30 to -0.68]; P = .006), depression (estimate, -3.06 [95% CI, -5.88 to -0.25]; P = .03), general life satisfaction (estimate, 1.23 [95% CI, 0.36-2.10]; P = .005), PTSD symptoms (estimate, -4.39 [95% CI, -8.44 to -0.34]; P = .03), PGIC score (estimate, 1.46 [95% CI, 0.77-2.15]; P < .001), and global treatment satisfaction (estimate, 0.28 [95% CI, 0.12-0.45]; P < .001) at posttreatment. Higher baseline depression (estimate, -1.55 [95% CI, -0.37 to 2.73]; P < .001), anxiety (estimate, -1.53 [95% CI, -2.19 to -0.88]; P < .001), and PTSD symptoms (estimate, -1.69 [95% CI, -2.96 to -0.42]; P = .009) moderated greater reduction in pain severity after EAET but not CBT. Conclusions and Relevance The results of this randomized clinical trial suggest that EAET may be a preferred intervention for medically and psychiatrically complex patients with pain. The societal burden of chronic pain could be improved by further incorporating the principles of EAET into mainstream clinical pain medicine. Trial Registration ClinicalTrials.gov Identifier: NCT03918642.
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Affiliation(s)
- Brandon C Yarns
- Department of Mental Health, VA Greater Los Angeles Healthcare System, California
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at University of California, Los Angeles
| | - Nicholas J Jackson
- Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles
| | - Alexander Alas
- Department of Mental Health, VA Greater Los Angeles Healthcare System, California
| | - Rebecca J Melrose
- Department of Mental Health, VA Greater Los Angeles Healthcare System, California
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at University of California, Los Angeles
| | - Mark A Lumley
- Department of Psychology, Wayne State University, Detroit, Michigan
| | - David L Sultzer
- Department of Mental Health, VA Greater Los Angeles Healthcare System, California
- Department of Psychiatry and Human Behavior, University of California, Irvine School of Medicine, Irvine
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Wi D, Ransom JC, Flynn DM, Steffen AD, Park C, Burke LA, Doorenbos AZ. Role of Pain Catastrophizing in the Effects of Cognitive Behavioral Therapy for Chronic Pain in Different Subgroups: An Exploratory Secondary Data Analysis Using Finite Mixture Models. Mil Med 2024:usae288. [PMID: 38829170 DOI: 10.1093/milmed/usae288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 03/08/2024] [Accepted: 05/22/2024] [Indexed: 06/05/2024] Open
Abstract
INTRODUCTION Providing effective treatment for debilitating chronic pain is a challenge among many populations including military service members. Cognitive behavioral therapy for chronic pain (CBT-CP) is a leading psychological pain treatment. Pain catastrophizing is a pivotal mediator of pain-related outcomes. The purpose of this study was (1) to identify patient subgroups who differ in response to CBT-CP and (2) to explore the characteristics that define these patient subgroups. The overall goal was to obtain a better understanding of factors that may influence response to CBT-CP. MATERIALS AND METHODS This study was a secondary analysis of data from a clinical trial of 149 U.S. active duty service members with chronic pain. Participants underwent group-based CBT-CP for 6 weeks and completed pre- and posttreatment assessments. Finite mixture models were employed to identify subgroups in treatment response, with pain impact score as the primary outcome measure. RESULTS We identified two classes of nearly equal size with distinct pain impact responses. One class reported improved pain impact scores following CBT-CP. This improvement was significantly associated with lower (better) baseline depression scores and greater improvement in posttreatment pain catastrophizing. In contrast, the other class reported slightly worse mean pain impact scores following CBT-CP treatment; this response was not related to baseline depression or change in pain catastrophizing. CONCLUSIONS Our findings demonstrate that a sizable proportion of individuals with chronic pain may not respond to group-based CBT-CP and may require a more individualized treatment approach.
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Affiliation(s)
- Dahee Wi
- Department of Human Development Nursing Science, College of Nursing, University of Illinois Chicago, Chicago, IL 60612, USA
| | - Jeffrey C Ransom
- Physical Performance Service Line, Interdisciplinary Pain Management Center, Madigan Army Medical Center, Tacoma, WA 98431, USA
| | - Diane M Flynn
- Physical Performance Service Line, Interdisciplinary Pain Management Center, Madigan Army Medical Center, Tacoma, WA 98431, USA
| | - Alana D Steffen
- Department of Population Health Nursing Science, College of Nursing, University of Illinois, Chicago, IL 60612, USA
| | - Chang Park
- Department of Population Health Nursing Science, College of Nursing, University of Illinois, Chicago, IL 60612, USA
| | - Larisa A Burke
- Office of Research Facilitation, College of Nursing, University of Illinois, Chicago, IL 60612, USA
| | - Ardith Z Doorenbos
- Department of Biobehavioral Nursing Science, College of Nursing, University of Illinois, Chicago, IL 60612, USA
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA 98195, USA
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Cesur R, Sabia JJ, Bradford WD. The effect of combat deployments on veteran opioid abuse. HEALTH ECONOMICS 2024; 33:1284-1318. [PMID: 38424463 DOI: 10.1002/hec.4812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 01/23/2024] [Accepted: 01/28/2024] [Indexed: 03/02/2024]
Abstract
Grim national statistics about the U.S. opioid crisis are increasingly well known to the American public. Far less well known is that U.S. servicemembers are at ground zero of the epidemic, with veterans facing an overdose death rate of up to twice that of civilians. Exploiting a quasi-experiment in overseas deployment assignment, this study estimates the causal impact of combat exposure among the deployed in the Global War on Terrorism on opioid abuse. We find that exposure to war theater substantially increased the risk of prescription painkiller abuse and illicit heroin use among active duty servicemen. The magnitudes of our estimates imply lower-bound combat exposure-induced healthcare costs of $1.04 billion per year for prescription painkiller abuse and $470 million per year for heroin use.
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Affiliation(s)
- Resul Cesur
- Finance Department, University of Connecticut, NBER & IZA, Storrs, Connecticut, USA
| | - Joseph J Sabia
- Center for Health Economics & Policy Studies, San Diego State University and IZA, San Diego, California, USA
| | - W David Bradford
- Department of Public Administration & Policy, University of Georgia, Athens, Georgia, USA
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Vollert J, Kumar A, Coady EC, Cullinan P, Dyball D, Fear NT, Gan Z, Miller EF, Sprinckmoller S, Schofield S, Bennett A, Bull AMJ, Boos CJ, Rice ASC, Kemp HI. Pain after combat injury in male UK military personnel deployed to Afghanistan. Br J Anaesth 2024; 132:1285-1292. [PMID: 38521656 PMCID: PMC11129277 DOI: 10.1016/j.bja.2024.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 02/13/2024] [Accepted: 02/13/2024] [Indexed: 03/25/2024] Open
Abstract
BACKGROUND Chronic pain after injury poses a serious health burden. As a result of advances in medical technology, ever more military personnel survive severe combat injuries, but long-term pain outcomes are unknown. We aimed to assess rates of pain in a representative sample of UK military personnel with and without combat injuries. METHODS We used data from the ADVANCE cohort study (ISRCTN57285353). Individuals deployed as UK armed forces to Afghanistan were recruited to include those with physical combat injuries, and a frequency-matched uninjured comparison group. Participants completed self-reported questionnaires, including 'overall' pain intensity and self-assessment of post-traumatic stress disorder, anxiety, and depression. RESULTS A total of 579 participants with combat injury, including 161 with amputations, and 565 uninjured participants were included in the analysis (median 8 yr since injury/deployment). Frequency of moderate or severe pain was 18% (n=202), and was higher in the injured group (n=140, 24%) compared with the uninjured group (n=62, 11%, relative risk: 1.1, 95% confidence interval [CI]: 1.0-1.2, P<0.001), and lower in the amputation injury subgroup (n=31, 19%) compared with the non-amputation injury subgroup (n=109, 26%, relative risk: 0.9, 95% CI: 0.9-1.0, P=0.034). Presence of at least moderate pain was associated with higher rates of post-traumatic stress (RR: 3.7, 95% CI: 2.7-5.0), anxiety (RR: 3.2, 95% CI: 2.4-4.3), and depression (RR: 3.4, 95% CI: 2.7-4.5) after accounting for injury. CONCLUSION Combat injury, but not amputation, was associated with a higher frequency of moderate to severe pain intensity in this cohort, and pain was associated with adverse mental health outcomes.
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Affiliation(s)
- Jan Vollert
- Department of Clinical and Biomedical Sciences, Faculty of Health and Life Sciences, University of Exeter, Exeter, UK; Pain Research, MSk Lab, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK.
| | - Alexander Kumar
- Pain Research, MSk Lab, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK; Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre, Stanford Hall Estate, Loughborough, UK
| | - Emma C Coady
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
| | - Paul Cullinan
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
| | - Daniel Dyball
- King's Centre for Military Health Research, King's College London, London, UK
| | - Nicola T Fear
- King's Centre for Military Health Research, King's College London, London, UK; Academic Department of Military Mental Health, King's College London, London, UK
| | - Zoe Gan
- Pain Research, MSk Lab, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Eleanor F Miller
- Department of Bioengineering, Faculty of Engineering, Imperial College London, London, UK
| | - Stefan Sprinckmoller
- Department of Bioengineering, Faculty of Engineering, Imperial College London, London, UK
| | - Suzie Schofield
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
| | - Alexander Bennett
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre, Stanford Hall Estate, Loughborough, UK; National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
| | - Anthony M J Bull
- Centre for Blast Injury Studies, Department of Bioengineering, Imperial College London, London, UK
| | - Christopher J Boos
- Department of Cardiology, University Hospital Dorset, NHS Trust, Poole, UK
| | - Andrew S C Rice
- Pain Research, MSk Lab, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK; Centre for Blast Injury Studies, Department of Bioengineering, Imperial College London, London, UK
| | - Harriet I Kemp
- Pain Research, MSk Lab, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
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Kelber MS, Smolenski DJ, Belsher BE, O'Gallagher K, Issa F, Stewart LT, Evatt DP. The associations of opioid and benzodiazepine prescriptions with injuries among US military service members. Pain 2024:00006396-990000000-00586. [PMID: 38709494 DOI: 10.1097/j.pain.0000000000003264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 03/18/2024] [Indexed: 05/07/2024]
Abstract
ABSTRACT Given the high rates of physical trauma and pain among service members, opioid-prescribing practices and use patterns have significant implications for the well-being of service members and can affect military medicine and personnel readiness. This study measured the association between prescribed opioid and benzodiazepine medications and subsequently reported injuries (accidental, alcohol and drug related, self-inflicted, and violence related) among active duty military members. Participants were service members who entered the military between January 1, 2005, and June 30, 2010. In a nested case-control design, we compared individuals with injuries to individuals without injuries with respect to their opioid and benzodiazepine prescriptions in the 30 days before the injury of an index case. We used a multiintercept, logistic regression model to compare coefficient estimates by injury type. Overall, approximately 17% of individuals with an injury and 4% of individuals without an injury had a recorded opioid prescription. Individuals with an injury of any type had greater odds of prior exposure to opioid prescriptions than controls. Although a dose-response effect was observed for all injury types, it reached a plateau sooner for natural or environmental accidents and self-inflicted injuries relative to alcohol-related and drug-related injuries, violence-related injuries, vehicle accidents, accidental falls, and other accidents. Benzodiazepine prescriptions were found in 3.5% of individuals with an injury and 0.5% of individuals without an injury. The association between benzodiazepine prescriptions and injuries was strongest for natural and environmental accidents.
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Affiliation(s)
- Marija S Kelber
- Psychological Health Center of Excellence, Defense Health Agency
| | | | - Bradley E Belsher
- Psychological Health Center of Excellence, Defense Health Agency
- Carl T Hayden Veterans Medical Center, Phoenix VA Health Care System
| | | | - Fuad Issa
- Psychological Health Center of Excellence, Defense Health Agency
| | | | - Daniel P Evatt
- Psychological Health Center of Excellence, Defense Health Agency
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Kumar A, Soliman N, Gan Z, Cullinan P, Vollert J, Rice AS, Kemp H. A systematic review of the prevalence of postamputation and chronic neuropathic pain associated with combat injury in military personnel. Pain 2024; 165:727-740. [PMID: 38112578 PMCID: PMC10949216 DOI: 10.1097/j.pain.0000000000003094] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 08/01/2023] [Accepted: 08/04/2023] [Indexed: 12/21/2023]
Abstract
ABSTRACT Combat trauma can lead to widespread tissue damage and limb loss. This may result in chronic neuropathic and post amputation pain, including phantom limb pain (PLP) and residual limb pain (RLP). The military population is distinct with respect to demographic, injury, and social characteristics compared with other amputation and trauma cohorts. We undertook a systematic review of studies of military personnel, with a history of combat injury, that reported a prevalence of any type of postamputation pain or chronic neuropathic pain, identified from Embase and MEDLINE databases.Using the inverse variance method with a random-effects model, we undertook a meta-analysis to determine an overall prevalence and performed exploratory analyses to identify the effect of the type of pain, conflict, and time since injury on prevalence. Pain definitions and types of pain measurement tools used in studies were recorded. Thirty-one studies (14,738 participants) were included. The pooled prevalence of PLP, RLP, and chronic neuropathic pain were 57% (95% CI: 46-68), 61% (95% CI: 50-71), and 26% (95% CI: 10-54), respectively. Between-study heterogeneity was high (I 2 : 94%-98%). Characterisation of duration, frequency, and impact of pain was limited. Factors reported by included studies as being associated with PLP included the presence of RLP and psychological comorbidity. The prevalence of postamputation pain and chronic neuropathic pain after combat trauma is high. We highlight inconsistency of case definitions and terminology for pain and the need for consensus in future research of traumatic injury.
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Affiliation(s)
- Alexander Kumar
- Department of Surgery and Cancer, Pain Research Group, Imperial College, London, United Kingdom
- Academic Department of Military Anaesthesia, Royal Centre for Defence Medicine, Birmingham, United Kingdom
| | - Nadia Soliman
- Department of Surgery and Cancer, Pain Research Group, Imperial College, London, United Kingdom
| | - Zoe Gan
- Department of Surgery and Cancer, Pain Research Group, Imperial College, London, United Kingdom
| | - Paul Cullinan
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Jan Vollert
- Department of Surgery and Cancer, Pain Research Group, Imperial College, London, United Kingdom
| | - Andrew S.C. Rice
- Department of Surgery and Cancer, Pain Research Group, Imperial College, London, United Kingdom
| | - Harriet Kemp
- Department of Surgery and Cancer, Pain Research Group, Imperial College, London, United Kingdom
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Snow T, Burke L, Sanford DC, Mathew A, Steffen AD, Flynn DM, Doorenbos AZ. Use of a treadmill, lift, and carry battery as a composite functional performance test: analysis of data from a pragmatic randomized controlled trial in a military population participating in a functional restoration program. Physiother Theory Pract 2024; 40:647-657. [PMID: 36282735 PMCID: PMC10126206 DOI: 10.1080/09593985.2022.2135149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 09/16/2022] [Accepted: 09/17/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND The treadmill, lift, and carry (TLC) battery is a composite functional performance test created to measure the effectiveness of a functional restoration (FR) program in a military population. PURPOSE To determine the validity, reliability, and minimal clinically important differences (MCIDs) of the individual tests and the composite TLC battery. METHODS We assessed the validity by mean differences, effect sizes, and standardized response means pre- and post-FR; and by correlations between the TLC battery and other established measures. We assessed reliability by correlating pre- and post-FR scores. We used principal component analysis (PCA) to create a composite measure. We determined MCIDs via distribution methods and receiver operator curve analysis. RESULTS There were significant (p < .001) mean changes and large effect sizes (0.6-0.8) pre- to post-FR. Pre- and posttest Spearman's correlations ranged from 0.5 to 0.6. Spearman's correlations between TLC battery scores and other measures were small (± 0.3-0.4) and significant (p < .001). PCA supported use of a single-component composite. MCIDs were treadmill time: 3 minutes; metabolic equivalent of task: 1.5 units; floor-to-waist lift: 15 lbs; waist-to-shoulder lift: 10 lbs; 40-foot carry: 10 lbs; and composite score: 6 units. CONCLUSION This secondary data analysis provides preliminary support for the validity and reliability of the TLC battery for use in military populations.
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Affiliation(s)
- Tyler Snow
- Department of Rehabilitative Medicine, Madigan Army Medical Center, 9040 Jackson Ave. Tacoma, WA, 98431 USA
| | - Larisa Burke
- College of Nursing, University of Illinois Chicago, 845 S. Damen Ave. Chicago, IL, 60612 USA
| | - Dana C. Sanford
- Department of Rehabilitative Medicine, Madigan Army Medical Center, 9040 Jackson Ave. Tacoma, WA, 98431 USA
| | - Asha Mathew
- College of Nursing, University of Illinois Chicago, 845 S. Damen Ave. Chicago, IL, 60612 USA
| | - Alana D. Steffen
- College of Nursing, University of Illinois Chicago, 845 S. Damen Ave. Chicago, IL, 60612 USA
| | - Diane M. Flynn
- Department of Rehabilitative Medicine, Madigan Army Medical Center, 9040 Jackson Ave. Tacoma, WA, 98431 USA
| | - Ardith Z. Doorenbos
- College of Nursing, University of Illinois Chicago, 845 S. Damen Ave. Chicago, IL, 60612 USA
- Department of Anesthesiology and Pain Medicine, University of Washington, 1959 NE Pacific St. Seattle, WA, USA
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8
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Wi D, Park C, Ransom JC, Flynn DM, Doorenbos AZ. A network analysis of pain intensity and pain-related measures of physical, emotional, and social functioning in US military service members with chronic pain. PAIN MEDICINE (MALDEN, MASS.) 2024; 25:231-238. [PMID: 37944054 PMCID: PMC10906708 DOI: 10.1093/pm/pnad148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 10/20/2023] [Accepted: 10/26/2023] [Indexed: 11/12/2023]
Abstract
OBJECTIVE The purpose of this study was to apply network analysis methodology to better understand the relationships between pain-related measures among people with chronic pain. METHODS We analyzed data from a cross-sectional sample of 4614 active duty service members with chronic pain referred to 1 military interdisciplinary pain management center between 2014 and 2021. Using a combination of Patient-Reported Outcomes Measurement Information System measures and other pain-related measures, we applied the "EBICglasso" algorithm to create regularized partial correlation networks that would identify the most influential measures. RESULTS Pain interference, depression, and anxiety had the highest strength in these networks. Pain catastrophizing played an important role in the association between pain and other pain-related health measures. Bootstrap analyses showed that the networks were very stable and the edge weights accurately estimated in 2 analyses (with and without pain catastrophizing). CONCLUSIONS Our findings offer new insights into the relationships between symptoms using network analysis. Important findings highlight the strength of association between pain interference, depression and anxiety, which suggests that if pain is to be treated depression and anxiety must also be addressed. What was of specific importance was the role that pain catastrophizing had in the relationship between pain and other symptoms suggesting that pain catastrophizing is a key symptom on which to focus for treatment of chronic pain.
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Affiliation(s)
- Dahee Wi
- Department of Biobehavioral Nursing Science, College of Nursing, University of Illinois Chicago, Chicago, IL 60612, United States
| | - Chang Park
- Department of Population Health Nursing Science, College of Nursing, University of Illinois Chicago, Chicago, IL 60612, United States
| | - Jeffrey C Ransom
- Physical Performance Service Line, Madigan Army Medical Center, Interdisciplinary Pain Management Center, Joint Base Lewis-McChord, WA 98431, United States
| | - Diane M Flynn
- Physical Performance Service Line, Madigan Army Medical Center, Interdisciplinary Pain Management Center, Joint Base Lewis-McChord, WA 98431, United States
| | - Ardith Z Doorenbos
- Department of Biobehavioral Nursing Science, College of Nursing, University of Illinois Chicago, Chicago, IL 60612, United States
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA 98195, United States
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9
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Miron RJ, Estrin NE, Sculean A, Zhang Y. Understanding exosomes: Part 2-Emerging leaders in regenerative medicine. Periodontol 2000 2024; 94:257-414. [PMID: 38591622 DOI: 10.1111/prd.12561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Revised: 02/16/2024] [Accepted: 02/21/2024] [Indexed: 04/10/2024]
Abstract
Exosomes are the smallest subset of extracellular signaling vesicles secreted by most cells with the ability to communicate with other tissues and cell types over long distances. Their use in regenerative medicine has gained tremendous momentum recently due to their ability to be utilized as therapeutic options for a wide array of diseases/conditions. Over 5000 publications are currently being published yearly on this topic, and this number is only expected to dramatically increase as novel therapeutic strategies continue to be developed. Today exosomes have been applied in numerous contexts including neurodegenerative disorders (Alzheimer's disease, central nervous system, depression, multiple sclerosis, Parkinson's disease, post-traumatic stress disorders, traumatic brain injury, peripheral nerve injury), damaged organs (heart, kidney, liver, stroke, myocardial infarctions, myocardial infarctions, ovaries), degenerative processes (atherosclerosis, diabetes, hematology disorders, musculoskeletal degeneration, osteoradionecrosis, respiratory disease), infectious diseases (COVID-19, hepatitis), regenerative procedures (antiaging, bone regeneration, cartilage/joint regeneration, osteoarthritis, cutaneous wounds, dental regeneration, dermatology/skin regeneration, erectile dysfunction, hair regrowth, intervertebral disc repair, spinal cord injury, vascular regeneration), and cancer therapy (breast, colorectal, gastric cancer and osteosarcomas), immune function (allergy, autoimmune disorders, immune regulation, inflammatory diseases, lupus, rheumatoid arthritis). This scoping review is a first of its kind aimed at summarizing the extensive regenerative potential of exosomes over a broad range of diseases and disorders.
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Affiliation(s)
- Richard J Miron
- Department of Periodontology, University of Bern, Bern, Switzerland
| | - Nathan E Estrin
- Advanced PRF Education, Venice, Florida, USA
- School of Dental Medicine, Lake Erie College of Osteopathic Medicine, Bradenton, Florida, USA
| | - Anton Sculean
- Department of Periodontology, University of Bern, Bern, Switzerland
| | - Yufeng Zhang
- Department of Oral Implantology, University of Wuhan, Wuhan, China
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Garland EL, Nakamura Y, Bryan CJ, Hanley AW, Parisi A, Froeliger B, Marchand WR, Donaldson GW. Mindfulness-Oriented Recovery Enhancement for Veterans and Military Personnel on Long-Term Opioid Therapy for Chronic Pain: A Randomized Clinical Trial. Am J Psychiatry 2024; 181:125-134. [PMID: 38196335 DOI: 10.1176/appi.ajp.20230272] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
OBJECTIVE This randomized clinical trial evaluated the efficacy of Mindfulness-Oriented Recovery Enhancement (MORE) among past and present U.S. military personnel with prescriptions for long-term opioid therapy for chronic pain. METHODS In this clinical trial, 230 past and present military personnel with prescriptions for long-term opioid therapy were randomized in a 1:1 ratio to MORE or supportive psychotherapy (initially delivered in person and then via videoconferencing after the onset of the COVID-19 pandemic). Primary outcomes were chronic pain, measured by the Brief Pain Inventory, and aberrant drug-related behaviors, measured by the Current Opioid Misuse Measure, through 8 months of follow-up. Opioid dose was a key secondary outcome. Other outcomes included psychiatric symptoms, catastrophizing, positive affect, ecological momentary assessments of opioid craving, and opioid attentional bias. RESULTS MORE was superior to supportive psychotherapy through the 8-month follow-up in reducing pain-related functional interference, pain severity, and opioid dose. MORE reduced daily opioid dose by 20.7%, compared with a dose reduction of 3.9% with supportive psychotherapy. Although there was no overall between-group difference in opioid misuse, the in-person MORE intervention outperformed supportive psychotherapy for reducing opioid misuse. MORE reduced anhedonia, pain catastrophizing, craving, and opioid attentional bias and increased positive affect to a greater extent than supportive psychotherapy. MORE also modulated therapeutic processes, including mindful reinterpretation of pain sensations, nonreactivity, savoring, positive attention, and reappraisal. CONCLUSIONS Among past and present U.S. military personnel, MORE led to sustained decreases in chronic pain, opioid use, craving, and opioid cue reactivity. MORE facilitated opioid dose reduction while preserving adequate pain control and preventing mood disturbances, suggesting its utility for safe opioid tapering.
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Affiliation(s)
- Eric L Garland
- Center on Mindfulness and Integrative Health Intervention Development, University of Utah, Salt Lake City (Garland, Nakamura, Hanley, Parisi); Veterans Health Care Administration VISN 19 Whole Health Flagship Site, VA Salt Lake City Health Care System, Salt Lake City (Garland, Marchand); Pain Research Center, Division of Pain Medicine, Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City (Nakamura, Donaldson); Department of Psychiatry and Behavioral Health, Ohio State University, Columbus (Bryan); Departments of Psychiatry and Psychological Sciences, University of Missouri, Columbia (Froeliger); Department of Psychiatry, University of Utah School of Medicine, Salt Lake City (Marchand)
| | - Yoshio Nakamura
- Center on Mindfulness and Integrative Health Intervention Development, University of Utah, Salt Lake City (Garland, Nakamura, Hanley, Parisi); Veterans Health Care Administration VISN 19 Whole Health Flagship Site, VA Salt Lake City Health Care System, Salt Lake City (Garland, Marchand); Pain Research Center, Division of Pain Medicine, Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City (Nakamura, Donaldson); Department of Psychiatry and Behavioral Health, Ohio State University, Columbus (Bryan); Departments of Psychiatry and Psychological Sciences, University of Missouri, Columbia (Froeliger); Department of Psychiatry, University of Utah School of Medicine, Salt Lake City (Marchand)
| | - Craig J Bryan
- Center on Mindfulness and Integrative Health Intervention Development, University of Utah, Salt Lake City (Garland, Nakamura, Hanley, Parisi); Veterans Health Care Administration VISN 19 Whole Health Flagship Site, VA Salt Lake City Health Care System, Salt Lake City (Garland, Marchand); Pain Research Center, Division of Pain Medicine, Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City (Nakamura, Donaldson); Department of Psychiatry and Behavioral Health, Ohio State University, Columbus (Bryan); Departments of Psychiatry and Psychological Sciences, University of Missouri, Columbia (Froeliger); Department of Psychiatry, University of Utah School of Medicine, Salt Lake City (Marchand)
| | - Adam W Hanley
- Center on Mindfulness and Integrative Health Intervention Development, University of Utah, Salt Lake City (Garland, Nakamura, Hanley, Parisi); Veterans Health Care Administration VISN 19 Whole Health Flagship Site, VA Salt Lake City Health Care System, Salt Lake City (Garland, Marchand); Pain Research Center, Division of Pain Medicine, Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City (Nakamura, Donaldson); Department of Psychiatry and Behavioral Health, Ohio State University, Columbus (Bryan); Departments of Psychiatry and Psychological Sciences, University of Missouri, Columbia (Froeliger); Department of Psychiatry, University of Utah School of Medicine, Salt Lake City (Marchand)
| | - Anna Parisi
- Center on Mindfulness and Integrative Health Intervention Development, University of Utah, Salt Lake City (Garland, Nakamura, Hanley, Parisi); Veterans Health Care Administration VISN 19 Whole Health Flagship Site, VA Salt Lake City Health Care System, Salt Lake City (Garland, Marchand); Pain Research Center, Division of Pain Medicine, Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City (Nakamura, Donaldson); Department of Psychiatry and Behavioral Health, Ohio State University, Columbus (Bryan); Departments of Psychiatry and Psychological Sciences, University of Missouri, Columbia (Froeliger); Department of Psychiatry, University of Utah School of Medicine, Salt Lake City (Marchand)
| | - Brett Froeliger
- Center on Mindfulness and Integrative Health Intervention Development, University of Utah, Salt Lake City (Garland, Nakamura, Hanley, Parisi); Veterans Health Care Administration VISN 19 Whole Health Flagship Site, VA Salt Lake City Health Care System, Salt Lake City (Garland, Marchand); Pain Research Center, Division of Pain Medicine, Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City (Nakamura, Donaldson); Department of Psychiatry and Behavioral Health, Ohio State University, Columbus (Bryan); Departments of Psychiatry and Psychological Sciences, University of Missouri, Columbia (Froeliger); Department of Psychiatry, University of Utah School of Medicine, Salt Lake City (Marchand)
| | - William R Marchand
- Center on Mindfulness and Integrative Health Intervention Development, University of Utah, Salt Lake City (Garland, Nakamura, Hanley, Parisi); Veterans Health Care Administration VISN 19 Whole Health Flagship Site, VA Salt Lake City Health Care System, Salt Lake City (Garland, Marchand); Pain Research Center, Division of Pain Medicine, Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City (Nakamura, Donaldson); Department of Psychiatry and Behavioral Health, Ohio State University, Columbus (Bryan); Departments of Psychiatry and Psychological Sciences, University of Missouri, Columbia (Froeliger); Department of Psychiatry, University of Utah School of Medicine, Salt Lake City (Marchand)
| | - Gary W Donaldson
- Center on Mindfulness and Integrative Health Intervention Development, University of Utah, Salt Lake City (Garland, Nakamura, Hanley, Parisi); Veterans Health Care Administration VISN 19 Whole Health Flagship Site, VA Salt Lake City Health Care System, Salt Lake City (Garland, Marchand); Pain Research Center, Division of Pain Medicine, Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City (Nakamura, Donaldson); Department of Psychiatry and Behavioral Health, Ohio State University, Columbus (Bryan); Departments of Psychiatry and Psychological Sciences, University of Missouri, Columbia (Froeliger); Department of Psychiatry, University of Utah School of Medicine, Salt Lake City (Marchand)
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Bounds CL, Coppieters MW, Thomson HW, Larsen B, Evans K. Efficacy of Conservative Interventions for Musculoskeletal Conditions on Pain and Disability in Active Serving Military Personnel-A Systematic Review. Mil Med 2024; 189:e66-e75. [PMID: 36722165 PMCID: PMC10824481 DOI: 10.1093/milmed/usac409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 08/21/2022] [Accepted: 12/12/2022] [Indexed: 02/02/2023] Open
Abstract
INTRODUCTION Musculoskeletal (MSK) injuries and associated pain disorders are one of the leading causes for soldiers not being medically fit for deployment, impacting force capability and readiness. Musculoskeletal pain continues to be a leading cause of disability within military services and is associated with a substantial financial burden. A better understanding of the effectiveness of MSK pain management strategies is required. This review was designed to determine the efficacy of nonsurgical interventions, such as physiotherapy, exercise, pharmacology, and multidisciplinary programs, to manage MSK conditions in active serving military populations. MATERIALS AND METHODS MEDLINE, Embase, CINAHL, and SPORTDiscus were searched to identify relevant randomized clinical trials. Recommended methods were used for article identification, selection, and data extraction. The Cochrane Risk of Bias tool and the Grade of Recommendation, Assessment, Development, and Evaluation were used to appraise the studies. Where possible, meta-analyses were performed. The review was conducted according to the PRISMA guidelines. RESULTS Nineteen articles (1,408 participants) met the eligibility criteria. Low back pain (LBP) was the most frequently investigated condition, followed by knee pain, neck pain, and shoulder pain. Early physiotherapy, exercise and adjunct chiropractic manipulation (for LBP), and multidisciplinary pain programs (physiotherapy, occupational therapy, and psychology) (for chronic MSK pain) improved pain (standardized mean difference ranged from -0.39 to -1.34; low strength of evidence). Participation in multidisciplinary pain programs, adjunct chiropractic manipulation, and early physiotherapy improved disability (for LBP) (standardized mean difference ranged from -0.45 to -0.86; low to very low strength of evidence). No studies evaluated pain medication. Dietary supplements (glucosamine, chondroitin sulfate, and manganese ascorbate), electrotherapy, isolated lumbar muscle exercises, home cervical traction, or training in virtual reality showed no benefit. The studies had a high risk of bias, were typically underpowered, and demonstrated high clinical heterogeneity. CONCLUSIONS Currently available randomized clinical trials do not provide sufficient evidence to guide military organizations or health care professionals in making appropriate treatment decisions to manage MSK pain in active serving military personnel. Future research is essential to enable evidence-based recommendations for the effective management of MSK pain conditions in this unique population.
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Affiliation(s)
- Courtney L Bounds
- Menzies Health Institute Queensland, Griffith University, Brisbane (Nathan), QLD 4111, Australia
| | - Michel W Coppieters
- Menzies Health Institute Queensland, Griffith University, Brisbane (Nathan), QLD 4111, Australia
- Amsterdam Movement Sciences-Program Musculoskeletal Health, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam 1081 BT, The Netherlands
| | - Hayley W Thomson
- Menzies Health Institute Queensland, Griffith University, Brisbane (Nathan), QLD 4111, Australia
- Gold Coast University Hospital, Gold Coast Hospital and Health Service, Southport, QLD 4125, Australia
- Griffith Sports Physiology and Performance, Griffith University, Southport QLD 4222, Australia
- Healthia Limited, Brisbane, QLD 4006, Australia
| | - Brianna Larsen
- School of Health and Medical Sciences, University of Southern Queensland, Ipswich, QLD 4305, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2006, Australia
| | - Kerrie Evans
- Griffith Sports Physiology and Performance, Griffith University, Southport QLD 4222, Australia
- Healthia Limited, Brisbane, QLD 4006, Australia
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Singh S, Sri Krishna V, Cherian Ambooken G, Peter DK. Nalbuphine: an underrecognized battlefield analgesic and its utilization in combat care and peripheral areas. Med J Armed Forces India 2024; 80:41-45. [PMID: 38239600 PMCID: PMC10793233 DOI: 10.1016/j.mjafi.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 03/04/2023] [Indexed: 01/22/2024] Open
Abstract
Battlefield injuries result in acute and severe uncontrolled pain, which can be reduced with the early use of analgesia. Apart from pain, battlefield injuries may also cause significant morbidity and a prolonged period of absence from active duty. Traditionally available opioids are known to cause various undesirable side effects such as respiratory depression that may worsen the condition of an already injured combatant. Nalbuphine is an opioid agonist-antagonist and has been increasingly used for postoperative analgesia over the last decade. In India, it is the only opioid analgesic that does not come under the Controlled Substances Act at the time of this publication. In today's world, where nalbuphine is being recommended for acute pain worldwide, its use in the Indian combat scenario needs to be conceptualized at the medical officer level (primary caregiver). This conceptualization will be discussed in detail in this review article.
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Affiliation(s)
- Shalendra Singh
- Senior Advisor (Anaesthesia & Neuro Anaesthesia), Command Hospital (Northern Command), Udhampur, India
| | | | | | - Deepu K. Peter
- Graded Specialist (Respiratory Medicine), Command Hospital (Northern Command), Udhampur, India
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Prent JM, van der Wurff P, Scholten-Peeters GG. Lifestyle factors and psychological factors are associated with central pain processing in service members with persistent low-back pain: A cross-sectional exploratory study. Medicine (Baltimore) 2023; 102:e36741. [PMID: 38134068 PMCID: PMC10735071 DOI: 10.1097/md.0000000000036741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 11/30/2023] [Indexed: 12/24/2023] Open
Abstract
Persistent low-back pain (LBP) is highly prevalent in the military. Altered central pain processing is one of the mechanisms found to underlie persistent LBP. Our aim was to explore which factors are associated with altered pain processing in Dutch service members with persistent LBP. This knowledge may guide clinicians in what factors to address in the treatment of dysfunctional pain processing in service members with persistent LBP. Twenty-one service members with persistent LBP (mean age 34.0 years, 18 males) were included in this cross-sectional exploratory study. Participants completed questionnaires regarding lifestyle and psychological factors. Altered central pain processing was measured by temporal summation of pain to examine the function of the pain facilitatory system and by conditioned pain modulation to examine the pain inhibitory function. Univariable and multivariable linear regression analyses were performed. A higher local temporal summation of pain was associated with a longer sitting time, a higher level of physical activity and a higher level of pain catastrophizing. A higher local conditioned pain modulation was associated with a higher level of pain catastrophizing, anxiety and depression symptoms, and with a lower sleep quality. A higher remote conditioned pain modulation effect was associated with a higher level of physical activity, a higher body mass index and a shorter sitting time. This study succeeded in identifying lifestyle and psychological factors associated with altered pain processing in service members with persistent LBP. Prospective studies are needed to examine causality in these relationships.
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Affiliation(s)
- Julia M. Prent
- Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences Program Musculoskeletal Health, Amsterdam, The Netherlands
- Research and Development, Military Rehabilitation Centre “Aardenburg”, Doorn, The Netherlands
| | - Peter van der Wurff
- Research and Development, Military Rehabilitation Centre “Aardenburg”, Doorn, The Netherlands
| | - Gwendolyne G.M. Scholten-Peeters
- Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences Program Musculoskeletal Health, Amsterdam, The Netherlands
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Hu J, Qin X. Hidden battle beyond the battlefield: unmasking chronic pain among military personnel. Evid Based Nurs 2023:ebnurs-2023-103737. [PMID: 37973211 DOI: 10.1136/ebnurs-2023-103737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2023] [Indexed: 11/19/2023]
Affiliation(s)
- Jiale Hu
- Department of Nurse Anesthesia, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Xiaojing Qin
- College of Health Science, Rush University, Chicago, Illinois, USA
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Schaaf S, Flynn DM, Steffen AD, Ransom J, Doorenbos A. Pain Catastrophizing and Its Association with Military Medical Disability Among US Active Duty Service Members with Chronic Predominately Musculoskeletal Pain: A Retrospective Cohort Analysis. J Pain Res 2023; 16:3837-3852. [PMID: 37965277 PMCID: PMC10642487 DOI: 10.2147/jpr.s400313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 07/06/2023] [Indexed: 11/16/2023] Open
Abstract
Context Pain catastrophizing is characterized by negative emotional and cognitive responses to pain and is a predictor of work-related disability. Its association with military medical disability has not been studied. Objective To (1) identify the pain catastrophizing scale (PCS) score cut point most strongly associated with military medical disability, (2) measure the difference in rate of disability between service members with baseline PCS scores above versus below the cut point, and (3) determine if improvement in PCS score during pain specialty care is associated with decreased likelihood of disability. Methods This was a retrospective cohort analysis comparing PCS scores collected from US Army active duty service members at time of initial visit to an interdisciplinary pain management center and periodically during pain treatment. Outcome was determination during the following year of a military service-disqualifying disability. Results Receiver operating characteristic (ROC) curves determined that a PCS score of 20 was the single cut point most closely associated with subsequent disability. Kaplan-Meier curves showed significantly higher disability rate during the following year among those with baseline PCS scores ≥20 (52%) compared to those with lower scores (26%). Scheffe-adjusted contrasts showed that service members with PCS scores ≥20 whose scores improved to <20 at follow-up were significantly less likely to have a medical disability (42.6%; 95% CI, 0.07-0.58) than those whose PCS score remained ≥20 (76.3%; 95% CI, 68.0%-84.7%). Conclusion A PCS score cut point of 20 distinguishes between high versus low likelihood of disability among service members. Those with high baseline PCS score had twice the likelihood of disability than those with low scores. Service members who decreased their PCS score from high to low during pain specialty care had lower likelihood of disability. Prospective research is needed to determine if treatments that lower pain catastrophizing yield reduced likelihood of subsequent disability.
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Affiliation(s)
- Sherrill Schaaf
- School of Health Sciences, A.T. Still University, Mesa, AZ, USA
| | - Diane M Flynn
- Interdisciplinary Pain Management Center, Madigan Army Medical Center, Tacoma, WA, USA
| | - Alana D Steffen
- College of Nursing, University of Illinois Chicago, Chicago, IL, USA
| | - Jeffrey Ransom
- Interdisciplinary Pain Management Center, Madigan Army Medical Center, Tacoma, WA, USA
| | - Ardith Doorenbos
- College of Nursing, University of Illinois Chicago, Chicago, IL, USA
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA, USA
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Smith CD, Gutierrez IA, Nassif TH, Jordan KL, Taylor KM, Jha AP, Adler AB. Impact of mindfulness training and yoga on injury and pain-related impairment: a group randomized trial in basic combat training. Front Psychol 2023; 14:1214039. [PMID: 37868598 PMCID: PMC10587413 DOI: 10.3389/fpsyg.2023.1214039] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 09/15/2023] [Indexed: 10/24/2023] Open
Abstract
Introduction Service members are at risk for pain-related difficulties in functioning and physical injury. Previous studies suggest that mindfulness training (MT) and yoga may prevent these outcomes. The present study was designed to determine the impact of MT and yoga on the health, pain, and injury of Army trainees completing 10 weeks of basic combat training (BCT). Methods Platoons (≈40 trainees per platoon) were randomized to MT and yoga or training-as-usual in October to December 2020 at a large installation in the US. Self-reported outcomes were health, pain level, and pain impact on training, sleep, mood, and stress. Objective outcomes were injury-related medical encounters and number of diagnoses. The trial was registered at ClinicalTrials. Gov (NCT05550610). Results Intervention trainees reported significantly better health (OR = 1.05, 95% CI [1.00, 1.10]) and less impact of pain on training (OR = 0.81, 95% CI [0.74, 0.90]), sleep (OR = 0.88, 95% CI [0.81, 0.95]), mood (OR = 0.86, 95% CI [0.78, 0.96]), and stress (OR = 0.88, 95% CI [0.79, 0.98]). There was no significant difference in injury-related medical encounters (AOR = 0.70, 95% CI [0.48, 1.03]), but intervention trainees had fewer diagnoses (OR = 0.67, 95% CI [0.47, 0.95]) and were 30% less likely to have a first medical encounter at any time during BCT. This difference emerged 3 weeks into BCT. Discussion A combined MT and yoga intervention resulted in better trainee health. The US Army and other organizations requiring resilience under extreme stress should consider implementing MT and yoga to offset risks to employee health.
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Affiliation(s)
- Carl D. Smith
- Center of Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, MD, United States
| | - Ian A. Gutierrez
- Center of Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, MD, United States
| | - Thomas H. Nassif
- Center of Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, MD, United States
| | | | - Kathryn M. Taylor
- Military Performance Division, U.S. Army Research Institute of Environmental Medicine, Natick, MA, United States
| | - Amishi P. Jha
- Department of Psychology, University of Miami, Coral Gables, FL, United States
| | - Amy B. Adler
- Center of Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, MD, United States
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Madsen C, Korona-Bailey J, Janvrin ML, Schoenfeld AJ, Koehlmoos TP. Opioid prescribing and use in the Military Health System: a framework synthesis, FY2016-FY2021. PAIN MEDICINE (MALDEN, MASS.) 2023; 24:1133-1137. [PMID: 37280084 PMCID: PMC10546480 DOI: 10.1093/pm/pnad072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 05/02/2023] [Accepted: 06/01/2023] [Indexed: 06/08/2023]
Abstract
BACKGROUND Opioid misuse is a nationwide issue and is of particular concern with regard to military readiness. The 2017 National Defense Authorization Act charges the Military Health System with greater oversight of opioid use and mitigation of misuse. METHODS We synthesized published articles using secondary analysis of TRICARE claims data, a nationally representative database of 9.6 million beneficiaries. We screened 106 articles for inclusion and identified 17 studies for data abstraction. Framework analysis was conducted, which assessed prescribing practices, patient use, and optimum length of opioid prescriptions after surgery, trauma, and common procedures, as well as factors leading to sustained prescription opioid use. RESULTS Across the studies, sustained prescription opioid use after surgery was low overall, with <1% of opioid-naïve patients still receiving opioids more than 1 year after spinal surgery or trauma. In opioid-exposed patients who had undergone spine surgery, sustained use was slightly lower than 10%. Higher rates of sustained use were associated with more severe trauma and depression, as well as with prior use and initial opioid prescriptions for low back pain or other undefined conditions. Black patients were more likely to discontinue opioid use than were White patients. CONCLUSIONS Prescribing practices are well correlated with degree of injury or intensity of intervention. Sustained prescription opioid use beyond 1 year is rare and is associated with diagnoses for which opioids are not the standard of care. More efficient coding, increased attention to clinical practice guidelines, and use of tools to predict risk of sustained prescription opioid use are recommended.
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Affiliation(s)
- Cathaleen Madsen
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, United States
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, United States
| | - Jessica Korona-Bailey
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, United States
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, United States
| | - Miranda Lynn Janvrin
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, United States
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, United States
| | - Andrew J Schoenfeld
- Center for Surgery and Public Health, Department of Orthopaedic Surgery, Harvard Medical School, Brigham & Women’s Hospital, Boston, MA 02115, United States
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Osgood JM, Yates HK, Holzinger JB, Quartana PJ. Cognitive reappraisal moderates the effect of combat or other exposures on negative behavioral health symptoms. MILITARY PSYCHOLOGY 2023:1-11. [PMID: 37643329 DOI: 10.1080/08995605.2023.2250709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 08/07/2023] [Indexed: 08/31/2023]
Abstract
Understanding the individual differences that can buffer the impact of combat and other adverse exposures on deleterious behavioral health outcomes could lead to more targeted prevention and intervention efforts. Cognitive reappraisal, an antecedent-focused emotion regulation strategy, is linked to positive health outcomes such as lower levels of post-traumatic stress disorder, anxiety, and depression. This study examined the moderating effect of individual differences in cognitive reappraisal use on the association between combat exposure and behavioral health outcomes in active-duty U.S. Soldiers (N = 2,290). This study utilized survey data collected approximately 18 months following a combat deployment to Afghanistan in 2014. Results showed that individual differences in cognitive reappraisal use significantly moderated the effect of combat exposure on anxiety and post-traumatic stress symptoms but not depressive symptoms. Specifically, increasing combat exposures predicted a steeper increase in negative behavioral health symptoms for Soldiers reporting lesser (versus greater) cognitive reappraisal use. These findings highlight a role for cognitive reappraisal as a targetable factor that can mitigate the behavioral health consequences of exposure to combat stressors.
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Affiliation(s)
- Jeffrey M Osgood
- US Army Medical Research Directorate West, Walter Reed Army Institute of Research, Joint Base Lewis McChord, WA, USA
| | - Hunter K Yates
- Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, MD, USA
| | - Jayne B Holzinger
- Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, MD, USA
| | - Phillip J Quartana
- Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, MD, USA
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Junge JM, Murray H, Goldman AH, Booth GJ, Balazs GC. Oral opioid prescribing to active duty US military personnel: a cross-sectional population. Reg Anesth Pain Med 2023:rapm-2023-104495. [PMID: 37507224 DOI: 10.1136/rapm-2023-104495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 07/16/2023] [Indexed: 07/30/2023]
Abstract
INTRODUCTION While civilian opioid prescriptions have seen a dramatic decline in recent years, there are few studies investigating trends in opioid prescription in the active duty military population. We evaluated oral opioid prescribing patterns to active duty military personnel in the Military Health System (MHS) from 2017 to 2020 to determine the incidence of opioid prescriptions as well as demographic and military-specific risk factors for receiving an oral opioid prescription. METHODS The MHS Data Repository was queried from 2017 to 2020 to identify all outpatient oral opioid prescriptions to active duty military personnel in August of each year as well as demographic information on the study population. Data were evaluated in a logistic regression model, and ORs of receiving an oral opioid prescription were calculated for each factor. RESULTS The proportion of active duty military personnel receiving an oral opioid prescription declined from 2.71% to 1.26% (53% relative reduction) over the study period. Within the logistic regression model, female military personnel were significantly more likely to receive opioid prescriptions compared with men, and there was a stepwise increase in likelihood of an opioid prescription with increasing age. Army and Marine personnel, personnel without a history of military deployment and those stationed within the continental USA were significantly more likely to receive an opioid prescription. DISCUSSION The substantial decrease in oral opioid prescriptions to active duty military personnel mirrors data published in the civilian community. The identified risk factors for receiving an opioid prescription may be potential targets for future interventions to further decrease prescribing.
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Affiliation(s)
- Joshua M Junge
- Department of Anesthesiology and Pain Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
- Department of Anesthesiology, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Naval Biotechnology Group, Naval Medical Center Portsmouth, Portsmouth, VA, USA
| | - Hailey Murray
- Family Medicine, US Naval Hospital Jacksonville, Jacksonville, Florida, USA
| | - Ashton H Goldman
- Bone & Joint Sports Medicine Institute, Department of Orthopaedic Surgery, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Gregory J Booth
- Department of Anesthesiology and Pain Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
- Department of Anesthesiology, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Naval Biotechnology Group, Naval Medical Center Portsmouth, Portsmouth, VA, USA
| | - George C Balazs
- Bone & Joint Sports Medicine Institute, Department of Orthopaedic Surgery, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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Moore BA, Vincent SR, Schlenk MA, McNamara CL. Opioid use disorder in the active service: Implications for intervention. Am J Addict 2023; 32:415-418. [PMID: 36960793 DOI: 10.1111/ajad.13415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 02/22/2023] [Accepted: 03/22/2023] [Indexed: 03/25/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Military service members experience occupational-specific injuries that may result in chronic pain and comorbid behavioral health concerns. METHODS Data from the Defense Medical Epidemiology Database was used to examine opioid use disorder (OUD) diagnoses between 2016 and 2021. Statistical analysis calculated incidence rates and diagnostic variability by demographic density. RESULTS The average incidence rate of OUD was 6.1 (per 10,000) and declined by 34% between 2016 and 2021. Diagnoses were most frequently made in service members classified as male, married, white, aged 30-39, junior enlisted, and serving in the Army. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE To our knowledge, this is the first study to examine the incidence rates of OUD among active duty personnel.
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Affiliation(s)
- Brian A Moore
- Department of Psychological Science, Kennesaw State University, Kennesaw, Georgia, USA
- Center for the Advancement of Military and Emergency Services (AMES) Research, Kennesaw, Georgia, USA
| | - Sophie R Vincent
- Center for the Advancement of Military and Emergency Services (AMES) Research, Kennesaw, Georgia, USA
- Department of Molecular and Cellular Biology, Kennesaw State University, Kennesaw, Georgia, USA
| | - Michael A Schlenk
- Center for the Advancement of Military and Emergency Services (AMES) Research, Kennesaw, Georgia, USA
| | - Corinne L McNamara
- Department of Psychological Science, Kennesaw State University, Kennesaw, Georgia, USA
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Eaton LH, Flynn DM, Steffen AD, Doorenbos AZ. The Role of Psychological Factors in Chronic Pain Treatment Outcomes in the Military. Pain Manag Nurs 2023; 24:123-129. [PMID: 36653221 PMCID: PMC10106383 DOI: 10.1016/j.pmn.2022.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 12/13/2022] [Accepted: 12/23/2022] [Indexed: 01/18/2023]
Abstract
PURPOSE Chronic pain treatment in the military includes complementary and integrative health (CIH) therapies that may affect psychological factors such as pain catastrophizing, chronic pain acceptance, pain self-efficacy, and patient activation. The unique roles that psychosocial factors play in how CIH approaches reduce pain are not clear. This study examined if a holistic pain management program improved pain outcomes through psychological mediators in service members with chronic pain. DESIGN Secondary analysis of a clinical trial. METHODS Active-duty service members (n = 210) were randomly assigned to a 3-week course of standard rehabilitative care or standard rehabilitative care combined with CIH therapies. Both treatments were followed by a 3-week functional restoration program. Study measures were completed pre- and post-treatment using the Military Health System's Pain Assessment Screening Tool and Outcomes Registry. Mediation analyses tested the indirect effects of the change in psychological factors before functional restoration on the change in pain impact (e.g., pain intensity, pain interference, functional status) after functional restoration. RESULTS All psychological factors except for chronic pain acceptance were related to improved pain impact (p<.05). Furthermore, a change in psychological factors prior to functional restoration was related to the change in pain impact after functional restoration. However, the addition of CIH therapies to standard rehabilitative care did not result in changes in pain outcomes mediated by the psychological factors. CONCLUSIONS Although psychological factors were related to pain outcomes, the effect of CIH therapies on chronic pain did not occur via a change in the four psychological factors.
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Affiliation(s)
- Linda H Eaton
- University of Washington Bothell, School of Nursing and Health Studies, Bothell, Washington
| | - Diane M Flynn
- Interdisciplinary Pain Management Center, Madigan Army Medical Center, Tacoma, Washington.
| | - Alana D Steffen
- University of Illinois at Chicago, College of Nursing, Chicago, Illinois.
| | - Ardith Z Doorenbos
- University of Illinois at Chicago, College of Nursing, Chicago, Illinois; University of Washington, Anesthesiology and Pain Medicine, Seattle, Washington.
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22
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Factors Associated With the Presence of Co-occurring Pain and Substance Use Disorder Programs in Substance Use Treatment Facilities. J Addict Med 2023; 17:e72-e77. [PMID: 35972137 DOI: 10.1097/adm.0000000000001051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The rise in deaths related to substance use has caused a push toward linking patients to pharmacological maintenance treatment and, when appropriate, to residential substance use treatment facilities. One of the underlying issues in a subset of patients with substance use disorder (SUD) is chronic pain. We evaluated the prevalence and characteristics of those facilities that offer treatment programs tailored for patients with co-occurring pain and SUD. METHODS This study was a retrospective review of data collected by the National Survey of Substance Abuse Treatment Services in 2019. The National Survey of Substance Abuse Treatment Services is sent annually to all substance use treatment facilities and collects information on their characteristics and services. We calculated prevalence of chronic pain programs, reported characteristics, and did a binomial logistic regression to determine predictors of a facility offering such a program. RESULTS Of 15,945 respondents, 2990 (18.8%) of facilities offered a tailored program for patients with co-occurring pain and SUDs. Characteristics that were best predictors included the following: facility has a tailored program for veterans ( P < 0.001), serves only clients with opioid use disorder ( P = 0.03), and provides maintenance services with methadone or buprenorphine for treating opioid use disorder ( P = 0.009). CONCLUSION As of 2019, only a small percentage of substance use treatment facilities reported having a program that treats patients with co-occurring pain and SUD. Given the known high prevalence of co-occurring pain and SUD, further understanding of the role of these programs and barriers to implementation may enhance acceptance in treatment programs.
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23
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Ritland BM, Judkins JL, Naylor JA, Kardouni JR, Pasiakos SM, Jayne JM. The relationship between sleep, pain,and musculoskeletal injuries in US Army Soldiers. BMJ Mil Health 2023:e002281. [PMID: 36792225 DOI: 10.1136/military-2022-002281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 12/27/2022] [Indexed: 02/17/2023]
Abstract
INTRODUCTION The purpose of this study was to investigate the relationship between sleep and pain in military personnel and to determine if metrics of sleep and pain intensity differ between the injured and uninjured in this population. METHODS Active-duty US Army Soldiers (n=308; 26.8±6.5 years, 82% male) from the 2nd Infantry Division, Joint Base Lewis-McChord, Washington, and 101st Airborne Division, Fort Campbell, Kentucky, completed the Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), and questionnaires about current musculoskeletal injuries and pain intensity (0=no pain to 10=worst imaginable pain). Pearson correlation coefficients were used to assess the association between pain and sleep. Differences in sleep and pain between injured and uninjured participants were determined using an analysis of covariance. RESULTS Pain intensity was positively correlated with sleep quality (global PSQI score, r=0.337, p<0.001) and daytime sleepiness (ESS score, r=0.163, p=0.005), and negatively associated with sleep duration (r=-0.118, p=0.039). Injured participants accounted for 37.7% (n=116) of the study population. Injured participants reported greater pain intensity (3.7±2.5 vs 1.3±1.9, p<0.001), were older (28.5±7.4 years vs 25.8±5.7 years, p=0.001) and in the service longer (6.3±6.3 years vs 4.6±4.7 years, p=0.013) than uninjured participants. Injured participants had higher global PSQI scores (9.0±4.1 vs 6.4±3.4, p<0.001), including each of the seven PSQI components (all p<0.050), and reported sleeping less per night than uninjured participants (5.7±1.3 hours vs 6.1±1.2 hours, p=0.026). CONCLUSION These data demonstrate that pain intensity is associated with sleep in active-duty US Army Soldiers and that those who report a musculoskeletal injury, regardless of age and time in service, report poorer sleep quality, shorter sleep durations, and greater levels of pain than uninjured Soldiers.
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Affiliation(s)
- Bradley M Ritland
- Military Performance Division, United States Army Research Institute of Environmental Medicine, Natick, Massachusetts, 01760, USA
| | - J L Judkins
- Military Performance Division, United States Army Research Institute of Environmental Medicine, Natick, Massachusetts, 01760, USA
| | - J A Naylor
- US Army Forces Command, Tacoma, Washington, 98433, USA
| | - J R Kardouni
- US Army Forces Command, Fort Bragg, North Carolina, 28310, USA
| | - S M Pasiakos
- Military Performance Division, United States Army Research Institute of Environmental Medicine, Natick, Massachusetts, 01760, USA
| | - J M Jayne
- Military Nutrition Division, United States Army Research Institute of Environmental Medicine, Natick, Massachusetts, 01760, USA
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24
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The Hidden Costs of War: Healthcare Utilization Among Individuals Sustaining Combat-related Trauma (2007-2018). Ann Surg 2023; 277:159-164. [PMID: 33651722 DOI: 10.1097/sla.0000000000004844] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We sought to evaluate long-term healthcare requirements of American military servicemembers with combat-related injuries. SUMMARY OF BACKGROUND DATA US military conflicts since 2001 have produced the most combat casualties since Vietnam. Long-term consequences on healthcare utilization and associated costs remain unknown. METHODS We identified servicemembers who were treated for combat-related injuries between 2007 and 2011. Controls consisted of active-duty servicemembers injured in the civilian sector, without any history of combat-related trauma, matched (1:1) on year of injury, biologic sex injury severity, and age at time of injury. Surveillance was performed through 2018. Total annual healthcare expenditures were evaluated overall and then as expenditures in the first year after injury and for subsequent years. Negative binomial regression was used to identify the adjusted influence of combat injury on healthcare costs. RESULTS The combat-injured cohort consisted of 3981 individuals and we identified 3979 controls. Total healthcare utilization during the follow-up period resulted in median costs of $142,214 (IQR $61,428, $323,060) per combat-injured servicemember as compared to $50,741 (IQR $26,669, $104,134) among controls. Median expenditures, adjusted for duration of follow-up, for the combat-injured were $45,211 (IQR $18,698, $105,437). In adjusted analysis, overall costs were 30% higher (1.30; 95% confidence interval: 1.23, 1.37) for combat-injured personnel. CONCLUSION This investigation represents the longest continuous observation of healthcare utilization among individuals after combat injury and the first to assess costs. Expenditures were 30% higher for individuals injured as a result of combat-related trauma when compared to those injured in the civilian sector.
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25
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Avoundjian T, Troszak L, Cohen J, Foglia MB, Trafton J, Midboe A. Impact of Informed Consent and Education on Care Engagement After Opioid Initiation in the Veterans Health Administration. J Pain Res 2022; 15:1553-1562. [PMID: 35642185 PMCID: PMC9148610 DOI: 10.2147/jpr.s317183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 09/06/2021] [Indexed: 11/25/2022] Open
Abstract
Objective To ensure all patients receiving long-term opioid therapy (LTOT) understand the risks, benefits and treatment alternatives, the Veterans Health Administration (VHA) released a national policy in 2014 to standardize a signature informed consent (SIC) process. We evaluated the impact of this policy on medical follow-up after LTOT initiation, a guideline recommended practice. Methods Using VHA administrative data, we identified patients initiating LTOT between May 2013 and May 2016. We used an interrupted time series design to compare the monthly rates of medical follow-up within 30 days and primary care visits within 3 months after LTOT initiation across three periods: 12 months before the policy (Year 1); 12 months after policy release (Year 2); and 12-24 months after policy release, when the SIC process was mandatory (Year 3). Results Among the 409,895 patients who experienced 758,416 LTOT initiations, medical follow-up within 30 days and primary care engagement within 3 months increased by 4% between Year 1 and Year 3. Compared to Year 1, patients in Year 3 were 1.12 times more likely to have any medical follow-up (95% CI: 1.10, 1.13) and 1.13 times more likely to have a primary care visit (95% CI: 1.12, 1.15). Facilities with a greater proportion of patients receiving SIC had increased medical follow-up (RR: 1.04, 95% CI: 1.01, 1.07) and primary care engagement (RR: 1.06, 95% CI: 1.03, 1.10). Conclusion The VHA's SIC policy is associated with increased medical follow-up among patients initiating LTOT, which may result in improved patient safety and has implications for other healthcare settings.
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Affiliation(s)
- Tigran Avoundjian
- Center for Innovation to Implementation, Va Palo Alto Health Care System, Palo Alto, CA, USA
| | - Lara Troszak
- Center for Innovation to Implementation, Va Palo Alto Health Care System, Palo Alto, CA, USA
- School of Medicine, Stanford University, Stanford, CA, USA
| | - Jennifer Cohen
- National Center for Ethics in Health Care, Veterans Affairs, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Mary Beth Foglia
- National Center for Ethics in Health Care, Veterans Affairs, Seattle, WA, USA
- Department of Bioethics and Humanities, School of Medicine, University of Washington, Seattle, WA, USA
| | - Jodie Trafton
- Center for Innovation to Implementation, Va Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Stanford University, Stanford, CA, USA
- VA Office of Mental Health and Suicide Prevention, VA Palo Alto Healthcare System, Menlo Park, CA, USA
| | - Amanda Midboe
- Center for Innovation to Implementation, Va Palo Alto Health Care System, Palo Alto, CA, USA
- School of Medicine, Stanford University, Stanford, CA, USA
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26
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Peppard SW, Burkard J, Georges J, Dye J. The Lived Experience of Military Women With Chronic Pain: A Phenomenological Study. Mil Med 2022; 188:1199-1206. [PMID: 35596551 PMCID: PMC9384100 DOI: 10.1093/milmed/usac134] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 01/27/2022] [Accepted: 05/01/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction Chronic pain, a persistent or recurrent pain lasting more than 3 months, is a widespread problem among military women due to combat-related injuries and post-deployment stressors. Risk factors associated with chronic pain include gender, mental health, post-traumatic stress disorder, and prior physical or military sexual trauma. The most common prevalence of chronic pain is musculoskeletal (e.g., low back and neck), migraine, osteoarthritis, and fibromyalgia. Following deployment, 25% of military women are at risk for chronic pain. Military women are prescribed opioids for pain at a higher rate than men and are at risk for prescription opioid addiction. The unique medical needs of military women, including chronic pain, are poorly understood by health care providers and need to be addressed to achieve full integration into the military. The purpose of this study was to explore a typical day for military women living with chronic pain by examining the participants’ daily life experiences. Material and Methods Using van Manen’s approach, 13 active duty, retired, and veteran women were interviewed to explore these lived experiences. The study was approved by the Institutional Review Board at the University of San Diego. Results Eight themes emerged from an analysis of the participants’ experiences: (1) chronic pain is a frustrating, persistent, daily, and an hourly struggle; (2) resilience in living with chronic pain is the new normal; (3) mission first and the impact of invisible pain; (4) self-care management and internal locus of control with nonpharmacological therapies; (5) pain accepted and managed to improve quality of life; (6) coronavirus disease 2019 (COVID-19) diminished social interactions; (7) pain of sexual trauma is not reported; and (8) disparities in health care due to self-perception of provider bias as pain is not understood. Conclusions The study generated new knowledge in Force Health Protection, ensuring (1) a fit and operational readiness force; (2) pre- to post-deployment care for women warriors; and (3) access to health care. The study findings supported previous research and could help direct future research into nursing, medicine, and allied health treatments for military and veterans’ gender-specific health care, education, and training. Furthermore, the military women in this study provided insight into the need for future research to explore unconscious gender bias, health disparities, and a raised awareness of military women living with chronic pain. Findings from this study merit further exploration using other qualitative research methodologies including mixed methods.
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Affiliation(s)
- Sandra W Peppard
- Hahn School of Nursing and Health Science, University of San Diego, San Diego, CA 92110-2492, USA
| | - Joseph Burkard
- Hahn School of Nursing and Health Science, University of San Diego, San Diego, CA 92110-2492, USA
| | - Jane Georges
- Hahn School of Nursing and Health Science, University of San Diego, San Diego, CA 92110-2492, USA
| | - Judy Dye
- School of Nursing, San Diego State University, San Diego, CA 92182-4158, USA
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27
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Affiliation(s)
- Sandro Galea
- School of Public Health, Boston University, Boston, Massachusetts
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28
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Ali J, Antonelli M, Bastian L, Becker W, Brandt CA, Burgess DJ, Burns A, Cohen SP, Davis AF, Dearth CL, Dziura J, Edwards R, Erdos J, Farrokhi S, Fritz J, Geda M, George SZ, Goertz C, Goodie J, Hastings SN, Heapy A, Ilfeld BM, Katsovich L, Kerns RD, Kyriakides TC, Lee A, Long CR, Luther SL, Martino S, Matheny ME, McGeary D, Midboe A, Pasquina P, Peduzzi P, Raffanello M, Rhon D, Rosen M, Esposito ER, Scarton D, Hastings SN, Seal K, Silliker N, Taylor S, Taylor SL, Tsui M, Wright FS, Zeliadt S. Optimizing the Impact of Pragmatic Clinical Trials for Veteran and Military Populations: Lessons From the Pain Management Collaboratory. Mil Med 2021; 187:179-185. [PMID: 34791412 PMCID: PMC9389906 DOI: 10.1093/milmed/usab458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 10/15/2021] [Accepted: 10/20/2021] [Indexed: 11/12/2022] Open
Abstract
Pragmatic clinical trials (PCTs) are well-suited to address unmet healthcare needs, such as those arising from the dual public health crises of chronic pain and opioid misuse, recently exacerbated by the COVID-19 pandemic. These overlapping epidemics have complex, multifactorial etiologies, and PCTs can be used to investigate the effectiveness of integrated therapies that are currently available but underused. Yet individual pragmatic studies can be limited in their reach because of existing structural and cultural barriers to dissemination and implementation. The National Institutes of Health, Department of Defense, and Department of Veterans Affairs formed an interagency research partnership, the Pain Management Collaboratory. The partnership combines pragmatic trial design with collaborative tools and relationship building within a large network to advance the science and impact of nonpharmacological approaches and integrated models of care for the management of pain and common co-occurring conditions. The Pain Management Collaboratory team supports 11 large-scale, multisite PCTs in veteran and military health systems with a focus on team science with the shared aim that the "whole is greater than the sum of the parts." Herein, we describe this integrated approach and lessons learned, including incentivizing all parties; proactively offering frequent opportunities for problem-solving; engaging stakeholders during all stages of research; and navigating competing research priorities. We also articulate several specific strategies and their practical implications for advancing pain management in active clinical, "real-world," settings.
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Affiliation(s)
- Joseph Ali
- Johns Hopkins Berman Institute of Bioethics and Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - Margaret Antonelli
- VA Connecticut Healthcare System, West Haven, CT 06516, USA,Yale University School of Medicine, New Haven, CT 06520, USA
| | - Lori Bastian
- VA Connecticut Healthcare System, West Haven, CT 06516, USA,Yale University School of Medicine, New Haven, CT 06520, USA
| | - William Becker
- VA Connecticut Healthcare System, West Haven, CT 06516, USA,Yale University School of Medicine, New Haven, CT 06520, USA
| | - Cynthia A Brandt
- VA Connecticut Healthcare System, West Haven, CT 06516, USA,Yale University School of Medicine, New Haven, CT 06520, USA
| | - Diana J Burgess
- Minneapolis VA Health Care System, Minneapolis, MN 55417, USA,University of Minnesota Medical School, Minneapolis, MN 55455, USA
| | - Amy Burns
- VA Connecticut Healthcare System, West Haven, CT 06516, USA,Yale University School of Medicine, New Haven, CT 06520, USA
| | - Steven P Cohen
- Johns Hopkins Medical Institutions, Clarksville, MD 21029, USA0
| | - Alison F Davis
- Yale University School of Medicine, New Haven, CT 06520, USA
| | - Christopher L Dearth
- DoD-VA Extremity Trauma and Amputation Center of Excellence, Bethesda, MD 20814, USA,Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
| | - Jim Dziura
- Yale University School of Medicine, New Haven, CT 06520, USA
| | - Rob Edwards
- Department of Anesthesiology, Harvard Medical School, Brigham and Women’s Hospital, Chestnut Hill, MA 02467, USA
| | - Joe Erdos
- VA Connecticut Healthcare System, West Haven, CT 06516, USA,Yale University School of Medicine, New Haven, CT 06520, USA
| | - Shawn Farrokhi
- Naval Medical Center San Diego, Department of Physical Therapy, San Diego, CA 92134, USA
| | - Julie Fritz
- University of Utah, College of Health, Salt Lake City, UT 84108, USA
| | - Mary Geda
- Yale University School of Medicine, New Haven, CT 06520, USA
| | - Steven Z George
- Duke Clinical Research Institute and Department of Orthopaedic Surgery, Duke University, Durham, NC 27715, USA
| | | | - Jeffrey Goodie
- School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Susan N Hastings
- Duke University School of Medicine, Durham, NC 27710, USA,Durham VA Health Care System, Durham, NC 27705, USA
| | - Alicia Heapy
- VA Connecticut Healthcare System, West Haven, CT 06516, USA,Yale University School of Medicine, New Haven, CT 06520, USA
| | - Brian M Ilfeld
- Department of Anesthesiology, University of California San Diego School of Medicine, LaJolla, CA 92093, USA
| | - Lily Katsovich
- Yale University School of Medicine, New Haven, CT 06520, USA
| | - Robert D Kerns
- VA Connecticut Healthcare System, West Haven, CT 06516, USA,Yale University School of Medicine, New Haven, CT 06520, USA
| | - Tassos C Kyriakides
- VA Connecticut Healthcare System, West Haven, CT 06516, USA,Yale University School of Medicine, New Haven, CT 06520, USA
| | - Allison Lee
- VA Connecticut Healthcare System, West Haven, CT 06516, USA,Yale University School of Medicine, New Haven, CT 06520, USA
| | - Cynthia R Long
- Palmer Center for Chiropractic Research, Davenport, IA 52803, USA
| | - Stephen L Luther
- James A. Haley Veterans Hospital, Tampa, FL 33612, USA,University of South Florida College of Public Health, Tampa, FL 33612, USA
| | - Steve Martino
- VA Connecticut Healthcare System, West Haven, CT 06516, USA,Yale University School of Medicine, New Haven, CT 06520, USA
| | - Michael E Matheny
- Tennessee Valley Healthcare System, Nashville, TN 37212, USA,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN 37212, USA
| | - Don McGeary
- Department of Psychiatry & Behavioral Sciences, University of Texas Health Science Center, San Antonio, TX 78229, USA
| | - Amanda Midboe
- VA Palo Alto Health Care System, Palo Alto, CA 94304, USA
| | - Paul Pasquina
- Department of Physical Medicine & Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA,Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
| | - Peter Peduzzi
- Yale University School of Medicine, New Haven, CT 06520, USA
| | | | - Daniel Rhon
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
| | - Marc Rosen
- VA Connecticut Healthcare System, West Haven, CT 06516, USA,Yale University School of Medicine, New Haven, CT 06520, USA
| | | | - Dylan Scarton
- Henry Jackson Foundation, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Susan N Hastings
- Durham VA Medical Center, Durham, NC 27701, USA,Department of Medicine, Duke University, Durham, NC 27708, USA
| | - Karen Seal
- University of California San Francisco, School of Medicine, San Francisco, CA 94143, USA,San Francisco VA Medical Center, San Francisco, CA 94121, USA
| | - Norman Silliker
- Yale University School of Medicine, New Haven, CT 06520, USA
| | - Sakasha Taylor
- VA Connecticut Healthcare System, West Haven, CT 06516, USA
| | - Stephanie L Taylor
- VA Greater Los Angeles Healthcare System, Los Angeles, CA 90073, USA,University of California Los Angeles Department of Medicine and Department of Health Policy and Management, Los Angeles, CA 90095, USA
| | - Megan Tsui
- Henry Jackson Foundation, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Fred S Wright
- VA Connecticut Healthcare System, West Haven, CT 06516, USA
| | - Steven Zeliadt
- VA Puget Sound Health Care System, Seattle, WA 98108, USA,University of Washington, School of Public Health, Seattle, WA 98195, USA
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Gupta S, Guleria RS, Szabo YZ. MicroRNAs as biomarker and novel therapeutic target for posttraumatic stress disorder in Veterans. Psychiatry Res 2021; 305:114252. [PMID: 34739954 PMCID: PMC8857765 DOI: 10.1016/j.psychres.2021.114252] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 10/04/2021] [Accepted: 10/23/2021] [Indexed: 12/16/2022]
Abstract
Posttraumatic stress disorder (PTSD) is a common psychiatric disorder for military Veterans, characterized by hyperarousal, intrusive thoughts, flashbacks, hypervigilance, and distress after experiencing traumatic events. Some of the known physiological effects of PTSD include hypothalamic-pituitary-adrenal (HPA)-axis imbalance, a cortical function resulting in neuronal deficit and changes in behavior. Moreover, excessive discharge of inflammatory molecules and a dysregulated immune system are implicated in the pathophysiology of PTSD. Due to complex nature of this disorder, the biological underpinnings of PTSD remain inexplicable. Investigating novel biomarkers to understanding the pathogenesis of PTSD may reflect the underlying molecular network for therapeutic use and treatment. Circulatory microRNAs (miRNAs) and exosomes are evolving biomarkers that have shown a key role in psychiatric and neurological disorders including PTSD. Given the unique nature of combat trauma, as well as evidence that a large portion of Veterans do not benefit from frontline treatments, focus on veterans specifically is warranted. In the present review, we delineate the identification and role of several miRNAs in PTSD among veterans. An association of miRNA with HPA-axis regulation through FKBP5, a key modulator in PTSD is discussed as an emerging molecule in psychiatric diseases. We conclude that miRNAs may be used as circulatory biomarker detection in Veterans with PTSD.
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Affiliation(s)
- Sudhiranjan Gupta
- VISN 17 Center of Excellence for Research on Returning War Veterans, Biomarkers & Genetics Core, Central Texas Veterans Health Care System, 4800 Memorial Drive (151C), Waco, TX, 76711, USA.
| | - Rakeshwar S. Guleria
- VISN 17 Center of Excellence for Research on Returning War Veterans, Biomarkers & Genetics Core, Central Texas Veterans Health Care System, 4800 Memorial Drive (151C), Waco, Texas, 76711
| | - Yvette Z. Szabo
- VISN 17 Center of Excellence for Research on Returning War Veterans, Biomarkers & Genetics Core, Central Texas Veterans Health Care System, 4800 Memorial Drive (151C), Waco, Texas, 76711
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Murray H, Gregoriou AN, Lepore A, Booth GJ, Goldman AH, Allen ML, Balazs GC. Why are US military personnel prescribed transdermal fentanyl patches? BMJ Mil Health 2021:bmjmilitary-2021-001894. [PMID: 34625516 DOI: 10.1136/bmjmilitary-2021-001894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 08/03/2021] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Transdermal fentanyl is a continuous release opioid delivery system intended for use in opioid-tolerant patients requiring around-the-clock opioid therapy. The purpose of this study is to identify the most common indications for transdermal fentanyl prescriptions in active duty US military personnel, and determine whether these prescriptions meet US Food and Drug Administration (FDA) labelling. METHODS Active duty US military personnel initiating transdermal fentanyl therapy with prescriptions filled at Military Health System pharmacies between 2015 and 2019 were identified in the Military Data Repository. Electronic health records were searched for patient demographic information, clinical information and prescription data. A total of 225 patients with complete data were identified. RESULTS The most common reason for transdermal fentanyl initiation was chronic non-cancer musculoskeletal pain. Among patients with non-cancer pain, 36% received their initial prescription from an internal medicine/primary care provider, and 35% did not meet published US FDA criteria for opioid tolerance prior to treatment initiation. There was an 81% decrease in patients initiating therapy between 2015 and 2019. CONCLUSIONS While a substantial minority of transdermal fentanyl prescriptions to US military personnel did not meet FDA guidelines on appropriate use, the overall number of prescriptions fell dramatically over the study period. This suggests that automated profile review or additional targeted policies to limit transdermal fentanyl prescribing are unnecessary at this time.
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Affiliation(s)
- Hailey Murray
- Eastern Virginia Medical School, Norfolk, Virginia, USA
| | - A N Gregoriou
- Eastern Virginia Medical School, Norfolk, Virginia, USA
| | - A Lepore
- Eastern Virginia Medical School, Norfolk, Virginia, USA
| | - G J Booth
- Department of Anesthesiology & Pain Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA.,Naval Biotechnology Group, Portsmouth, Virginia, USA
| | - A H Goldman
- Bone & Joint Sports Medicine Institute, Department of Orthopaedic Surgery, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
| | - M L Allen
- Pharmacy Department, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
| | - G C Balazs
- Bone & Joint Sports Medicine Institute, Department of Orthopaedic Surgery, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
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Traumatic Brain Injury and Opioid Use: Additional Evidence Supporting the "Perfect Storm" of Cascading Vulnerabilities. J Head Trauma Rehabil 2021; 36:303-309. [PMID: 34489381 DOI: 10.1097/htr.0000000000000730] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Teyhen DS, Capaldi VF, Drummond SPA, Rhon DI, Barrett AS, Silvernail JL, Boland DM. How sleep can help maximize human potential: The role of leaders. J Sci Med Sport 2021; 24:988-994. [PMID: 34481741 DOI: 10.1016/j.jsams.2021.08.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 03/23/2021] [Accepted: 08/11/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE During multi-domain operations (MDO), soldiers need the physical supremacy, cognitive dominance, and emotional resilience to help defend and win our nation's wars. Optimal sleep has been shown to boost physical performance and cognitive processing. This manuscript will discuss how recent advances in sleep science strongly argue for the integration of sleep planning into military operations. DESIGN Review article. METHODS We reviewed the current understanding of how sleep affects Soldier readiness, how sleep and pain are interrelated, and unique challenges to obtaining adequate sleep in military training environments. We then address solutions that can be implemented by leaders and individuals to manage warfighter fatigue and optimize unit performance. RESULTS Since sleep is foundational to soldier health and readiness, improving warfighter fatigue management is a priority for leaders. CONCLUSION To succeed in MDO, military personnel require physical supremacy, cognitive dominance, and emotional resilience to fight and win. Sleep science is a rapidly emerging field, and the clear implications for maximizing human performance argue strongly for more deliberate integration into military training and operations. Leaders that incorporate sleep and fatigue management into the planning and execution phases of operations will help facilitate mission priorities and prove a powerful force multiplier.
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Affiliation(s)
| | | | - Sean P A Drummond
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Australia
| | | | - Amelia S Barrett
- Consortium for Health and Military Performance, Department of Military and Emergency Medicine, F. Edward Hébert School of Medicine, Uniformed Services University, USA; Henry M. Jackson Foundation for the Advancement of Military Medicine, USA
| | | | - David M Boland
- Army-Baylor University Doctoral Program in Physical Therapy, USA
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Hammett PJ, Businelle MS, Taylor BC, Erbes CR, Bastian L, Doran N, Sherman SE, Rogers ES, Burgess DJ, Fu SS. The Association Between Smoking Abstinence and Pain Trajectory Among Veterans Engaged in U.S. Department of Veterans Affairs Mental Health Care. PAIN MEDICINE 2021; 22:1793-1803. [PMID: 33502511 DOI: 10.1093/pm/pnab009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To prospectively examine associations between smoking and nicotine abstinence and pain trajectory over 12 months among smokers with low, moderate, and severe pain and to assess whether these associations differ over time. DESIGN A secondary analysis of the "Proactive Outreach for Smokers in VA Mental Health" study, a randomized controlled trial of proactive outreach for veteran smokers engaged in U.S. Department of Veterans Affairs (VA) mental health care. METHODS Participants were categorized into "low" (n = 616), "moderate" (n = 479), and "severe" pain (n = 656) groups according to baseline pain score. Associations between self-reported abstinence from smoking and nicotine at 6 and 12 months and pain trajectory, measured via the PEG scale (Pain intensity, Enjoyment of life, General activity) composite score, were assessed through the use of general linear mixed models. Interaction tests assessed whether these associations differed at 6 and 12 months. Analyses were conducted within the overall sample and within the separate pain groups. RESULTS There were significant interactions in the overall sample and the low and moderate pain groups, such that 7-day point prevalence smoking abstinence was associated with lower pain scores at 6 but not 12 months. In the severe pain group, 7-day abstinence from both smoking and nicotine was associated with lower pain scores across both time points. Six-month prolonged abstinence was not associated with pain scores. CONCLUSIONS In this prospective analysis conducted among veteran smokers engaged in mental health services, 7-day abstinence from smoking and nicotine was associated with significantly lower levels of pain. Education efforts could help better inform smokers on the relationship between smoking and pain.
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Affiliation(s)
- Patrick J Hammett
- VA HSR&D Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota.,Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Michael S Businelle
- Department of Family and Preventive Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma.,Oklahoma Tobacco Research Center, Stephenson Cancer Center, Oklahoma City, Oklahoma
| | - Brent C Taylor
- VA HSR&D Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota.,Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Christopher R Erbes
- VA HSR&D Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota.,Department of Psychiatry, University of Minnesota Medical School, Minnesota
| | - Lori Bastian
- VA Connecticut Healthcare System, West Haven, Connecticut.,School of Medicine, Yale University, New Haven, Connecticut
| | - Neal Doran
- VA San Diego Healthcare System, San Diego, California.,Department of Psychiatry, University of California, San Diego, California
| | - Scott E Sherman
- VA New York Harbor Healthcare System, New York.,Department of Population Health, New York University Grossman School of Medicine, New York, USA
| | - Erin S Rogers
- VA New York Harbor Healthcare System, New York.,Department of Population Health, New York University Grossman School of Medicine, New York, USA
| | - Diana J Burgess
- VA HSR&D Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota.,Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Steven S Fu
- VA HSR&D Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota.,Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota
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Donahue ML, Dunne EM, Gathright EC, DeCosta J, Balletto BL, Jamison RN, Carey MP, Scott-Sheldon LAJ. Complementary and integrative health approaches to manage chronic pain in U.S. military populations: Results from a systematic review and meta-analysis, 1985-2019. Psychol Serv 2021; 18:295-309. [PMID: 32134305 PMCID: PMC7483193 DOI: 10.1037/ser0000417] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The objective of this study was to examine the efficacy of complementary and integrative health (CIH) approaches for reducing pain intensity (primary outcome) and depressive symptoms (secondary outcome) as well as improving physical functioning (secondary outcome) among U.S. military personnel living with chronic pain. Studies were retrieved from bibliographic databases, databases of funded research, and reference sections of relevant articles. Studies that (a) evaluated a CIH approach to promote chronic pain management among military personnel, (b) used a randomized controlled trial design, and (c) assessed pain intensity were included. Two coders extracted data from each study and calculated effect sizes. Discrepancies between coders were resolved through discussion. Comprehensive searches identified 12 studies (k = 15 interventions) that met inclusion criteria. CIH practices included cognitive-behavioral therapies (k = 5), positive psychology (k = 3), yoga (k = 2), acupuncture (k = 2), mindfulness-based interventions (k = 2), and biofeedback (k = 1). Across these studies, participants who received the intervention reported greater reductions in pain intensity (d+ = 0.44, 95% CI [0.21, 0.67], k = 15) compared to controls. Statistically significant improvements were also observed for physical functioning (d+ = 0.36, 95% CI [0.11, 0.61], k = 11) but not for depressive symptoms (d+ = 0.21, 95% CI [-0.15, 0.57], k = 8). CIH approaches reduced pain intensity and improved physical functioning. These approaches offer a nonpharmacological, nonsurgical intervention for chronic pain management for military personnel. Future studies should optimize interventions to improve depressive symptoms in military populations experiencing chronic pain. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Affiliation(s)
- Marissa L. Donahue
- Centers for Behavioral and Preventive Medicine, The Miriam Hospital, Providence, RI
| | - Eugene M. Dunne
- Centers for Behavioral and Preventive Medicine, The Miriam Hospital, Providence, RI
- Department of Psychiatry and Human Behavior, Alpert School of Medicine, Brown University, Providence, RI
| | - Emily C. Gathright
- Centers for Behavioral and Preventive Medicine, The Miriam Hospital, Providence, RI
- Department of Psychiatry and Human Behavior, Alpert School of Medicine, Brown University, Providence, RI
| | - Julie DeCosta
- Centers for Behavioral and Preventive Medicine, The Miriam Hospital, Providence, RI
| | - Brittany L. Balletto
- Centers for Behavioral and Preventive Medicine, The Miriam Hospital, Providence, RI
| | - Robert N. Jamison
- Pain Management Center, Brigham and Women’s Hospital, Chestnut Hill, MA
- Harvard Medical School, Boston, MA
| | - Michael P. Carey
- Centers for Behavioral and Preventive Medicine, The Miriam Hospital, Providence, RI
- Department of Psychiatry and Human Behavior, Alpert School of Medicine, Brown University, Providence, RI
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI
| | - Lori A. J. Scott-Sheldon
- Centers for Behavioral and Preventive Medicine, The Miriam Hospital, Providence, RI
- Department of Psychiatry and Human Behavior, Alpert School of Medicine, Brown University, Providence, RI
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI
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Pre-deployment personality traits predict prescription opioid receipt over 2-year post-deployment period in a longitudinal cohort of deployed National Guard soldiers. Addict Behav 2021; 119:106919. [PMID: 33845256 PMCID: PMC9904077 DOI: 10.1016/j.addbeh.2021.106919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 02/25/2021] [Accepted: 03/18/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND While military service members are at risk forpain conditions, receipt of prescribed opioids is associated with a range of serious adverse outcomes. The goal of this study is to examine the association between pre-deployment personality traits and receipt of prescription opioids after return from deployment. METHOD Data were drawn from the Readiness and Resilience in National Guard Soldiers (RINGS) cohort study, an ongoing study of post-deployment health. Participants (N = 522) completed baseline assessments one month prior to deploying to Iraq (2006-2007). At baseline, we assessed personality traits using abbreviated versions of the Personality Psychopathology Five scales from the Minnesota Multiphasic Personality Inventory-2. Follow-up assessments were conducted three months, one year, and two years post-deployment. The primary outcome was total amount of prescribed opioids dispensed from Department of Veterans Affairs outpatient pharmacies in the two-year period following soldiers' return from deployment. Unadjusted and adjusted negative binomial regression models examined the relationships of pre-deployment personality traits, demographics (age, gender, and rank), baseline trauma symptoms, deployment related risk factors (difficult living/working environment, deployment injury, combat exposure), and post-deployment trauma symptoms with post-deployment opioid prescribing. RESULTS Disconstraint, negative emotionality, and introversion/low positive emotionality were associated with receipt of more prescribed opioids over the two years after return from deployment. Personality traits measured at baseline remained statistically significantly after adjusting for all eight baseline and deployment risk factors of interest. CONCLUSIONS Understanding how pre-deployment personality traits contribute to post-deployment prescription opioid use could inform efforts to improve veterans' health.
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Sparks AC, Radakrishnan S, Corry NH, McDonald D, Carlson K, Carballo CE, Stander V. Associations between spouse and service member prescriptions for high-risk and long-term opioids: A dyadic study. Addict Behav Rep 2021; 14:100364. [PMID: 34189246 PMCID: PMC8219988 DOI: 10.1016/j.abrep.2021.100364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 05/24/2021] [Accepted: 06/08/2021] [Indexed: 11/21/2022] Open
Abstract
Military spouses were more likely to have risky opioid Rx if their spouse did. High-risk opioid therapy was linked to pain, disability, smoking, and ACES Reducing risky opioid Rx for service members may reduce similar risky Rx for spouses.
Background Estimates suggest approximately 2.4% of service members, and 15% of service members who have engaged in recent combat, report misusing pain relievers in the past year. This study explores the extent to which military spouses’ obtainment of opioids is associated with their service member partners’ obtainment of opioid prescriptions, in addition to other factors such as service member health, state prescribing patterns, and sociodemographic characteristics. Methods Data were drawn from the Millennium Cohort Family Study, a large, longitudinal survey of married spouses of service members from all service branches, and archival data analyzed from 2018 to 2020. The dependent variables were spouse long-term opioid therapy and spouse opioid prescriptions that pose a high risk of adverse outcomes. Results Seven percent of spouse and service member dyads met the criteria for high-risk opioid use, generally because they had purchased a prescription for a ≥90 Morphine Milligram Equivalents daily dose (76.7% for spouses, 72.8% for service members). Strong associations were found between spouse and service member opioid therapies (OR = 5.53 for long-term; OR = 2.20 for high-risk). Conclusions Findings suggest that reducing the number of long-term and high-risk opioid prescriptions to service members may subsequently reduce the number of similar prescriptions obtained by their spouses. Reducing the number of service members and spouses at risk for adverse events may prove to be effective in stemming the opioid epidemic and improve the overall health and safety of military spouses and thus, the readiness of the U.S. Armed Forces.
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Affiliation(s)
- Alicia C Sparks
- Division of Health and Environment, Abt Associates, Rockville, MD, United States
| | | | - Nida H Corry
- Division of Health and Environment, Abt Associates, Rockville, MD, United States
| | - Doug McDonald
- Division of Health and Environment, Abt Associates, Rockville, MD, United States
| | - Kenneth Carlson
- Division of Health and Environment, Abt Associates, Rockville, MD, United States
| | - Carlos E Carballo
- Deployment Health Research Department, Naval Health Research Center, San Diego, CA, United States.,Leidos, Reston, VA, United States
| | - Valerie Stander
- Deployment Health Research Department, Naval Health Research Center, San Diego, CA, United States
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Adams RS, Meerwijk EL, Larson MJ, Harris AHS. Predictors of Veterans Health Administration utilization and pain persistence among soldiers treated for postdeployment chronic pain in the Military Health System. BMC Health Serv Res 2021; 21:494. [PMID: 34030684 PMCID: PMC8145830 DOI: 10.1186/s12913-021-06536-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 05/17/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chronic pain presents a significant burden for both federal health care systems designed to serve combat Veterans in the United States (i.e., the Military Health System [MHS] and Veterans Health Administration [VHA]), yet there have been few studies of Veterans with chronic pain that have integrated data from both systems of care. This study examined 1) health care utilization in VHA as an enrollee (i.e., linkage to VHA) after military separation among soldiers with postdeployment chronic pain identified in the MHS, and predictors of linkage, and 2) persistence of chronic pain among those utilizing the VHA. METHODS Observational, longitudinal study of soldiers returning from a deployment in support of the Afghanistan/Iraq conflicts in fiscal years 2008-2014. The analytic sample included 138,206 active duty soldiers for whom linkage to VHA was determined through FY2019. A Cox proportional hazards model was estimated to examine the effects of demographic characteristics, military history, and MHS clinical characteristics on time to linkage to VHA after separation from the military. Among the subpopulation of soldiers who linked to VHA, we described whether they met criteria for chronic pain in the VHA and pain management treatments received during the first year in VHA. RESULTS The majority (79%) of soldiers within the chronic pain cohort linked to VHA after military separation. Significant predictors of VHA linkage included: VHA utilization as a non-enrollee prior to military separation, separating for disability, mental health comorbidities, and being non-Hispanic Black or Hispanic. Soldiers that separated because of misconduct were less likely to link than other soldiers. Soldiers who received nonpharmacological treatments, opioids/tramadol, or mental health treatment in the MHS linked earlier to VHA than soldiers who did not receive these treatments. Among those who enrolled in VHA, during the first year after linking to the VHA, 49.7% of soldiers met criteria for persistent chronic pain in VHA. CONCLUSIONS The vast majority of soldiers identified with chronic pain in the MHS utilized care within VHA after military separation. Careful coordination of pain management approaches across the MHS and VHA is required to optimize care for soldiers with chronic pain.
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Affiliation(s)
- Rachel Sayko Adams
- Heller School for Social Policy & Management, Institute for Behavioral Health, Brandeis University, 415 South Street MS 035, Waltham, MA, 02453, USA.
- Rocky Mountain Mental Illness Research Education and Clinical Center, Veterans Health Administration, 1700 N. Wheeling Street, Aurora, CO, 80045, USA.
| | - Esther L Meerwijk
- VA Health Services Research & Development, Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, 94025, USA
| | - Mary Jo Larson
- Heller School for Social Policy & Management, Institute for Behavioral Health, Brandeis University, 415 South Street MS 035, Waltham, MA, 02453, USA
| | - Alex H S Harris
- VA Health Services Research & Development, Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, 94025, USA
- Department of Surgery, Stanford University, Stanford, CA, 94305, USA
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Leonard C, Ayele R, Ladebue A, McCreight M, Nolan C, Sandbrink F, Frank JW. Barriers to and Facilitators of Multimodal Chronic Pain Care for Veterans: A National Qualitative Study. PAIN MEDICINE 2021; 22:1167-1173. [PMID: 32974662 DOI: 10.1093/pm/pnaa312] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Chronic pain is more common among veterans than among the general population. Expert guidelines recommend multimodal chronic pain care. However, there is substantial variation in the availability and utilization of treatment modalities in the Veterans Health Administration. We explored health care providers' and administrators' perspectives on the barriers to and facilitators of multimodal chronic pain care in the Veterans Health Administration to understand variation in the use of multimodal pain treatment modalities. METHODS We conducted semi-structured qualitative interviews with health care providers and administrators at a national sample of Veterans Health Administration facilities that were classified as either early or late adopters of multimodal chronic pain care according to their utilization of nine pain-related treatments. Interviews were conducted by telephone, recorded, and transcribed verbatim. Transcripts were coded and analyzed through the use of team-based inductive and deductive content analysis. RESULTS We interviewed 49 participants from 25 facilities from April through September of 2017. We identified three themes. First, the Veterans Health Administration's integrated health care system is both an asset and a challenge for multimodal chronic pain care. Second, participants discussed a temporal shift from managing chronic pain with opioids to multimodal treatment. Third, primary care teams face competing pressures from expert guidelines, facility leadership, and patients. Early- and late-adopting sites differed in perceived resource availability. CONCLUSIONS Health care providers often perceive inadequate support and resources to provide multimodal chronic pain management. Efforts to improve chronic pain management should address both organizational and patient-level challenges, including primary care provider panel sizes, accessibility of training for primary care teams, leadership support for multimodal pain care, and availability of multidisciplinary pain management resources.
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Affiliation(s)
- Chelsea Leonard
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, Colorado
| | - Roman Ayele
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, Colorado.,Colorado School of Public Health, University of Colorado-Anschutz Medical Campus, Aurora, Colorado
| | - Amy Ladebue
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, Colorado
| | - Marina McCreight
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, Colorado
| | - Charlotte Nolan
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, Colorado
| | - Friedhelm Sandbrink
- Department of Neurology, Washington DC VA Medical Center, Washington, DC.,Department of Neurology, George Washington University, Washington, DC
| | - Joseph W Frank
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, Colorado.,Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado
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Kerns RD, Brandt CA. NIH-DOD-VA Pain Management Collaboratory: Pragmatic Clinical Trials of Nonpharmacological Approaches for Management of Pain and Co-occurring Conditions in Veteran and Military Health Systems: Introduction. PAIN MEDICINE 2021; 21:S1-S4. [PMID: 33313722 DOI: 10.1093/pm/pnaa358] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Robert D Kerns
- Departments of Psychiatry, Neurology, and Psychology, Yale University, New Haven, Connecticut
| | - Cynthia A Brandt
- Department of Emergency Medicine and Yale Center for Medical Informatics, Yale University School of Medicine, New Haven, Connecticut.,Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, New Haven, Connecticut, USA
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Scarton DV, Roddy WT, Taylor JA, Geda M, Brandt CA, Peduzzi P, Kerns RD, Pasquina PF. Development and Implementation of the Military Treatment Facility Engagement Committee (MTFEC) to Support Pragmatic Clinical Trials in the Military Health System. Mil Med 2021; 186:70-75. [PMID: 33499543 DOI: 10.1093/milmed/usaa368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 09/04/2020] [Accepted: 09/21/2020] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Within the population of military service members and veterans, chronic pain is highly prevalent, often complex, and frequently related to traumatic experiences that are more likely to occur to members of this demographic, such as individuals with traumatic brain injury or limb loss. In September 2017, the National Institutes of Health (NIH), Department of Defense (DOD), and Department of Veterans Affairs (VA) Pain Management Collaboratory (PMC) was formed as a significant and innovative inter-government agency partnership to support a multicomponent research initiative focusing on nonpharmacological approaches for pain management addressing the needs of service members, their dependents, and veterans. METHODS A Pain Management Collaboratory Coordinating Center (PMC3) was also established to facilitate collective learning across 11 individually funded pragmatic clinical trials (PCTs) designed to optimize the impact of the PMC as an integrated whole. Although the DOD and VA health care systems are ideal sites for the enactment of PCTs, executing these trials within the local context of DOD military treatment facilities (MTFs) can present unique challenges. The Military Treatment Facility Engagement Committee (MTFEC) was created to support the efforts of the PMC3 in its role as a national resource for development and refinement of innovative tools, best practices, and other resources in the conduct of high impact PCTs. RESULTS The MTFEC is composed of experts from each service who bring experiences in executing clinical pain management trials that can enhance the planning and execution of the PCTs. It provides expertise and leadership in the execution of research studies at within MTFs and within the DOD health care system, with guidance from PMC3 Directors and in collaboration with NIH, DOD, and VA program and scientific officers. DISCUSSION/CONCLUSION Considering the importance of enacting large-scale, pragmatic studies to implement effective strategies in clinical practice for chronic pain management, the MTFEC has begun to actualize its purpose by identifying potential barriers and challenges to study implementation and exploring how the PMC can support and aid in the execution of PCTs by applying similar approaches to stakeholder and subject matter engagement for their research.
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Affiliation(s)
- Dylan V Scarton
- Center for Rehabilitation Sciences Research, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.,Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA.,The Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20817, USA
| | - William T Roddy
- Center for Rehabilitation Sciences Research, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.,Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA.,The Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20817, USA
| | - Jerika A Taylor
- Center for Rehabilitation Sciences Research, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.,Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA.,The Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20817, USA
| | - Mary Geda
- The Pain Management Collaboratory Coordinating Center, Yale University, New Haven, CT 06510, USA.,Department of General Internal Medicine, Yale School of Medicine, New Haven, CT 06520, USA
| | - Cynthia A Brandt
- The Pain Management Collaboratory Coordinating Center, Yale University, New Haven, CT 06510, USA.,Department of General Internal Medicine, Yale School of Medicine, New Haven, CT 06520, USA
| | - Peter Peduzzi
- The Pain Management Collaboratory Coordinating Center, Yale University, New Haven, CT 06510, USA.,Department of Biostatistics, and Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT 06520, USA
| | - Robert D Kerns
- The Pain Management Collaboratory Coordinating Center, Yale University, New Haven, CT 06510, USA.,Veteran's Administration Connecticut Healthcare System, West Haven, CT 06516, USA.,Department of Psychiatry, Yale School of Medicine, New Haven, CT 06511, USA
| | - Paul F Pasquina
- Center for Rehabilitation Sciences Research, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.,Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
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Byrne T, Spevak C. The Use of Telepain for Chronic Pain in the U.S. Armed Forces: Patient Experience from Walter Reed National Military Medical Center. Mil Med 2021; 185:e632-e637. [PMID: 32175573 DOI: 10.1093/milmed/usaa022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 12/23/2019] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Chronic pain affects over 100 million American adults. The prevalence of chronic pain is even higher among U.S. military personnel. Approximately 44% of active duty military experience pain upon returning from deployment compared with 26% of the general public who experience chronic pain. The high prevalence of chronic pain within the Military Health System is compounded by limited access to chronic pain specialists, specifically with regard to patients at remote military treatment facilities (MTFs). Thus, when compared to personnel at tertiary care MTFs, they often have decreased access to care and experience increased time away from their mission to receive care. Since 2009, Walter Reed National Military Medical Center (WRNMMC) has been using telemedicine to extend chronic pain consults to remote MTFs within the National Capital Region (NCR). The goal of this study was to determine if patients referred to the WRNMMC Telepain Program reported improvements in subjective measures associated with accessing care. To accomplish this, we surveyed a convenience sample of patients using the service to determine if participation: (1) improved pain, (2) improved quality of life, (3) decreased travel time, (4) improved access to care, and (5) decreased time away from work. MATERIALS AND METHODS An official on behalf of the Institutional Review Board at WRNMMC determined this research to be not human subject research. Over a 13-month period, surveys were administered at the conclusion of all initial Telepain Consults. The survey consisted of an eight question, 5-point balanced Likert scale survey with 1 (strongly disagree) being the most negative and 5 (strongly agree) being most positive. The questions were designed to gauge impact on patient's perceived access to care, quality of life, overall patient satisfaction, and privacy concerns. The percentages of answers, including strongly agree or agree for positive toned questions and strongly disagree and disagree for negatively toned questions, were calculated and presented in a clustered bar graph. RESULTS A total of 66 Telepain surveys were collected over 13 months with an overall positive reception. Respondents agreed or strongly agreed that Telepain increased access to care (98.5%) and decreased travel time (96.9%). When asked if they would recommend a Telepain visit to others, 93.9% of indicated strongly agree or agree. When asked about overall satisfaction, 83.3% of patients answered completely satisfied or very satisfied. CONCLUSIONS The majority of pain specialists within the Military Health System are located at major military medical centers, the most of which are distant from surrounding MTFs. Prior to the development of the WRNMMC Telepain service, personnel at remote MTFs had to endure extended time away from their mission to receive care. The majority of patients that participated in the NCR Telepain program reported a positively perceived impact on pain, access to care, quality of life, transportation burden, and time away from work. In conclusion, The NCR Telepain team of providers have worked together to successfully establish a viable Telepain program at WRNMMC, one that will continue to be further improved and successful in the future.
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Affiliation(s)
- Taylor Byrne
- Department of Anesthesia and Pain Medicine, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD 20889
| | - Christopher Spevak
- Department of Anesthesia and Pain Medicine, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD 20889
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Jasuja GK, Bettano A, Smelson D, Bernson D, Rose AJ, Byrne T, Berlowitz DR, McCullough MB, Miller DR. Homelessness and Veteran Status in Relation to Nonfatal and Fatal Opioid Overdose in Massachusetts. Med Care 2021; 59:S165-S169. [PMID: 33710090 DOI: 10.1097/mlr.0000000000001437] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Compared with non-Veterans, Veterans are at higher risk of experiencing homelessness, which is associated with opioid overdose. OBJECTIVE To understand how homelessness and Veteran status are related to risks of nonfatal and fatal opioid overdose in Massachusetts. DESIGN A cross-sectional study. PARTICIPANTS All residents aged 18 years and older during 2011-2015 in the Massachusetts Department of Public Health's Data Warehouse (Veterans: n=144,263; non-Veterans: n=6,112,340). A total of 40,036 individuals had a record of homelessness, including 1307 Veterans and 38,729 non-Veterans. MAIN MEASURES The main independent variables were homelessness and Veteran status. Outcomes included nonfatal and fatal opioid overdose. RESULTS A higher proportion of Veterans with a record of homelessness were older than 45 years (77% vs. 48%), male (80% vs. 62%), or receiving high-dose opioid therapy (23% vs. 15%) compared with non-Veterans. The rates of nonfatal and fatal opioid overdose in Massachusetts were 85 and 16 per 100,000 residents, respectively. Among individuals with a record of homelessness, these rates increased 31-fold to 2609 and 19-fold to 300 per 100,000 residents. Homelessness and Veteran status were independently associated with higher odds of nonfatal and fatal opioid overdose. There was a significant interaction between homelessness and Veteran status in their effects on risk of fatal overdose. CONCLUSIONS Both homelessness and Veteran status were associated with a higher risk of fatal opioid overdoses. An understanding of health care utilization patterns can help identify treatment access points to improve patient safety among vulnerable individuals both in the Veteran population and among those experiencing homelessness.
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Affiliation(s)
- Guneet K Jasuja
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford
- Department of Health Law, Policy and Management, Boston University School of Public Health
| | - Amy Bettano
- Office of Population Health, Department of Public Health, The Commonwealth of Massachusetts, Boston
| | - David Smelson
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford
- Department of Psychiatry, University of Massachusetts Medical School, Worcester
| | - Dana Bernson
- Office of Population Health, Department of Public Health, The Commonwealth of Massachusetts, Boston
| | - Adam J Rose
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine
| | - Thomas Byrne
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford
- Boston University School of Social Work, Boston
| | - Dan R Berlowitz
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford
- Department of Public Health
| | - Megan B McCullough
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford
- Department of Public Health
| | - Donald R Miller
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford
- Center for Population Health, University of Massachusetts, Lowell, MA
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Santini A, Petruzzo A, Giannetta N, Ruggiero A, Di Muzio M, Latina R. Management of chronic musculoskeletal pain in veterans: a systematic review. ACTA BIO-MEDICA : ATENEI PARMENSIS 2021; 92:e2021011. [PMID: 33855991 PMCID: PMC8138808 DOI: 10.23750/abm.v92is2.11352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 03/04/2021] [Indexed: 11/23/2022]
Abstract
Background and aim of the work. Veterans are military with health problems due to military conditions. The improved body armor and operational conditions has reduced the number of deaths, but increased the number of veterans with severe injuries, affected by musculoskeletal pain and associated syndromes, such as post-traumatic stress disorder. Multimodal approaches are considered in USA the gold standard for the treatment of these problems, while in Europe and Italy the data are unknown. The aim of this review was to describe and summarize multimodal therapeutic approaches that apply to the veteran population for chronic musculoskeletal pain and relate syndromes management. Methods. A comprehensive systematic review of the literature on Cochrane Library, PubMed, CINAHL e PsycINFO databases was conducted, from 2001 to 2020. Results. 228 papers have been found, 134 were selected after the first screening. 24 quantitative studies were included in the review, all from USA. Different multimodal interventions with different kind of treatment types emerged. The analyzed studies’ sample size was 11 million (mean age = 57.67 years; SD=±11.94). The multimodal approaches showed a significant improvement in all outcomes (pain reduction and control, opioid therapy reduction, psychosocial outcomes) compared to traditional therapy. Conclusions. Multimodal therapeutic approaches seem to guarantee a good management chronic musculoskeletal pain and related mental disorders, and the reduction and control to opioid use. Military nurses emerged as professionals who have a central role in this approach. European and Italian authorities should consider veterans, in order to assess their expected increase in the future. (www.actabiomedica.it)
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Affiliation(s)
| | - Antonio Petruzzo
- School of Nursing Science and Midwifery, Sapienza University of Rome, A.O. S. Camillo-Forlanini Hospital, Rome, Italy.
| | - Noemi Giannetta
- Vita-Salute San Raffaele University, Tor Vergata, University of Rome, Italy.
| | - Antonio Ruggiero
- School of Nursing Science and Midwifery, Sapienza University of Rome, A.O. S. Camillo-Forlanini Hospital, Rome, Italy.
| | - Marco Di Muzio
- Department of Molecular Medicine, Sapienza University of Rome, Italy.
| | - Roberto Latina
- School of Nursing Science and Midwifery, Sapienza University of Rome, A.O. S. Camillo-Forlanini Hospital, Rome, Italy.
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Brintz CE, Miller S, Olmsted KR, Bartoszek M, Cartwright J, Kizakevich PN, Butler M, Asefnia N, Buben A, Gaylord SA. Adapting Mindfulness Training for Military Service Members With Chronic Pain. Mil Med 2021; 185:385-393. [PMID: 31621856 DOI: 10.1093/milmed/usz312] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION Rates of chronic pain in military personnel are disproportionately high. Chronic pain is often associated with mental health and substance use disorders as comorbid conditions, making treatment of chronic pain complex. Mindfulness-based interventions (MBIs) are a promising behavioral approach to managing chronic pain and psychosocial sequelae. The unique nature of the military context may require adaptations to original MBIs for successful delivery in active-duty military populations. This study adapted the mindfulness-based stress reduction (MBSR) program to create a mindfulness training program that was relevant to active-duty Army personnel experiencing chronic pain. This article delineates the adaptation process employed to modify the MBSR program to the military context and discusses the resulting training program. MATERIALS AND METHODS The adaptation process consisted of three iterative stages: 1) Drafting the preliminary intervention protocol with recommendations from stakeholders, including military healthcare providers; 2) Refining the preliminary protocol after pretesting the sessions with research team members and a military Veteran advisory committee; and 3) Delivering the preliminary protocol to one cohort of active-duty Soldiers with chronic pain, collecting feedback, and further refining the intervention protocol. RESULTS Military-related adaptations to MBSR addressed three areas: military culture, language and terminology, and practical and logistical factors relevant to implementation in the military setting. This adaptation process resulted in a live, online program with six, weekly, sessions. Feedback from a military Veteran advisory committee resulted in modifications, including increasing military-relevant examples; preliminary testing with the target population resulted in additional modifications, including shortening the sessions to 75 min and structuring discussions more efficiently. CONCLUSIONS The adaptation process was successful in generating an engaging mindfulness training program that was highly relevant to the military context. Obtaining input from stakeholders, such as military healthcare providers and active-duty soldiers, and iterative feedback and modification, were key to the process. Moreover, the program was designed to maintain the integrity and core elements of MBIs while adapting to military culture. A future randomized controlled trial design will be used to evaluate the effectiveness of the intervention in improving chronic pain in military personnel. This program is responsive to the military's call for nonpharmacologic treatments for chronic pain that are easily accessible. If effective, the mindfulness program has the potential for widespread dissemination to complement standard care for Service Members experiencing chronic pain.
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Affiliation(s)
- Carrie E Brintz
- University of North Carolina School of Medicine, 321 S. Columbia St, Chapel Hill, NC 27516
| | - Shari Miller
- RTI International, 3040 East Cornwallis Road, Research Triangle Park, NC 27713
| | | | | | - Joel Cartwright
- RTI International, 3040 East Cornwallis Road, Research Triangle Park, NC 27713
| | - Paul N Kizakevich
- RTI International, 3040 East Cornwallis Road, Research Triangle Park, NC 27713
| | - Michael Butler
- Womack Army Medical Center, 2817 Reilly Rd, Fort Bragg, NC 28310
| | - Nakisa Asefnia
- University of South Carolina, Department of Psychology, 1512 Pendleton St, Columbia SC 29208
| | - Alex Buben
- RTI International, 3040 East Cornwallis Road, Research Triangle Park, NC 27713
| | - Susan A Gaylord
- University of North Carolina School of Medicine, 321 S. Columbia St, Chapel Hill, NC 27516
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45
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Willman AS. Chronic non-cancer pain training and practice-based small group learning in defence primary healthcare. BMJ Mil Health 2021; 168:243. [PMID: 33664090 DOI: 10.1136/bmjmilitary-2021-001805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 02/15/2021] [Accepted: 02/17/2021] [Indexed: 11/03/2022]
Affiliation(s)
- Antony Sean Willman
- Academic Department of General Practice, Royal Defence Medical College, Birmingham, UK
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46
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Elbogen EB, Alsobrooks A, Battles S, Molloy K, Dennis PA, Beckham JC, McLean SA, Keith JR, Russoniello C. Mobile Neurofeedback for Pain Management in Veterans with TBI and PTSD. PAIN MEDICINE (MALDEN, MASS.) 2021; 22:329-337. [PMID: 31697371 PMCID: PMC7901853 DOI: 10.1093/pm/pnz269] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE Chronic pain is common in military veterans with traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD). Neurofeedback, or electroencephalograph (EEG) biofeedback, has been associated with lower pain but requires frequent travel to a clinic. The current study examined feasibility and explored effectiveness of neurofeedback delivered with a portable EEG headset linked to an application on a mobile device. DESIGN Open-label, single-arm clinical trial. SETTING Home, outside of clinic. SUBJECTS N = 41 veterans with chronic pain, TBI, and PTSD. METHOD Veterans were instructed to perform "mobile neurofeedback" on their own for three months. Clinical research staff conducted two home visits and two phone calls to provide technical assistance and troubleshoot difficulties. RESULTS N = 36 veterans returned for follow-up at three months (88% retention). During this time, subjects completed a mean of 33.09 neurofeedback sessions (10 minutes each). Analyses revealed that veterans reported lower pain intensity, pain interference, depression, PTSD symptoms, anger, sleep disturbance, and suicidal ideation after the three-month intervention compared with baseline. Comparing pain ratings before and after individual neurofeedback sessions, veterans reported reduced pain intensity 67% of the time immediately following mobile neurofeedback. There were no serious adverse events reported. CONCLUSIONS This preliminary study found that veterans with chronic pain, TBI, and PTSD were able to use neurofeedback with mobile devices independently after modest training and support. While a double-blind randomized controlled trial is needed for confirmation, the results show promise of a portable, technology-based neuromodulatory approach for pain management with minimal side effects.
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Affiliation(s)
- Eric B Elbogen
- Veterans Affairs (VA) Mid-Atlantic Mental Illness Research, Education and Clinical Center (MIRECC), Durham, North Carolina, USA
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Amber Alsobrooks
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sara Battles
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kiera Molloy
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Paul A Dennis
- Veterans Affairs (VA) Mid-Atlantic Mental Illness Research, Education and Clinical Center (MIRECC), Durham, North Carolina, USA
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jean C Beckham
- Veterans Affairs (VA) Mid-Atlantic Mental Illness Research, Education and Clinical Center (MIRECC), Durham, North Carolina, USA
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Samuel A McLean
- Department of Anesthesiology, University of North Carolina-Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Julian R Keith
- Department of Psychology, University of North Carolina-Wilmington, Wilmington, North Carolina, USA
| | - Carmen Russoniello
- Center for Applied Psychophysiology, East Carolina University, Greenville, North Carolina, USA
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Doolittle J, Kansal J, Dietrich P, Brink S, McNamara M, Moyer A, Medairos R, Sandlow J. Is Opioid-free Post-Vasectomy Analgesia a Pain? A Single Surgeon Experience. Urology 2021; 154:40-44. [PMID: 33561471 DOI: 10.1016/j.urology.2021.01.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 01/12/2021] [Accepted: 01/25/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To determine the impact of transitioning from opioid to non-opioid analgesia post-vasectomy on unplanned opioid prescriptions and health encounters. METHODS A retrospective review for patients who underwent vasectomy from October 2018 through December 2019 was performed. Beginning February 1st, 2019, patients were counseled to take scheduled acetaminophen and ibuprofen in lieu of acetaminophen with codeine, with an opioid prescription only provided upon request. Analysis was performed comparing 200 consecutive patients before and after this transition. Baseline patient characteristics, unplanned postoperative encounters for pain within 30 days of vasectomy, and associated narcotic prescriptions were compared between groups. RESULTS 400 patients were included, consisting of 200 patients pre and 200 patients postintervention. There were no differences in socioeconomic characteristics between groups. No differences between the pre- and postintervention groups were observed in terms of generating telephone calls to clinic (9% vs 11%, P = .5), clinic visits (2.5% vs 2.5%, P = 1), or ED visits (0% vs 1%), P = .5) for the pre and postintervention cohorts, respectively. CONCLUSIONS Patients that are not prescribed opioids after vasectomy do not generate additional phone calls, clinic, or ED visits compared to those that were routinely prescribed prior to our institutional change. We have permanently discontinued the routine use of opioids for post-vasectomy analgesia. Other physicians performing vasectomy should consider making this change as well.
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Affiliation(s)
| | - Jagan Kansal
- Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Sarah Brink
- Hackensack University Medical Center, Hackensack, New Jersey
| | | | - Andrea Moyer
- Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Jay Sandlow
- Medical College of Wisconsin, Milwaukee, Wisconsin
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48
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The Prevalence and Impact of Back and Neck Pain in Veterans with Upper Limb Amputation. Am J Phys Med Rehabil 2021; 100:1042-1053. [DOI: 10.1097/phm.0000000000001694] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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49
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Fritz JM, Rhon DI, Teyhen DS, Kean J, Vanneman ME, Garland EL, Lee IE, Thorp RE, Greene TH. A Sequential Multiple-Assignment Randomized Trial (SMART) for Stepped Care Management of Low Back Pain in the Military Health System: A Trial Protocol. PAIN MEDICINE 2020; 21:S73-S82. [PMID: 33313724 DOI: 10.1093/pm/pnaa338] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND The Defense Health Agency has prioritized system-level pain management initiatives within the Military Health System (MHS), with low back pain as one of the key focus areas. A stepped care model focused on nonpharmacologic treatment to promote self-management is recommended. Implementation of stepped care is complicated by lack of information on the most effective nonpharmacologic strategies and how to sequence and tailor the various available options. The Sequential Multiple-Assignment Randomization Trial for Low Back Pain (SMART LBP) is a multisite pragmatic trial using a SMART design to assess the effectiveness of nonpharmacologic treatments for chronic low back pain. DESIGN This SMART trial has two treatment phases. Participants from three military treatment facilities are randomized to 6 weeks of phase I treatment, receiving either physical therapy (PT) or Army Medicine's holistic Move2Health (M2H) program in a package specific to low back pain. Nonresponders to treatment in phase I are again randomized to phase II treatment of combined M2H + PT or mindfulness-based treatment using the Mindfulness-Oriented Recovery Enhancement (MORE) program. The primary outcome is the Patient-Reported Outcomes Measurement Information System pain interference computer-adapted test score. SUMMARY This trial is part of an initiative funded by the National Institutes of Health, Veterans Affairs, and the Department of Defense to establish a national infrastructure for effective system-level management of chronic pain with a focus on nonpharmacologic treatments. The results of this study will provide important information on nonpharmacologic care for chronic LBP in the MHS embedded within a stepped care framework.
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Affiliation(s)
| | - Daniel I Rhon
- Brooke Army Medical Center, San Antonio, Texas.,Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Deydre S Teyhen
- Walter Reed Army Institute of Research, Silvers Spring, Maryland
| | - Jacob Kean
- University of Utah, Salt Lake City, Utah
| | | | | | - Ian E Lee
- Defense Health Management Systems, Falls Church, Virginia
| | - Richard E Thorp
- Directorate of Program Analysis and Evaluation, Office of the Army Surgeon General, Joint Base San Antonio Fort Sam Houston, San Antonio, Texas, USA
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50
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Vest BM, Hoopsick RA, Homish DL, Homish GG. Lower levels of bodily pain increase risk for non-medical use of prescription drugs among current US reserve soldiers. Addict Behav 2020; 108:106443. [PMID: 32315933 DOI: 10.1016/j.addbeh.2020.106443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 03/09/2020] [Accepted: 04/13/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Military populations have a higher prevalence of pain compared to their civilian counterparts and are also at increased risk for substance use. The link between clinically significant pain and substance use has been established, but it is unclear if lower levels of pain relate to risk. The goal of this inquiry was to determine if level of bodily pain was associated with increased risk of current substance use over time among a community sample of U.S. Army Reserve/National Guard (USAR/NG) soldiers. METHODS Data were drawn from an ongoing study of USAR/NG soldiers. We used generalized estimating equations to examine the longitudinal impact of baseline bodily pain level (modeled in standard deviations from the mean pain score) on current drug use (illicit and non-medical use of prescription drugs [NMUPD]) among soldiers (n = 387) over two-years. Final models controlled for baseline post-traumatic stress disorder (PTSD), anxiety, and depression symptomatology, history of deployment (yes/no), years of military service, and substance use norms. RESULTS Bodily pain was longitudinally associated with increased odds of current NMUPD (AOR: 1.49, p < .05), but not with the current use of illicit drugs (AOR: 1.18, p > .05), controlling for symptoms of PTSD, anxiety, depression, deployment, years of service, and substance use norms. CONCLUSIONS Overall, our findings indicate that bodily pain is longitudinally associated with NMUPD among male soldiers, but not with illicit drugs. Significantly, our results stem from a non-clinical sample of soldiers with overall lower levels of pain. This indicates that pain may be important, even at lower levels, and underscores the importance of early non-pharmacologic interventions for pain.
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Affiliation(s)
- Bonnie M Vest
- Department of Family Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, NY, USA.
| | - Rachel A Hoopsick
- Department of Family Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, NY, USA; Department of Community Health and Health Behavior, School of Public Health and Health Professions, University at Buffalo, The State University of New York, Buffalo, NY, USA
| | - D Lynn Homish
- Department of Community Health and Health Behavior, School of Public Health and Health Professions, University at Buffalo, The State University of New York, Buffalo, NY, USA
| | - Gregory G Homish
- Department of Community Health and Health Behavior, School of Public Health and Health Professions, University at Buffalo, The State University of New York, Buffalo, NY, USA
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