Addressing Chronic Back Pain in Veterans
Female veterans more likely to experience persistent pain than male counterparts.
During the American Pain Society's 35th Annual Meeting in Austin, TX, Robert Kerns, PhD, Professor of Psychiatry, Neurology and Psychology at Yale University, recently retired from the Veteran's Affairs (VA) Connecticut Healthcare System, presented work conducted at the Pain Research, Informatics, Medical co-morbidities and Education (PRIME) Center in Connecticut.1 These studies performed with collaborators across the country, highlight each of the chapters of the National Pain Strategy (NPS).2
Dr Kerns covered the population research aspect of the NPS, which is data-intensive, by using the example of a VA-funded project, the Musculoskeletal Diagnosis (MSD) Cohort project, conducted in collaboration with Joseph Goulet, PhD and Cynthia Brandt, MD.3 For this project, VA electronic health records and other clinical and administrative databases were organized and used to build a cohort of patients -- all veterans diagnosed with musculoskeletal conditions since 2001 (>5.2 million veterans). Medicare and Medicaid data was also included.
The goal investigators had for this study was to describe pain, describe course of care, and examine outcomes of care in this cohort, which included 6% of women, a large majority of Caucasians, and had a mean age of 59.3 Veterans who had been admitted as inpatients with a MSD condition, or with documentation of at least 2 outpatient visits during the year and with documentation of a MSD, were included in the cohort.
The top 3 conditions within the MSD cohort were non-traumatic joint (27%), back conditions (25%), and osteoarthritis (OA, 21%).3 The rest of the cohort was diagnosed with a broad array of MSDs. Dr Kerns highlighted the effort for every clinical encounter in the VA system to record a pain intensity rating on a 0 to 10 numeric rating scale (NRS) at the date of diagnosis. However, this rating is not always asked of patients in the VA, and less so in specialty clinics outside of the VA.
An interesting finding of this study was that about 35% of the time, on the date of MSD, patients reported no pain. Dr Kerns inferred that this may be due to the fact that some patients might present for a follow-up visit for an injury that occurred outside the VA, and no longer experience pain at the time of diagnosis; alternatively patients might experience fluctuations in pain (e.g. for OA), and may not feel pain on the day of diagnosis.
Back pain rated third on the NRS across various conditions, behind sprains and strains (mean NRS=4.8) and fractures (mean NRS=5) which are more likely to be acute pain conditions with high levels of pain. However, among chronic MSD conditions, patients with back pain reported the highest levels of pain.3
When comparing patients solely consulting for back pain vs pain from OA or joint pain, researchers did not record many differences. Back pain patients tended to be younger than those with OA, and did not differ significantly from OA and joint pain patients in terms of race, gender and comorbidities, including mood disorders, substance and alcohol use disorders, hypertension and diabetes, as OA patients who belong to an older demographics may also present with these. Mental health and overweight/obesity comorbidities were however observed at higher rates in patients with back conditions. Also, veterans with back conditions were found to be more likely to have moderate to severe pain and to receive long-term opioid therapy, relative to the other clusters of conditions.
Opportunities afforded by big data
Using big data allowed researchers to examine complex interactions, and in this case, interactions between depression or mood disorders, and pain intensity. Pain ratings were higher for veterans with back conditions and depressive disorders, so that depression seems to be contributing to back pain intensity, relative to other conditions.
These results highlighted the need to examine interactions among individual variables (demographic variables and clinical care characteristics) in order to acquire an adequate picture of issues experienced by veterans, and to contrast them with other painful medical conditions, such as OA, non-traumatic joint disorders and others.
The focus again here, Dr Kerns pointed, is on data, with the goal of identifying characteristics that may ultimately contribute to development, progression or transition from acute to chronic pain, and also on the importance of pain self-management.
Research that Dr Kerns then presented sprung from the foundational work on cognitive behavioral therapy (CBT), and more broadly, on conceptualization of effects of promoting adaptive pain self-management. The Kerns group has extended its research in two different ways, to study the process of change itself in CBT, looking at the ‘guts' of CBT delivered to veterans, and on factors associated with engagement, participation, and outcomes of treatment.4, 5
The Kerns group along with the VA has been vested in promoting broader dissemination, implementation and uptake of CBT for pain management nationally. An article published in 2015 was the first to report on a national dissemination plan, focusing on fidelity to the CBT training program, the intervention itself as well as on preliminary outcomes.6 About 500 medical providers in the VA are now trained for delivery of CBT, so that veterans have potential access to a trained behavioral therapist in virtually every one of the VA's 140 core healthcare facilities in the country.6
Work by Alicia Heapy, PhD, associate director of the PRIME Center in collaboration with John Piette, PhD at the University of Michigan, sought to develop the use of technology-assisted approaches to promote access to CBT and self-management interventions, all in the service of reaching veterans where they are, through the internet, smartphone applications and phone-based interventions.7
Other work done by Kerns and colleagues at the PRIME Center focused on 2 extreme groups of patients in the VA: veterans from the Enduring Freedom, Iraqi Freedom, and New Dawn operations in Afghanistan and Iraq. This study funded by the VA Women Veterans Cohort Study was designed to look at gender differences. One group of patients had strong evidence of persistent pain over 5 consecutive years, and had any of the following indications: pain intensity ratings >4, prescription of an opioid, specialty pain clinic visit. The comparative group had had similar opportunities to have pain documented, with frequent visits to the VA over the same 5 years, but absolutely no evidence of pain.8 The study revealed that female veterans were more likely to have persistent pain than their male colleagues, and were more likely to be of racial and ethnic minorities, have lower levels of education, and to be overweight or obese.
Veterans with persistent pain had a higher likelihood of mental health comorbidities, particularly mood and anxiety disorders, PTSD, and substance use disorders, compared to veterans with no pain. There was no strong evidence of alcohol use disorder, and no particular differences around medical comorbidities.
1.Better Self Management Improves Outcomes for Chronic Pain Care. 35th Annual Meeting of the American Pain Society. May 11-14, 2017, Austin, TX http://americanpainsociety.org/about-us/press-room/better-self-management-improves-outcomes-for-chronic-pain-care
2.The National Pain Strategy: https://iprcc.nih.gov/National_Pain_Strategy/NPS_Main.htm
3.Goulet JL, Kerns RD, Bair M, et al. The Musculoskeletal Diagnosis Cohort: Examining Pain and Pain Care among Veterans. Pain. 2016.
4.Burns JW, Nielson WR, Jensen MP, Heapy A, Czlapinski R, Kerns RD. Specific and general therapeutic mechanisms in cognitive behavioral treatment of chronic pain. J Consult Clin Psychol. 2015;83(1):1-11.
5.Kerns RD, Burns JW, Shulman M, et al. Can we improve cognitive-behavioral therapy for chronic back pain treatment engagement and adherence? A controlled trial of tailored versus standard therapy. Health Psychol. 2014;33(9):938-47.
6.Stewart MO, Karlin BE, Murphy JL, et al. National dissemination of cognitive-behavioral therapy for chronic pain in veterans: therapist and patient-level outcomes. Clin J Pain. 2015;31(8):722-9.
7.Piette JD, Krein SL, Striplin D, et al. Patient-Centered Pain Care Using Artificial Intelligence and Mobile Health Tools: Protocol for a Randomized Study Funded by the US Department of Veterans Affairs Health Services Research and Development Program. JMIR Res Protoc. 2016;5(2):e53.
8.Driscoll MA, Higgins DM, Seng EK, et al. Trauma, social support, family conflict, and chronic pain in recent service veterans: does gender matter?. Pain Med. 2015;16(6):1101-11.