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1.  Predictors of Improvements in Pain Intensity in a National Cohort of Older Veterans with Chronic Pain 
Little is known about the factors associated with pain-related outcomes in older adults. In this observational study, we sought to identify patient factors associated with improvements in pain intensity in a national cohort of older veterans with chronic pain. We included 12,924 veterans receiving treatment from the Veterans Health Administration with persistently elevated numeric rating scale scores in 2010 who had not been prescribed opioids in the prior 12 months. We examined 1) percentage decrease over 12 months in average pain intensity scores relative to average baseline pain intensity score; and 2) time to sustained improvement in average pain intensity scores, defined as a 30% reduction in 3-month scores compared to baseline. Average relative improvement in pain intensity scores from baseline ranged from 25% to 29%; almost two-thirds met criteria for sustained improvement during the 12-month follow-up period. In models, higher baseline pain intensity and older age were associated with greater likelihood of improvement in pain intensity, while VA service-connected disability, mental health, and certain pain-related diagnoses were associated with lower likelihood of improvement. Opioid prescription initiation during follow-up was associated with lower likelihood of sustained improvement. The findings call for further characterization of heterogeneity in pain outcomes in older adults as well as further analysis of the relationship between prescription opioids and treatment outcomes.
doi:10.1016/j.jpain.2016.03.006
PMCID: PMC4925248  PMID: 27058162
Chronic pain; Veterans; Numeric Rating Scale; Aged; Analgesics; opioid
2.  A Qualitative Analysis of How Online Access to Mental Health Notes Is Changing Clinician Perceptions of Power and the Therapeutic Relationship 
Background
As part of the national OpenNotes initiative, the Veterans Health Administration (VHA) provides veterans online access to their clinical progress notes, raising concern in mental health settings.
Objective
The aim of this study was to examine the perspectives and experiences of mental health clinicians with OpenNotes to better understand how OpenNotes may be affecting mental health care.
Methods
We conducted individual semi-structured interviews with 28 VHA mental health clinicians and nurses. Transcripts were analyzed using a thematic analysis approach, which allows for both inductive and deductive themes to be explored using an iterative, constant comparative coding process.
Results
OpenNotes is changing VHA mental health care in ways that mental health clinicians perceive as both challenging and beneficial. At the heart of these changes is a shifting power distribution within the patient-clinician relationship. Some clinicians view OpenNotes as an opportunity to better partner with patients, whereas others feel that it has the potential to undo the therapeutic relationship. Many clinicians are uncomfortable with OpenNotes, but acknowledge that this discomfort could both improve and diminish care and documentation practices. Specifically, we found that (1) OpenNotes is empowering patients, (2) OpenNotes is affecting how clinicians build and maintain the therapeutic relationship, and (3) mental health clinicians are adjusting their practices to protect patients and themselves from adverse consequences of OpenNotes.
Conclusions
Our findings suggest that future research should monitor whether OpenNotes notes facilitates stronger patient-clinician relationships, enhancing patient-centered mental health care, or diminishes the quality of mental health care through disruptions in the therapeutic relationship and reduced documentation.
doi:10.2196/jmir.6915
PMCID: PMC5489707  PMID: 28615152
eHealth; physician-patient relations; mental health; patient-centered care
3.  Pain-Related Anxiety Mediates the Relationship between Depressive Symptoms and Pain Interference in Veterans with Hepatitis C 
General hospital psychiatry  2015;37(6):533-537.
Objective
Depression and chronic pain are common in persons chronically infected with the hepatitis C virus (HCV), although little is known about the rate of co-occurrence or mechanisms by which they are associated. We evaluated whether pain-related anxiety mediates the relationship between depressive symptoms and pain-related physical functioning in patients with HCV.
Methods
Patients with HCV (n=175) completed self-report measures assessing demographic characteristics, pain-related function, and mental health. Path analyses examined direct effects of cognitive-affective and somatic symptoms of depression on pain interference and indirect effects of these relationships via four subscales of the Pain Anxiety Symptoms Scale-20.
Results
Cognitive-affective and somatic symptoms of depression were positively and significantly related to pain interference. Pain-related anxiety mediated the relationship between both cognitive-affective and somatic symptoms of depression, and this mediation was predominantly accounted for by the escape-avoidance component of pain-related anxiety.
Conclusions
Findings indicate a potential mediating role of pain-related anxiety, particularly escape-avoidance anxiety, on the relationship between depression and pain interference in patients with HCV. These findings suggest that escape-avoidance anxiety may be a particularly germane target for treatment in patients with HCV and chronic pain, particularly when depression, with characteristic features of withdrawal and inhibition, is a comorbid condition.
doi:10.1016/j.genhosppsych.2015.07.003
PMCID: PMC4630124  PMID: 26265311
Pain-related anxiety; Chronic pain; Depression; Hepatitis C virus; Comorbidity
4.  Short-term Variability in Outpatient Pain Intensity Scores in a National Sample of Older Veterans with Chronic Pain 
Pain medicine (Malden, Mass.)  2014;16(5):855-865.
Objective
The Department of Veterans Affairs (VA) uses the 11-point pain numeric rating scale (NRS) to gather pain intensity information from veterans at outpatient appointments. Yet, little is known about how NRS scores may vary over time within individuals; NRS variability may have important ramifications for treatment planning. Our main objective was to describe variability in NRS scores within a one-month timeframe, as obtained during routine outpatient care in older patients with chronic pain treated in VA hospitals. A secondary objective was to explore for patient characteristics associated with within-month NRS score variability.
Design
Retrospective cohort study.
Subjects
National sample of veterans 65 years or older seen in VA in 2010 who had multiple elevated NRS scores indicating chronic pain.
Methods
VA datasets were used to identify the sample and demographic and clinical variables including NRS scores. For the main analysis, we identified subjects with 2 or more NRS scores obtained in each of 2 or more months in a 12 month period; we examined ranges in NRS scores across the first 2 qualifying months.
Results
Among 4,336 individuals in the main analysis cohort, the mean and median of the average NRS score range across the two months were 2.7 and 2.5, respectively. In multivariable models, main significant predictors of within-month NRS score variability were baseline pain intensity, overall medical comorbidity, and being divorced/separated.
Conclusions
The majority of patients in the sample had clinically meaningful variation in pain scores within a given month. This finding highlights the need for clinicians and their patients to consider multiple NRS scores when making chronic pain treatment decisions.
doi:10.1111/pme.12643
PMCID: PMC4439348  PMID: 25545398
Chronic pain; Veterans; Numeric Rating Scale; Aged
5.  Correlates of prescription opioid initiation and long-term opioid use in veterans with persistent pain 
The Clinical journal of pain  2013;29(2):102-108.
Objectives
Little is known about how opioid prescriptions for chronic pain are initiated. We sought to describe patterns of prescription opioid initiation, identify correlates of opioid initiation, and examine correlates of receipt of chronic opioid therapy (COT) among veterans with persistent non-cancer pain.
Methods
Using Veterans Affairs (VA) administrative data, we identified 5,961 veterans from the Pacific Northwest with persistent elevated pain intensity scores who had not been prescribed opioids in the prior 12 months. We compared veterans not prescribed opioids over the subsequent 12 months to those prescribed any opioid and to those prescribed COT (≥90 consecutive days).
Results
During the study year, 34% of the sample received an opioid prescription, and 5% received COT. Most first opioid prescriptions were written by primary care clinicians. Veterans prescribed COT were younger, had greater pain intensity, and high rates of psychiatric and substance use disorders (SUDs) compared to veterans in the other two groups. Among patients receiving COT, 29% were prescribed long-acting opioids, 37% received one or more urine drug screens, and 24% were prescribed benzodiazepines. Adjusting for age, sex, and baseline pain intensity, major depression (OR 1.24 [1.10–1.39]; 1.48 [1.14–1.93]) and nicotine dependence (1.34 [1.17–1.53]; 2.02 [1.53–2.67]) were associated with receiving any opioid prescription and with COT, respectively.
Discussion
Opioid initiations are common among veterans with persistent pain, but most veterans are not prescribed opioids long-term. Psychiatric disorders and SUDs are associated with receiving COT. Many Veterans receiving COT are concurrently prescribed benzodiazepines and many do not receive urine drug screening; additional study regarding practices that optimize safety of COT in this population is indicated.
doi:10.1097/AJP.0b013e3182490bdb
PMCID: PMC3531630  PMID: 23269280
Chronic pain; Opioids; Veteran
6.  Collaborative care for pain results in both symptom improvement and sustained reduction of pain and depression 
General hospital psychiatry  2014;37(2):139-143.
Objective
Traditional analytic approaches may oversimplify the mechanisms by which interventions effect change. Transition probability models can quantify both symptom improvement and sustained reduction in symptoms. We sought to quantify transition probabilities between higher and lower states for four outcome variables, and to compare two treatment arms with respect to these transitions.
Method
Secondary analysis of a year-long collaborative care intervention for chronic musculoskeletal pain in veterans. Forty-two clinicians were randomized to intervention or treatment as usual (TAU), with 401 patients nested within clinician. The outcome variables, pain intensity, pain interference, depression, and disability scores, were dichotomized (lower/higher). Probabilities of symptom improvement (transitioning from higher to lower) or sustained reduction (remaining lower) were compared between intervention and TAU groups at 0–3, 3–6 and 6–12 month intervals. General estimating equations quantified the effect of the intervention on transitions.
Results
In adjusted models, the intervention group showed about 1.5 times greater odds of both symptom improvement and sustained reduction compared to TAU, for all the outcomes except disability.
Conclusions
Despite no formal relapse prevention program, intervention patients were more likely than TAU patients to experience continued relief from depression and pain. Collaborative care interventions may provide benefits beyond just symptom reduction.
doi:10.1016/j.genhosppsych.2014.11.007
PMCID: PMC4361309  PMID: 25554014
pain; collaborative; transition; remission; relapse
7.  Correlates of Suicide Among Veterans Treated in Primary Care: Case–Control Study of a Nationally Representative Sample 
Journal of General Internal Medicine  2014;29(Suppl 4):853-860.
ABSTRACT
BACKGROUND
Veterans receiving Veterans Affairs (VA) healthcare have increased suicide risk compared to the general population. Many patients see primary care clinicians prior to suicide. Yet little is known about the correlates of suicide among patients who receive primary care treatment prior to death.
OBJECTIVE
Our aim was to describe characteristics of veterans who received VA primary care in the 6 months prior to suicide; and to compare these to characteristics of control patients who also received VA primary care.
DESIGN
This was a retrospective case–control study.
SUBJECTS
The investigators partnered with VA operations leaders to obtain death certificate data from 11 states for veterans who died by suicide in 2009. Cases were matched 1:2 to controls based on age, sex, and clinician.
MAIN MEASURES
Demographic, diagnosis, and utilization data were obtained from VA’s Corporate Data Warehouse. Additional clinical and psychosocial context data were collected using manual medical record review. Multivariate conditional logistic regression was used to examine associations between potential predictor variables and suicide.
KEY RESULTS
Two hundred and sixty-nine veteran cases were matched to 538 controls. Average subject age was 63 years; 97 % were male. Rates of mental health conditions, functional decline, sleep disturbance, suicidal ideation, and psychosocial stressors were all significantly greater in cases compared to controls. In the final model describing men in the sample, non-white race (OR = 0.51; 95 % CI = 0.27–0.98) and VA service-connected disability (OR = 0.54; 95 % CI = 0.36–0.80) were associated with decreased odds of suicide, while anxiety disorder (OR = 3.52; 95 % CI = 1.79–6.92), functional decline (OR = 2.52; 95 % CI = 1.55–4.10), depression (OR = 1.82; 95 % CI = 1.07–3.10), and endorsement of suicidal ideation (OR = 2.27; 95 % CI = 1.07–4.83) were associated with greater odds of suicide.
CONCLUSIONS
Assessment for anxiety disorders and functional decline in addition to suicidal ideation and depression may be especially important for determining suicide risk in this population. Continued development of interventions that support identifying and addressing these conditions in primary care is indicated.
doi:10.1007/s11606-014-3028-1
PMCID: PMC4239287  PMID: 25355088
mental health; veterans; primary care; health services research
8.  Biopsychosocial Factors Associated with Pain in Veterans with the Hepatitis C Virus 
Journal of behavioral medicine  2013;37(5):902-911.
Background
Little research has examined etiological factors associated with pain in patients with the hepatitis C virus (HCV). The purpose of this study was to evaluate the relationship between biopsychosocial factors and pain among patients with HCV.
Methods
Patients with HCV and pain (n=119) completed self-report measures of pain, mental health functioning, pain-specific psychosocial variables (pain catastrophizing, self-efficacy for managing pain, social support), prescription opioid use, and demographic characteristics.
Results
In multivariate models, biopsychosocial factors accounted for 37% of the variance in pain severity and 56% of the variance in pain interference. In adjusted models, factors associated with pain severity include pain catastrophizing and social support, whereas variables associated with pain interference were age, pain intensity, prescription opioid use, and chronic pain self-efficacy (all p-values<0.05).
Conclusions
The results provide empirical support for incorporating the biopsychosocial model in evaluating and treating chronic pain in patients with HCV.
doi:10.1007/s10865-013-9549-y
PMCID: PMC4057993  PMID: 24338521
Chronic pain; Biopsychosocial model; Hepatitis C
9.  Systematic Review of the Literature on Pain in Patients with Polytrauma Including Traumatic Brain Injury 
Pain medicine (Malden, Mass.)  2009;10(7):1200-1217.
Objective
To review the literature addressing the assessment and management of pain in patients with polytraumatic injuries including traumatic brain injury (TBI) and blast-related headache, and to identify patient, clinician and systems factors associated with pain-related outcomes.
Design
Systematic review.
Methods
We conducted searches in MEDLINE of literature published from 1950 through July 2008. Due to a limited number of studies using controls or comparators, we included observational and rigorous qualitative studies. We systematically rated the quality of systematic reviews, cohort, and case-control design studies.
Results
One systematic review, 93 observational studies, and one qualitative research study met inclusion criteria. The literature search yielded no published studies that assessed measures of pain intensity or pain-related functional interference among patients with cognitive deficits due to TBI, that compared patients with blast-related headache with patients with other types of headache, or that assessed treatments for blast-related headache pain. Studies on the association between TBI severity and pain reported mixed findings. There was limited evidence that the following factors are associated with pain among TBI patients: severity, location, and multiplicity of injuries; insomnia; fatigue; depression; and post-traumatic stress disorder.
Conclusions
Very little evidence is currently available to guide pain assessment and treatment approaches in patients with polytrauma. Further research employing systematic observational as well as controlled intervention designs is clearly indicated.
doi:10.1111/j.1526-4637.2009.00721.x
PMCID: PMC2995299  PMID: 19818031
Pain; Multiple Trauma; Blast Injuries; Traumatic Brain Injury; Veterans
10.  Sex Differences in the Medical Care of VA Patients with Chronic Non-Cancer Pain 
Pain medicine (Malden, Mass.)  2013;14(12):10.1111/pme.12177.
Objective
Despite a growing number of women seeking medical care in the VA system, little is known about the characteristics of their chronic pain or the pain care they receive. This study sought to determine if sex differences are present in the medical care veterans received for chronic pain.
Design
Retrospective cohort study using VA administrative data.
Subjects
17,583 veteran patients with moderate to severe chronic non-cancer pain treated in the Pacific Northwest during 2008.
Methods
Multivariate logistic regression assessed for sex differences in primary care utilization, prescription of chronic opioid therapy, visits to emergency departments for a pain-related diagnosis, and physical therapy referral.
Results
Compared to male veterans, female veterans were more often diagnosed with two or more pain conditions and had more of the following pain-related diagnoses: fibromyalgia, low back pain, inflammatory bowel disease, migraine headache, neck or joint pain, and arthritis. After adjustment for demographic characteristics, pain diagnoses, mental health diagnoses, substance use disorders, and medical comorbidity, women had lower odds of being prescribed chronic opioid therapy (AOR 0.67, 95% CI 0.58–0.78), greater odds of visiting an emergency department for a pain-related complaint (AOR 1.40, 95% CI 1.18–1.65), and greater odds of receiving physical therapy (AOR 1.19, 95% CI 1.05–1.33). Primary care utilization was not significantly different between sexes.
Conclusions
Sex differences are present in the care female veterans receive for chronic pain. Further research is necessary to understand the etiology of the observed differences and their associations with clinical outcomes.
doi:10.1111/pme.12177
PMCID: PMC3866355  PMID: 23802846
Chronic pain; veteran women; sex differences; chronic opioid therapy
11.  Care management practices for chronic pain in veterans prescribed high doses of opioid medications 
Family Practice  2013;30(6):671-678.
Background.
There is growing interest in the primary care management of patients with chronic non-cancer pain (CNCP) who are prescribed long-term opioid therapy.
Objective.
The aim of this study was to examine the care management practices and medical utilization of patients prescribed high doses of opioids relative to patients prescribed traditional doses of opioids.
Methods.
We conducted a retrospective cohort study of veterans who had CNCP in 2008 and reviewed medical care for the prior 2 years. Patients with CNCP who were prescribed high-dose opioid therapy (≥180mg morphine equivalent per day for 90+ consecutive days; n = 60) were compared with patients prescribed traditional dose opioid therapy (5–179mg morphine equivalent per day for 90+ consecutive days; n = 60).
Results.
Patients in the high-dose group had several aspects of documented care that differed from patients in the traditional dose group, including more medical visits, attempting an opioid taper, receiving a urine drug screen and developing a pain goal. The majority of variables that were assessed did not differ between groups, including documented assessments of functional status or co-morbid psychopathology, opioid rotation, discussion of treatment side effects, non-pharmacological treatments or collaboration with mental health or pain specialists.
Conclusions.
Further work is needed to identify mechanisms for optimizing care management for patients with CNCP who are prescribed high doses of opioid medications.
doi:10.1093/fampra/cmt038
PMCID: PMC3896000  PMID: 23901065
Chronic pain; clinical treatment guidelines; high-dose opioids; opioids; primary care.
12.  Trust is the Basis for Effective Suicide Risk Screening and Assessment in Veterans 
Journal of General Internal Medicine  2013;28(9):1215-1221.
ABSTRACT
BACKGROUND
To reduce suicides among Veterans, the Department of Veterans Affairs (VA) has designated suicide risk assessments for Veterans who screen positive for depression or post-traumatic stress disorder as a national performance goal. Many VA Medical Centers (VAMCs) are using brief suicidal ideation screens, administered in non-mental health ambulatory care settings, as the first step in the assessment process.
OBJECTIVE
To explore Veterans’ perceptions of the suicide screening and risk assessment process, the barriers and facilitators to disclosing suicidal thoughts, and perceptions of possible consequences of revealing suicidal thoughts.
DESIGN
Investigators recorded one semi-structured interview with each Veteran. Transcripts were analyzed using a modified grounded theory approach.
PARTICIPANTS
Thirty-four Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans who screened positive for suicidal ideation in non-mental health ambulatory care settings in 2009 and 2010.
KEY RESULTS
Veterans accepted the need to assess suicide risk. They increasingly experienced attempts to suppress and avoid thoughts of suicide as burdensome and exhausting. Despite this, Veterans often failed to disclose severe and pervasive suicidal thoughts when screened because: (1) they considered suicidal thoughts as shameful and a sign of weakness; (2) they believed suicidal thoughts were private and not to be divulged to strangers; (3) they worried that disclosure would lead to unwanted hospitalization or medication recommendations; and (4) the templated computer reminder process was perceived as perfunctory and disrespectful. In contrast, admitting and discussing thoughts of suicide with a health provider who focused on building a relationship, demonstrated genuineness and empathy, offered information on the rationale for suicide risk assessment, and used straightforward and understandable language, all promoted trust that resulted in more honest disclosure of suicidal thoughts.
CONCLUSION
In ambulatory care settings, both provider behaviors and system modifications may lead to more honest disclosure of suicidal thoughts.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-013-2412-6) contains supplementary material, which is available to authorized users.
doi:10.1007/s11606-013-2412-6
PMCID: PMC3744302  PMID: 23580131
depression; post-traumatic stress disorder; qualitative methods; screening; suicide; veterans
13.  Patterns of Care and Side Effects for Patients Prescribed Methadone for Treatment of Chronic Pain 
Journal of opioid management  2013;9(5):325-333.
Objectives
This manuscript evaluates physician monitoring practices and incidence of cardiac side effects following initiation of methadone for treatment of chronic pain as compared to patients who began treatment for chronic pain with morphine sustained release (SR).
Design
We retrospectively reviewed medical record data on all new initiations of methadone and compared results of physician monitoring practices to patients with new initiations of morphine SR. A standardized chart tool was used to capture clinical data. Data related to health service utilization and clinical diagnoses were obtained from the VA clinical information system.
Setting
A single VA medical center in the Pacific Northwest.
Patients
Chronic pain patients prescribed methadone (n=92) or morphine (n=90) in the calendar year 2008.
Results
There was no difference between patients prescribed methadone versus patients prescribed morphine SR in the likelihood of receiving an electrocardiogram (ECG) prior to initiating medication (53% versus 54%) or in the year after opioid initiation (37% versus 40%). The two groups also did not differ in rates of developing prolonged QTc intervals (>450 ms) (11% versus 17%). Seventy-two percent of all patients discontinued their long-acting opioid regimens before 90 days due to adverse effects or insufficient pain relief.
Conclusion
Despite recommendations for standardized assessment and cardiac risk monitoring, few patients prescribed methadone received an ECG, and this occurred at a rate that did not differ from patients prescribed morphine SR. Patients discontinued both medications at high rates. Further research is needed to evaluate the clinical significance of QTc prolongation in patients treated with methadone.
doi:10.5055/jom.2013.0175
PMCID: PMC4001870  PMID: 24353045
Chronic pain; Opioids; Veteran; Pain/drug therapy; Methadone; QTc prolongation; ECG; medication side effects
14.  Prescription Opioids for Back Pain and Use of Medications for Erectile Dysfunction 
Spine  2013;38(11):909-915.
Study Design
Cross-sectional analysis of electronic medical and pharmacy records.
Objective
To examine associations between use of medication for erectile dysfunction or testosterone replacement and use of opioid therapy, patient age, depression, and smoking status
Summary of Background Data
Men with chronic pain may experience erectile dysfunction related to depression, smoking, age, or opioid-related hypogonadism. The prevalence of this problem in back pain populations and the relative importance of several risk factors are unknown.
Methods
We examined electronic pharmacy and medical records for men with back pain in a large group model HMO during 2004. Relevant prescriptions were considered for six months before and after the index visit.
Results
There were 11,327 men with a diagnosis of back pain. Men who received medications for erectile dysfunction or testosterone replacement (n = 909) were significantly older than those who did not, and had greater comorbidity, depression, smoking, and use of sedative-hypnotic medications. In logistic regressions, long-term opioid use was associated with greater use of medications for erectile dysfunction or testosterone replacement, compared to patients with no opioid use (OR 1.45, 95% CI 1.12, 1.87, p<0.01). Age, comorbidity, depression, and use of sedative-hypnotics were also independently associated with use of medications for erectile dysfunction or testosterone replacement. Patients prescribed daily opioid doses of 120 mg morphine-equivalent or more had greater use of medication for erectile dysfunction or testosterone replacement than patients without opioid use (OR 1.58, 95% CI 1.03, 2.43), even with adjustment for duration of opioid therapy.
Conclusion
Opioid dose and duration, as well as age, comorbidity, depression, and use of sedative-hypnotics were associated with evidence of erectile dysfunction. These findings may be important in the process of decision-making for long-term opioid use.
doi:10.1097/BRS.0b013e3182830482
PMCID: PMC3651746  PMID: 23459134
opioids; low back pain; erectile dysfunction; sexual dysfunction
15.  The Relationship between PTSD and Chronic Pain: Mediating Role of Coping Strategies and Depression 
Pain  2013;154(4):609-616.
People with chronic pain and comorbid posttraumatic stress disorder (PTSD) report more severe pain and poorer quality of life than those with chronic pain alone. This study evaluated the extent to which associations between PTSD and chronic pain interference and severity are mediated by pain-related coping strategies and depressive symptoms. Veterans with chronic pain were divided into two groups, those with (n=65) and those without (n=136) concurrent PTSD. All participants completed measures of pain severity, interference, emotional functioning, and coping strategies. Those with current PTSD reported significantly greater pain severity and pain interference, had more symptoms of depression, and were more likely to meet diagnostic criteria for a current alcohol or substance use disorder (all p-values ≤ 0.01). Participants with PTSD reported more use of several coping strategies, including guarding, resting, relaxation, exercise/stretching, and coping self-statements. Illness-focused pain coping (i.e., guarding, resting, and asking for assistance) and depressive symptoms jointly mediated the relationship between PTSD and both pain interference (total indirect effect = 0.194, p < 0.001) and pain severity (total indirect effect = 0.153, p = 0.004). Illness-focused pain coping also evidenced specific mediating effects, independent of depression. In summary, specific pain coping strategies and depressive symptoms partially mediated the relationship between PTSD and both pain interference and severity. Future research should examine whether changes in types of coping strategies following targeted treatments predict improvements in pain-related function for chronic pain patients with concurrent PTSD.
doi:10.1016/j.pain.2013.01.001
PMCID: PMC3609886  PMID: 23398939
16.  Risk for Prescription Opioid Misuse among Patients with a History of Substance Use Disorder 
Drug and alcohol dependence  2012;127(1-3):193-199.
BACKGROUND
History of substance use disorder (SUD) is associated with risk for prescription opioid misuse in chronic pain patients; however, little data are available regarding risk for prescription opioid misuse within the subgroup of patients with SUD histories.
METHODS
Participants with chronic pain, histories of SUD, and current opioid prescriptions were recruited from a single VA Medical Center. Participants (n=80) completed measures of risk for prescription opioid misuse, pain severity, pain-related interference, pain catastrophizing, attitudes about managing pain, emotional functioning, and substance abuse.
RESULTS
Participants were divided into three groups based on risk for prescription opioid misuse, as assessed by the Pain Medication Questionnaire (PMQ). Participants in the High-PMQ group reported more pain severity, interference, catastrophizing, depressive symptoms, and lowest self-efficacy for managing pain, relative to the Low-PMQ group; the High-PMQ group and Moderate-PMQ group differed on measures of pain severity, catastrophizing, and psychiatric symptoms (all p-values <0.05). The High-PMQ group had the highest rates of current SUD (32% versus 20% and 0, p=0.009). A regression analysis evaluated factors associated with PMQ scores: pain catastrophizing was the only variable significantly associated with risk for prescription opioid misuse.
CONCLUSIONS
Among patients with SUD histories, those with higher risk for prescription opioid misuse reported more pain and impairment, symptoms of depression, and were more likely to have current SUD, relative to patients with lower risk for prescription opioid misuse. In adjusted analyses, pain catastrophizing was significantly associated with risk for prescription opioid misuse, but current SUD status was not a significant predictor.
doi:10.1016/j.drugalcdep.2012.06.032
PMCID: PMC3484237  PMID: 22818513
Prescription opioid misuse; Chronic pain; Substance use disorder; Aberrant medication-related behaviors; Quality of life
17.  Opioids for Back Pain Patients: Primary Care Prescribing Patterns and Use of Services 
Journal of the American Board of Family Medicine : JABFM  2011;24(6):10.3122/jabfm.2011.06.100232.
Background
Opioid prescribing for non-cancer pain has increased dramatically. We examined whether the prevalence of unhealthy lifestyles, psychological distress, healthcare utilization, and co-prescribing of sedative-hypnotics increased with increasing duration of prescription opioid use.
Methods
We analyzed electronic data for 6 months before and after an index visit for back pain in a large managed care plan. Use of opioids was characterized as “none”, “acute” (≤ 90 days), “episodic”, or “long-term.” Associations with lifestyle factors, psychological distress, and utilization were adjusted for demographics and comorbidity.
Results
There were 26,014 eligible patients. Among these, 61% received a course of opioid therapy, and 19% were long-term users. Psychological distress, unhealthy lifestyles, and utilization were associated in stepwise fashion with duration of opioid prescribing, not just with chronic use. Among long-term opioid users, 59% received only short-acting drugs; 39% received both long and short acting drugs; 44% received a sedative-hypnotic. Of those with any opioid use, 36% had an emergency visit.
Conclusions
Opioid prescribing was common among patients with back pain. The prevalence of psychological distress, unhealthy lifestyles, and healthcare utilization increased incrementally with duration of opioid use. Despite safety concerns, co-prescribing of sedative-hypnotics was common. These data may help in predicting long-term opioid use and improving the safety of opioid prescribing.
doi:10.3122/jabfm.2011.06.100232
PMCID: PMC3855548  PMID: 22086815
18.  Chronic Pain Treatment and Health Service Utilization of Veterans with Hepatitis C Virus Infection 
Pain medicine (Malden, Mass.)  2012;13(11):1407-1416.
Objectives
Hepatitis C virus (HCV) infection is estimated to affect 2% of the general U.S. population and chronic pain is a common comorbidity among persons with HCV. The primary purpose of this study was to compare health service utilization of U.S. military veterans with HCV with and without the presence of comorbid chronic pain.
Design
Cross-sectional study with retrospective review of patient medical records.
Patients
One hundred seventy-one U.S. military veterans with confirmed HCV, recruited through a single U.S. Veterans Administration hospital.
Outcome Measures
Medical service utilization data from the past five years were extracted from participants’ electronic medical records.
Results
Sixty-four percent of veterans with HCV (n = 110) had chronic pain. Veterans with HCV and chronic pain utilized more health services including total inpatient stays (OR = 2.58 [1.46, 4.56]) and days hospitalized for psychiatric services (OR = 5.50 [3.37, 8.99]), compared to participants with HCV and no chronic pain, after statistically adjusting for demographic, psychiatric, substance use, medical comorbidity, and disability covariates. In addition, those with HCV and chronic pain had more total outpatient visits with primary care providers (OR = 1.73 [1.15, 2.59]), physical therapists (OR = 9.57 [4.79, 19.11]), and occupational therapists (OR = 2.72 [1.00, 7.48]).
Conclusions
Patients with HCV and chronic pain utilize medical services to a greater extent than patients with HCV but no chronic pain. Future studies that examine the efficacy of both pharmacological and nonpharmacological pain treatment for patients with comorbid HCV and chronic pain appear warranted.
doi:10.1111/j.1526-4637.2012.01476.x
PMCID: PMC3501572  PMID: 22958315
Hepatitis C; Chronic Pain; Veterans; Health Service Utilization
19.  Patterns and Correlates of Prescription Opioid Use in OEF/OIF Veterans with Chronic Non-Cancer Pain 
Pain medicine (Malden, Mass.)  2011;12(10):1502-1509.
Objectives
Little is known about the treatment Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans receive for chronic non-cancer pain (CNCP). We sought to describe the prevalence of prescription opioid use, types and doses of opioids received, and identify correlates of receiving prescription opioids for CNCP among OEF/OIF veterans.
Design
Retrospective review of VA administrative data.
Setting
Ambulatory clinics within a VA regional healthcare network.
Patients
OEF/OIF veterans who had at least 3 elevated pain screening scores within a 12-month period in 2008. Within this group, those prescribed opioids (n=485) over the next 12 months were compared to those not prescribed opioids (n=277). In addition, patients receiving opioids short term (<90 days, n=284) were compared to patients receiving them long-term (≥90 consecutive days, n=201).
Results
Of 762 OEF/OIF veterans with CNCP, 64% were prescribed at least one opioid medication over the 12 months following their index dates. Of those prescribed an opioid, 59% were prescribed opioids short-term and 41% were prescribed opioids long-term. The average morphine-equivalent opioid dose for short-term users was 23.7 mg (SD=20.5) compared with 40.8 mg (SD=36.1) for long-term users (p<0.001). Fifty-one percent of long-term opioid users were prescribed short-acting opioids only and one-third were also prescribed sedative-hypnotics. In adjusted analyses, diagnoses of low back pain, migraine headache, post-traumatic stress disorder, and nicotine use disorder were associated with an increased likelihood of receiving an opioid prescription.
Conclusion
Prescription opioid use is common among OEF/OIF veterans with CNCP and is associated with several pain diagnoses and medical conditions.
doi:10.1111/j.1526-4637.2011.01226.x
PMCID: PMC3724513  PMID: 21899715
Chronic pain; Opioids; Veteran; Pain/drug therapy
20.  Smoking Cigarettes as a Coping Strategy for Chronic Pain is Associated with Greater Pain Intensity and Poorer Pain-Related Function 
The Journal of Pain  2012;13(3):285-292.
Smoking cigarettes is prevalent among individuals with chronic pain. Some studies indicate nicotine reduces pain and others suggest it may cause or exacerbate pain. Participants in this cross-sectional study were 151 chronic pain patients from a large, urban VA medical center. Patients were divided into 3 groups: (1) non-smokers, (2) smokers who deny using cigarettes to cope with pain, and (3) smokers who report using cigarettes to cope with pain. Patients who reported smoking as a coping strategy for chronic pain scored significantly worse compared to the other 2 groups on the majority of measures of pain-related outcome. Non-smokers and smokers who denied smoking to cope did not differ on any variable examined. After controlling for the effects of demographic and clinical factors, smoking cigarettes as a coping strategy for pain was significantly and positively associated with pain intensity (p=0.04), pain interference (p=0.005), and fear of pain (p=0.04). In addition to the assessment of general smoking status, a more specific assessment of the chronic pain patient’s reasons for smoking may be an important consideration as part of interdisciplinary pain treatment.
doi:10.1016/j.jpain.2011.11.008
PMCID: PMC3293999  PMID: 22325299
Smoking; Cigarettes; Chronic Pain; Coping
21.  Adherence to Clinical Guidelines for Opioid Therapy for Chronic Pain in Patients with Substance Use Disorder 
BACKGROUND
Patients with chronic non-cancer pain (CNCP) have high rates of substance use disorders (SUD). SUD complicates pain treatment and may lead to worse outcomes. However, little information is available describing adherence to opioid treatment guidelines for CNCP generally, or guideline adherence for patients with comorbid SUD.
OBJECTIVE
Examine adherence to clinical guidelines for opioid therapy over 12 months, comparing patients with SUD diagnoses made during the prior year to patients without SUD.
DESIGN
Cohort study.
PARTICIPANTS
Administrative data were collected from veterans with CNCP receiving treatment within a Veterans Affairs regional healthcare network who were prescribed chronic opioid therapy in 2008 (n = 5814).
KEY RESULTS
Twenty percent of CNCP patients prescribed chronic opioid therapy had a prior-year diagnosis of SUD. Patients with SUD were more likely to have pain diagnoses and psychiatric comorbidities. In adjusted analyses, patients with SUD were more likely than those without SUD to have had a mental health appointment (29.7% versus 17.2%, OR = 1.49, 95% CI = 1.26–1.77) and a urine drug screen (UDS) (47.0% versus 18.2%, OR = 3.53, 95% CI = 3.06–4.06) over 12 months. There were no significant differences between groups on receiving more intensive treatment in primary care (63.4% versus 61.0%), long-acting opioids (26.9% versus 26.0%), prescriptions for antidepressants (88.2% versus 85.8%, among patients with depression), or participating in physical therapy (30.6% versus 28.6%). Only 35% of patients with SUD received substance abuse treatment.
CONCLUSIONS
CNCP patients with SUD were more likely to have mental health appointments and receive UDS monitoring, but not more likely to participate in other aspects of pain care compared to those without SUD. Given data suggesting patients with comorbid SUD may need more intensive treatment to achieve improvements in pain-related function, SUD patients may be at high risk for poor outcomes.
doi:10.1007/s11606-011-1734-5
PMCID: PMC3157527  PMID: 21562923
chronic pain; substance use disorder; opioids; treatment guidelines; medical utilization
22.  Association between Substance Use Disorder Status and Pain-Related Function Following 12 Months of Treatment in Primary Care Patients with Musculoskeletal Pain 
The goal of this study was to examine relationships between substance use disorder (SUD) history and 12-month outcomes among primary care patients with chronic noncancer pain (CNCP). Patients were enrolled in a randomized trial of collaborative care intervention (CCI) versus treatment-as-usual (TAU) to improve pain-related physical and emotional function. At baseline, 72 of 362 patients (20.0%) had a history of SUD. Compared to CNCP patients without SUD, those with comorbid SUD had poorer pain-related function and were more likely to meet criteria for current major depression and posttraumatic stress disorder (all p-values<0.05). Logistic regression analyses were conducted to examine whether SUD status was associated with clinically significant change over 12 months in pain-related function (30% reduction in Roland Morris Disability Questionnaire Score). The overall model was not significant in the CCI group. However, within the TAU group, participants with a SUD history were significantly less likely to show improvements in pain-related function (OR=0.30, 95% CI=0.11–0.82). CNCP patients with comorbid SUD reported greater functional impairment at baseline. Patients with SUD who received usual care were 70% less likely to have clinically significant improvements in pain-related function 12 months post-baseline, and SUD status did not impede improvement for the CCI group.
Perspective
Chronic non-cancer pain patients with a history of a substance use disorder (SUD) report poorer pain-related functioning and are less likely to experience clinically significant improvements from usual pain treatment. Providers should assess for SUD status and provide more intensive interventions for these patients.
doi:10.1016/j.jpain.2010.07.010
PMCID: PMC3008310  PMID: 20851057
Chronic pain; Substance use disorder; Pain functioning; Treatment; Collaborative care intervention
23.  Systematic Review of Prevalence, Correlates, and Treatment Outcomes for Chronic Non-Cancer Pain in Patients with Comorbid Substance Use Disorder 
Pain  2010;152(3):488-497.
Summary
Co-occurring substance use disorders (SUDs) are common among chronic pain patients. However, limited data are available to guide treatment for chronic pain patients with SUD.
Recent data suggest that comorbid substance use disorders (SUDs) are common among chronic non-cancer pain (CNCP) patients; however, prevalence rates vary across studies and findings are limited regarding treatment options for CNCP patients with comorbid SUD. The purpose of this systematic review is to assess the prevalence, associated demographic and clinical characteristics, and treatment outcomes for CNCP patients with comorbid SUD. We conducted searches from Ovid MEDLINE, PsychINFO, and PubMED from 1950 through February 2010 and retrieved the references. Thirty-eight studies met inclusion criteria and provided data that addressed our key questions. Three to forty-eight percent of CNCP patients have a current SUD. There are no demographic or clinical factors that consistently differentiate CNCP patients with comorbid SUD from patients without SUD, though SUD patients appear to be at greater risk for aberrant medication-related behaviors. CNCP patients with SUD are more likely to be prescribed opioid medications and at higher doses than CNCP patients without a history of SUD. CNCP patients with comorbid SUD do not significantly differ in their responses to treatment compared to CNCP patients without SUD, though the quality of this evidence is low. Limited data are available to identify predictors of treatment outcome. Although clinical experience and research suggests that SUDs are common among CNCP patients, only limited data are available to guide clinicians who treat this population. Research is needed to increase understanding of the prevalence, correlates, and responses to treatment of CNCP patients with comorbid SUDs.
doi:10.1016/j.pain.2010.10.009
PMCID: PMC3053013  PMID: 21185119
Chronic pain; Substance use disorder; Treatment outcomes; Opioids; Systematic review; Quality of life
24.  Clinical Characteristics of Veterans Prescribed High Doses of Opioid Medications for Chronic Non-Cancer Pain 
Pain  2010;151(3):625-632.
Little is known about patients prescribed high doses of opioids to treat chronic non-cancer pain, though these patients may be at higher risk for medication-related complications. We describe the prevalence of high-dose opioid use and associated demographic and clinical characteristics among veterans treated in a VA regional healthcare network. Veterans with chronic non-cancer pain prescribed high doses of opioids (>=180 mg/day morphine equivalent; n=478) for 90+ consecutive days were compared to two groups with chronic pain: Traditional-dose (5–179 mg/day; n=500) or no opioid (n=500). High-dose opioid use occurred in 2.4% of all chronic pain patients and in 3.4% of all chronic pain patients prescribed opioids long-term. The average dose in the high-dose group was 324.9 (SD=285.1) mg/day. The only significant demographic difference among groups was race (p=0.03) with black veterans less likely to receive high doses. High-dose patients were more likely to have four or more pain diagnoses and the highest rates of medical, psychiatric, and substance use disorders. After controlling for demographic factors and VA facility, neuropathy, low back pain, and nicotine dependence diagnoses were associated with increased likelihood of high-dose prescriptions. High-dose patients frequently did not receive care consistent with treatment guidelines: there was frequent use of short-acting opioids, urine drug screens were administered to only 40.8% of patients in the prior year, and 32.0% received concurrent benzodiazepine prescriptions, which may increase risk for overdose and death. Further study is needed to identify better predictors of high-dose usage, as well as the efficacy and safety of such dosing.
doi:10.1016/j.pain.2010.08.002
PMCID: PMC2972371  PMID: 20801580
Chronic pain; Opioids; Epidemiology; Quality of life; Pain/drug therapy

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