Non-pharmacological Treatment for Chronic Pain in US Veterans Treated Within the Veterans Health Administration: Implications for Expansion in US Healthcare Systems

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Abstract

Background

Consensus guidelines recommend multimodal chronic pain treatment with increased use of non-pharmacological treatment modalities (NPM), including as first-line therapies. However, with many barriers to NPM uptake in US healthcare systems, NPM use may vary across medical care settings. Military veterans are disproportionately affected by chronic pain. Many veterans receive treatment through the Veterans Health Administration (VHA), an integrated healthcare system in which specific policies promote NPM use.

Objective

To examine whether veterans with chronic pain who utilize VHA healthcare were more likely to use NPM than veterans who do not utilize VHA healthcare.

Design

Cross-sectional nationally representative study.

Participants

US military veterans ( N = 2,836).

Main Measures

In the 2019 National Health Interview Survey, veterans were assessed for VHA treatment, chronic pain (i.e., past 3-month daily or almost daily pain), symptoms of depression and anxiety, substance use, and NPM (i.e., physical therapy, chiropractic/spinal manipulation, massage, psychotherapy, educational class/workshop, peer support groups, or yoga/tai chi).

Key Results

Chronic pain (45.2% vs. 26.8%) and NPM use (49.8% vs. 39.4%) were more prevalent among VHA patients than non-VHA veterans. After adjusting for sociodemographic characteristics, psychiatric symptoms, physical health indicators, and use of cigarettes or prescription opioids, VHA patients were more likely than non-VHA veterans to use any NPM (adjusted odds ratio [aOR] = 1.52, 95% CI: 1.07–2.16) and multimodal NPM (aOR = 1.80, 95% CI: 1.12–2.87) than no NPM. Among veterans with chronic pain, VHA patients were more likely to use chiropractic care (aOR = 1.90, 95% CI = 1.12–3.22), educational class/workshop (aOR = 3.02, 95% CI = 1.35–6.73), or psychotherapy (aOR = 4.28, 95% CI = 1.69–10.87).

Conclusions

Among veterans with chronic pain, past-year VHA use was associated with greater likelihood of receiving NPM. These findings may suggest that the VHA is an important resource and possible facilitator of NPM. VHA policies may offer guidance for expanding use of NPM in other integrated US healthcare systems.

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Most cited references 66

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A brief measure for assessing generalized anxiety disorder: the GAD-7.

Robert L Spitzer, Kurt Kroenke, Janet B W Williams … (2006)

Generalized anxiety disorder (GAD) is one of the most common mental disorders; however, there is no brief clinical measure for assessing GAD. The objective of this study was to develop a brief self-report scale to identify probable cases of GAD and evaluate its reliability and validity. A criterion-standard study was performed in 15 primary care clinics in the United States from November 2004 through June 2005. Of a total of 2740 adult patients completing a study questionnaire, 965 patients had a telephone interview with a mental health professional within 1 week. For criterion and construct validity, GAD self-report scale diagnoses were compared with independent diagnoses made by mental health professionals; functional status measures; disability days; and health care use. A 7-item anxiety scale (GAD-7) had good reliability, as well as criterion, construct, factorial, and procedural validity. A cut point was identified that optimized sensitivity (89%) and specificity (82%). Increasing scores on the scale were strongly associated with multiple domains of functional impairment (all 6 Medical Outcomes Study Short-Form General Health Survey scales and disability days). Although GAD and depression symptoms frequently co-occurred, factor analysis confirmed them as distinct dimensions. Moreover, GAD and depression symptoms had differing but independent effects on functional impairment and disability. There was good agreement between self-report and interviewer-administered versions of the scale. The GAD-7 is a valid and efficient tool for screening for GAD and assessing its severity in clinical practice and research.

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The PHQ-8 as a measure of current depression in the general population.

Kurt Kroenke, Tara Strine, Robert L Spitzer … (2009)

The eight-item Patient Health Questionnaire depression scale (PHQ-8) is established as a valid diagnostic and severity measure for depressive disorders in large clinical studies. Our objectives were to assess the PHQ-8 as a depression measure in a large, epidemiological population-based study, and to determine the comparability of depression as defined by the PHQ-8 diagnostic algorithm vs. a PHQ-8 cutpoint > or = 10. Random-digit-dialed telephone survey of 198,678 participants in the 2006 Behavioral Risk Factor Surveillance Survey (BRFSS), a population-based survey in the United States. Current depression as defined by either the DSM-IV based diagnostic algorithm (i.e., major depressive or other depressive disorder) of the PHQ-8 or a PHQ-8 score > or = 10; respondent sociodemographic characteristics; number of days of impairment in the past 30 days in multiple domains of health-related quality of life (HRQoL). The prevalence of current depression was similar whether defined by the diagnostic algorithm or a PHQ-8 score > or = 10 (9.1% vs. 8.6%). Depressed patients had substantially more days of impairment across multiple domains of HRQoL, and the impairment was nearly identical in depressed groups defined by either method. Of the 17,040 respondents with a PHQ-8 score > or = 10, major depressive disorder was present in 49.7%, other depressive disorder in 23.9%, depressed mood or anhedonia in another 22.8%, and no evidence of depressive disorder or depressive symptoms in only 3.5%. The PHQ-8 diagnostic algorithm rather than an independent structured psychiatric interview was used as the criterion standard. The PHQ-8 is a useful depression measure for population-based studies, and either its diagnostic algorithm or a cutpoint > or = 10 can be used for defining current depression.

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Chronic pain as a symptom or a disease

Rolf-Detlef Treede, Winfried Rief, Antonia Barke … (2019)

Chronic pain is a major source of suffering. It interferes with daily functioning and often is accompanied by distress. Yet, in the International Classification of Diseases, chronic pain diagnoses are not represented systematically. The lack of appropriate codes renders accurate epidemiological investigations difficult and impedes health policy decisions regarding chronic pain such as adequate financing of access to multimodal pain management. In cooperation with the WHO, an IASP Working Group has developed a classification system that is applicable in a wide range of contexts, including pain medicine, primary care, and low-resource environments. Chronic pain is defined as pain that persists or recurs for more than 3 months. In chronic pain syndromes, pain can be the sole or a leading complaint and requires special treatment and care. In conditions such as fibromyalgia or nonspecific low-back pain, chronic pain may be conceived as a disease in its own right; in our proposal, we call this subgroup "chronic primary pain." In 6 other subgroups, pain is secondary to an underlying disease: chronic cancer-related pain, chronic neuropathic pain, chronic secondary visceral pain, chronic posttraumatic and postsurgical pain, chronic secondary headache and orofacial pain, and chronic secondary musculoskeletal pain. These conditions are summarized as "chronic secondary pain" where pain may at least initially be conceived as a symptom. Implementation of these codes in the upcoming 11th edition of International Classification of Diseases will lead to improved classification and diagnostic coding, thereby advancing the recognition of chronic pain as a health condition in its own right.

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Author and article information

Contributors

Deborah S. Hasin: dsh2@cumc.columbia.edu

Journal

Journal ID (nlm-ta): J Gen Intern Med

Journal ID (iso-abbrev): J Gen Intern Med

Title: Journal of General Internal Medicine

Publisher: Springer International Publishing (Cham )

ISSN (Print): 0884-8734

ISSN (Electronic): 1525-1497

Publication date (Electronic): 19 January 2022

Publication date PMC-release: 19 January 2022

Pages: 1-10

Affiliations

[1 ]GRID grid.21729.3f, ISNI 0000000419368729, Department of Epidemiology, , Columbia University Mailman School of Public Health, ; New York, NY USA

[2 ]GRID grid.413734.6, ISNI 0000 0000 8499 1112, New York State Psychiatric Institute, ; 1051 Riverside Drive, Box 123, New York, NY 10032 USA

[3 ]GRID grid.21729.3f, ISNI 0000000419368729, Department of Psychiatry, , Columbia University Irving Medical Center, ; New York, NY USA

[4 ]GRID grid.189504.1, ISNI 0000 0004 1936 7558, Department of Epidemiology, , Boston University School of Public Health, ; Boston, MA USA

[5 ]GRID grid.189504.1, ISNI 0000 0004 1936 7558, Department of Psychiatry, , Boston University School of Medicine, ; Boston, MA USA

[6 ]GRID grid.34477.33, ISNI 0000000122986657, Department of Psychiatry & Behavioral Sciences, , University of Washington School of Medicine, ; Seattle, WA USA

[7 ]GRID grid.413919.7, ISNI 0000 0004 0420 6540, VA Puget Sound Healthcare System, ; Seattle, WA USA

Article

Publisher ID: 7370

DOI: 10.1007/s11606-021-07370-8

PMC ID: 8769678

PubMed ID: 35048300

SO-VID: 0807c9ca-ab17-46f8-b01a-737a646e65a4

License:

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

History

Date received : 23 September 2021

Date accepted : 16 December 2021

Funding

Funded by: FundRef http://dx.doi.org/10.13039/100000026, National Institute on Drug Abuse;

Award ID: R01DA048860

Award ID: 5T32DA031099

Award Recipient : Deborah S. Hasin

Funded by: FundRef http://dx.doi.org/10.13039/100014546, New York State Psychiatric Institute;

Non-pharmacological Treatment for Chronic Pain in US Veterans Treated Within the Veterans Health Administration: Implications for Expansion in US Healthcare Systems

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Abstract

Background

Objective

Design

Participants

Main Measures

Key Results

Conclusions

Related collections

ScienceOpen Clinical Case Reports Collection

Most cited references 66

A brief measure for assessing generalized anxiety disorder: the GAD-7.

The PHQ-8 as a measure of current depression in the general population.

Chronic pain as a symptom or a disease

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