Pain In Veterans Research Articles

Suicide Attempts in US Veterans with Chronic Headache Disorders: A 10-Year Retrospective Cohort Study.

ObjectivesA large-scale retrospective analysis of veterans with chronic pain was conducted to examine (1) the annual incidence of suicide attempts (SA) in veterans with chronic headache and other chronic pain conditions, and (2) the risk of SA in men and women with chronic headache and chronic headache concurrent with traumatic brain injury (TBI) as compared to non-headache chronic pain.MethodsThis retrospective study (N=3,247,621) analyzed National Veterans Affair Health Administrative data of patients diagnosed with chronic head, neck, back and other chronic pain from 2000 to 2010. Multivariable Poisson regression was used to explore the relative risks of SA in veterans with chronic headache and chronic headache concurrent with TBI as stratified by sex.ResultsVeterans with chronic headaches had the highest annual incidence of SA (329 to 491 per 100,000) each year among all identified types of chronic pain conditions. Compared to other non-headache chronic pain, chronic headache is associated with increased risk of SA [men RR (1.48), CI (1.37,1.59); women RR (1.64), CI (1.28,2.09)], after adjusting for demographic factors, TBI, and psychiatric comorbidities. The risk increased further when chronic headache is comorbid with TBI [men RR (2.82), CI (2.60, 3.05); women RR (2.16, CI (1.67–2.78)].ConclusionVeterans with chronic headache have a higher risk of SA than those with other chronic pain and women with chronic headache are at a higher risk than men with chronic headache. Chronic headache concurrent with TBI further heightened this risk, especially in men. Our data underscore the importance of identifying specific types of chronic pain in veterans with comorbid TBI and sex disparity associated with SA when targeting suicide prevention measures.

Pain in Veterans with COPD: relationship with physical activity and exercise capacity

BackgroundPain is a common but underappreciated symptom experienced by people with Chronic Obstructive Pulmonary Disease (COPD). The relationships between pain and physical activity (PA) and exercise capacity are poorly understood.MethodsThis retrospective secondary analysis includes three cohorts of Veterans with COPD who participated in longitudinal studies evaluating PA and exercise capacity with objective measures of daily step counts and 6-min walk test (6MWT) distance, respectively. Pain was assessed using the bodily pain domain of the Veterans RAND-36. In two cohorts, participants were randomly assigned to a web-based, pedometer-mediated PA intervention which has previously been demonstrated to improve PA.ResultsThree-hundred and seventy-three (373) unique study participants were included in this analysis. Eighty-three percent (n = 311) of the population reported at least mild pain and/or at least a little bit of interference due to pain at baseline. Cross-sectionally, greater bodily pain was associated with lower 6MWT distance (β = 0.51; 95% CI 0.20, 0.82; p = 0.0013). Longitudinally, worsening bodily pain was associated with a decline in 6MWT distance (β = 0.30; 95% CI 0.03, 0.58; p = 0.0312). There was no association between baseline bodily pain and baseline daily step counts, baseline bodily pain and change in PA, or change in bodily pain and change in PA. Compared to usual care, our PA intervention improved bodily pain scores (β = 6.17; 95% CI 1.84, 10.45; p = 0.0054). Bodily pain scores did not affect the impact of the intervention on daily step counts.ConclusionPain is highly prevalent and significantly associated with lower exercise capacity among Veterans with COPD. Worsening pain co-occurred with decline in exercise capacity but not PA. Our intervention reduced pain, although pain did not affect the impact of the intervention on PA.

Co-occurrence of pain and dyspnea in Veterans with COPD:Relationship to functional status and a pilot study of neural correlatesusing structural and functional magnetic resonance imaging.

Persons with COPD experience co-occurring dyspnea and pain. Little is known about the relationship between symptom co-occurrence with physical activity (PA) and exercise. Novel diagnostic tools are needed for accurate symptom discrimination. In this secondary analysis, we examined relationships between baseline assessments of pain, dyspnea, objectively measured PA, and exercise capacity in persons with COPD who previously enrolled in three PA studies. Pain was assessed with the bodily pain domain of the Veterans RAND-36 (VR-36), and dyspnea with the modified Medical Research Council (mMRC) scale. Average daily step count was assessed with the Omron HJ-720ITC or FitBit Zip pedometer, and exercise capacity with 6-minute walk test (6MWT). We also conducted a pilot neuroimaging study. Neuroimaging data were acquired on a Siemens 3-Tesla Magnetom Prismafit whole-body scanner. Analysis of variance assessed trends in daily step count and 6MWT distance across categories of co-occurring pain and dyspnea. General linear models examined relationships between cortical thickness and resting state functional connectivity (fc) with symptoms and functional status. In 373 Veterans, 98% were male with mean age 70.5± 8.3 years and FEV1% predicted 59 ± 21%. Compared to those with no co-occurrence of pain and dyspnea, those with co-occurrence walked 1,291–1,444 fewer steps per day and had an 80–85 m lower 6MWT distance. Ten males participated in the pilot neuroimaging study. Predominant findings were that lower cortical thickness and greater fc were associated with higher pain and dyspnea, p<0.05. Greater cortical thickness and lower fc were associated with higher daily step count and 6MWT distance, p<0.05. Regional patterns of associations differed for pain and dyspnea, suggesting that cortical thickness and fc may discriminate symptoms. Co-occurring dyspnea and pain in COPD are associated with significant reductions in PA and exercise capacity. It may be feasible for neuroimaging markers to discriminate between pain and dyspnea.

The Prevalence and Impact of Back and Neck Pain in Veterans With Upper Limb Amputation.

The aims of the study were (1) to describe frequency of back pain only, neck pain only, and co-occurring pain in veterans with upper limb amputation, (2) to examine changes in pain over 1 yr, and (3) to quantify the association of pain and health-related quality of life and disability. This is an observational cohort study with a survey of a sample of 792 veterans with upper limb amputation, with 1-yr reassessment of 585 (85.3%) of 777 eligible participants. Pain prevalence and intensity were examined. Logistic and linear regressions identified variables associated with pain and examined associations between intensity and veterans RAND-12 mental component score and physical component score and QuickDASH. At baseline, 52.3% had co-occurring pain, 20.0% had back pain, and 8.3% had neck pain. Persistent back and neck pain is present in 60.8% and 48.1% respondents, respectively. Pain intensity was unchanged for 59.1% with back pain and 61.3% with neck pain. Mental component score and QuickDASH were significantly worse with severe and moderate back and neck pain, compared with no pain. Severe/moderate back pain intensity was associated with lower physical component score. Back and neck pain is highly prevalent and persistent in veterans with upper limb amputation. Pain intensity is negatively associated with health-related quality of life and disability. Pain prevention and intervention are needed in this population.

Vagal nerve stimulation as a possible non-invasive treatment for chronic widespread pain in Gulf Veterans with Gulf War Illness

AimsWidespread pain and headache are common in Gulf War Illness with suboptimal treatments available. We tested the efficacy of non-invasive, transcutaneous vagal nerve stimulation (nVNS) for relief of widespread pain and migraine in Gulf War Veterans with GWI. Main methodsA 10-week double-blind, randomized controlled trial of nVNS used the gammaCore (ElectroCore, Inc.) compared to sham stimulation with the same device followed by a 10-week open-label follow up with active nVNS. The primary outcome was a numerical pain rating at the end of the blinded period. Secondary outcomes included physical function, migraine frequency and severity, and impression of change during the blinded and open-label periods. Two-factor MANOVA models tested for significant differences between groups from baseline to end of the blinded period and during the open-label period. Key findingsAmong 27 participants enrolled and issued a nVNS device, there was a slight improvement in pain ratings from baseline to the end of the blinded phase [6.18 (±0.82) vs. 5.05 (±2.3); p = 0.040] which did not differ between active and sham nVNS. Physical function was also slightly improved overall without group differences. There were no significant changes in migraine frequency or severity during the blinded period. Twenty participants started in the open-label phase; no statistically significant changes in pain, physical function, migraine measures, or impression of change were noted during this phase. SignificanceVeterans with GWI actively treated with nVNS reported no improvement in either widespread pain or migraine frequency or severity relative to Veterans with GWI who received sham nVNS.

The acceptability and feasibility of screening, brief intervention, and referral to treatment for pain management among new England veterans with chronic pain: A pilot study.

Musculoskeletal disorders often lead to chronic pain in Veterans. Chronic pain puts sufferers at risk for substance misuse, and early intervention is needed for both conditions. This pilot study tested the feasibility and acceptability of a Screening, Brief Intervention, and Referral to Treatment for Pain Management intervention (SBIRT-PM) to help engage Veterans seeking disability compensation for painful musculoskeletal disorders in multimodal pain treatment and to reduce risky substance use, when indicated. This pilot study enrolled 40 Veterans from 8 medical centers across New England in up to 4 sessions of telephone-based counseling using a motivational interviewing framework. Counseling provided education about, and facilitated engagement in, multimodal pain treatments. Study eligibility required Veterans be engaged in no more than 2 Veteran Affairs (VA) pain treatment modalities, and study participation involved a 12-week postassessment and semistructured interview about the counseling process. Majorities of enrolled Veterans screened positive for comorbid depression and problematic substance use. Regarding the offered counseling, 80% of participants engaged in at least one session, with a mean of 3 sessions completed. Ninety percent of participants completed the postassessment. Numerically, most measures improved slightly from baseline to week 12. In semistructured interviews, participants described satisfaction with learning about new pain care services, obtaining assistance connecting to services, and receiving support from their counselors. It was feasible to deliver SBIRT-PM to Veterans across New England to promote engagement in multimodal pain treatment and to track study outcomes over 12weeks. Preliminary results suggest SBIRT-PM was well-received and has promise for the targeted outcomes.

Possible effects of agent orange and posttraumatic stress disorder on hyperglycemia in Korean veterans from the US-Vietnam war.

This study was conducted to examine whether Korean veterans from the US-Vietnam War who had a diagnosis of type II diabetes mellitus (T2DM) as well as past history of exposure to agent orange (AO) are vulnerable to hyperglycemia when receiving intra-articular corticosteroid injection (IACI) for pain relief.The current study included a total of 49 patients (n = 49) who received an injection of triamcinolone 20 or 40 mg to the shoulder under sonographic guidance or did that of dexamethasone 10 mg or triamcinolone 40 mg combined with dexamethasone 20 mg to the spine under fluoroscopic guidance. Their 7-day fasting blood glucose (FBG) levels were measured and then averaged, serving as baseline levels. This is followed by measurement of FBG levels for 14 days of IACI. Respective measurements were compared with baseline levels. The patients were also evaluated for whether there are increases in FBG levels depending on insulin therapy as well as HbA1c ≥ 7% or HbA1c < 7%.Overall, there were significant increases in FBG levels by 64.7 ± 42.5 mg/dL at 1 day of IACI from baseline (P < .05). HbA1c ≥ 7% and HbA1c < 7% showed increases in FBG levels by 106.1 ± 49.0 mg/dL and 46.5 ± 3.8 mg/dL, respectively, at 1 day of IACI from baseline (P < .05). In the presence and absence of insulin therapy, there were significant increases in them by 122.6 ± 48.7 mg/dL and 48.0 ± 20.4 mg/dL, respectively, at 1 day of IACI from baseline (P < .05). But there were decreases in them to baseline levels at 2 days of IACI.Clinicians should consider the possibility of hyperglycemia when using corticosteroids for relief of musculoskeletal pain in Korean veterans from the US-Vietnam War who had a history of exposure to AO.

Brainstem damage is associated with poorer sleep quality and increased pain in gulf war illness veterans

AimsGulf War Illness (GWI) is manifested as multiple chronic symptoms, including chronic pain, chronic fatigue, sleep problems, neuropsychiatric disorders, respiratory, gastrointestinal, and skin problems. No single target tissue or unifying pathogenic process has been identified that accounts for this variety of symptoms. The brainstem has been suspected to contribute to this multiple symptomatology. The aim of this study was to assess the role of the brainstem in chronic sleep problems and pain in GWI veterans. Materials and methodsWe enrolled 90 veterans (Age = 50 ± 5, 87% Male) who were deployed to the 1990–91 Gulf War and presented with GWI symptoms. Sleep quality was evaluated using the global Pittsburgh Sleep Quality Index. Pain intensities were obtained with the Brief Pain Inventory sum score. Volumes in cortical, subcortical, brainstem, and brainstem subregions and diffusion tensor metrics in 10 bilateral brainstem tracts were tested for correlations with symptom measures. Key findingsPoorer sleep quality was significantly correlated with atrophy of the whole brainstem and brainstem subregions (including midbrain, pons, medulla). Poorer sleep quality also significantly correlated with lower fractional anisotropy in the nigrostriatal tract, medial forebrain tract, and the dorsal longitudinal fasciculus. There was a significant correlation between increased pain intensity and decreased fractional anisotropy in the dorsal longitudinal fasciculus. These correlations were not altered after controlling for age, sex, total intracranial volumes, or additional factors, e.g., depression and neurological conditions. SignificanceThese findings suggest that the brainstem plays an important role in the aberrant neuromodulation of sleep and pain symptoms in GWI.

The Impact of a Music Video on Procedural Pain and State Anxiety

PurposePatients with chronic pain and/or spasticity who have an intrathecal targeted drug delivery (TDD) pump require frequent needle access procedures to refill the pump's medication reservoir. Some patients find the access procedure painful and/or anxiety provoking. The purpose of this study was to determine if a nursing intervention of providing a distraction with a music relaxation video during the pump access procedure would reduce patients’ pain and state anxiety. Design/MethodsIn this longitudinal, pre-test post-test, quasi-experimental design, patients watched a 13-minute calming music video while the nurse performed the needle access procedure. Data collection instruments included a combination of researcher-developed questionnaires, the Defense & Veterans Pain Rating Scale (DVPRS), and the State Trait Anxiety Inventory (STAI). Pain and anxiety were measured pre- and post-pump refill procedures at baseline with no intervention (T1) and at two subsequent pump refills with the music video intervention (T2 and T3). ResultsThe sample consisted of 31 adults with chronic pain (n = 28) or spasticity (n = 3). All participants had an implanted pump for at least six months. Specialty trained nurses refilled the participants’ pump in their home. The findings support the use of a music video as an effective intervention for reducing participants’ perception of pain and anxiety during the pump refill procedure. Neither pre-test pain nor pre-test anxiety scores differed across time. Post-test mean pain scores decreased consistently across time (T1 = 5.55, T2 = 4.42, T3 = 4.23; P = .002). Post-test anxiety scores showed a significant decrease (P <.05) between T1 (M = 37.87) and T2 (M = 30.94) which was not sustained at T3 (M = 35.68, P = .284). Overall, the majority of participants indicated liking the music video intervention. They also expressed interest in using the intervention for future refill procedures or other stressful situations. ConclusionsThe music video was effective in producing a sustained reduction over time of participants’ pain during the pump refill procedures; it was most effective in initially reducing participants’ state anxiety at the initial intervention visit; however, it did not demonstrate a progressively sustained effect. Participants’ opinions about the music video experience were positive.

Brief Report on the Outcomes of an Integrated Approach on Stress, Anxiety, and Persistent Pain for Veterans; Mindful Yoga and Auricular Acupuncture

Objective: The aim of this study was to pilot test an integrated treatment approach, including mindful yoga and auricular acupuncture, for Veterans with overlapping mental health disorders and persistent pain. Design: A single-arm, quasi-experimental study with a 12-week intervention period. Methods: Veterans were referred to the program through their established mental health provider, which was marketed as a trauma sensitive mindful yoga program with optional auricular acupuncture for Veterans currently undergoing mental health treatment. The program consisted of 12 weekly 90-minute group yoga sessions that included mindful breathing, mindful movement, and guided relaxation. Auricular acupuncture was also offered but not required prior to each yoga session, where five acupuncture points were targeted for relaxation and stress relief. Stress, pain, and anxiety were assessed pre and post intervention using the Perceived Stress Scale, the PEG scale, and the Generalized Anxiety Disorder-7 Scale. Results: Out of fifty-five Veterans entering the program with a mental health diagnosis, twenty-seven Veterans completed the 12-week Mindful Yoga program. For those that completed the program, the average attendance was 9.5 out of 12 sessions. Means scores show improvement in perceived stress, pain, and anxiety compared with baseline scores. Statistically significant improvements were noted in both perceived stress (P = 0.0007) and anxiety (P = 0.0093). Conclusions: This study suggests that combining mindful yoga with auricular acupuncture can reduce symptoms of stress, pain, and anxiety in Veterans that commit to the program. Although this was a small sample, mean scores showed statistically significant improvements in perceived stress and anxiety and modest improvements in pain, warranting further study.

Posttraumatic Stress Disorder and Pain in Veterans: Indirect Association Through Anxiety Sensitivity

Despite high rates of comorbidity between pain and posttraumatic stress disorder (PTSD), little is known about factors that may account for this association. Previous research demonstrates that anxiety sensitivity (AS), the tendency to fear bodily sensations associated with anxious arousal, is elevated among patients with these conditions. However, no research to date has examined whether AS explains the association between pain and PTSD symptom severity. The current sample included 115 veterans with a trauma- and stressor-related disorder (i.e., PTSD or subthreshold PTSD) presenting for psychological services to an outpatient PTSD clinic at a Veterans Affairs hospital. Findings revealed a significant association between self-reported pain and PTSD symptom severity that was indirect via AS and in particular, AS cognitive concerns. These findings, though limited by their cross-sectional nature, provide support for AS as a risk factor for perceived pain and PTSD symptoms, particularly among veteran samples.

069 Chronic pain in Veterans with TBI is associated with decreased EEG slow wave coherence during NREM sleep

Abstract Introduction Chronic pain and sleep disturbances are intricately linked to one another, especially in individuals with a history of traumatic brain injury (TBI) who are at greater risk for both symptoms. Although prior studies have analyzed differences in sleep electroencephalogram (EEG) in these clinical populations, the association between sleep EEG slow wave coherence and pain complaints is not fully examined or known. Our novel slow wave coherence approach may provide new insights into the relationship between TBI, chronic pain, and sleep Methods Ninety-six veterans were recruited and enrolled under a VA IRB-approved protocol. Participants completed a semi-structured clinical interview to determine their history of TBI, Symptom Impact Questionnaire Revised (SIQR), a measure of chronic pain complaints, and underwent an attended overnight in-lab polysomnogram (PSG). We developed a novel computational signal processing algorithm to identify and quantify EEG slow waves within 100 ms bins across the 6 standard PSG EEG channels. When a slow wave was simultaneously observed in 4 or more of the 6 leads, slow wave coherence was inferred, and a percentage of slow wave coherence across each of the sleep stages was then calculated for each subject. Results In our sample, 65 participants (67.7%) endorsed experiencing chronic pain lasting 3 months or longer, and 54 had a history of TBI (56.3%). Participants endorsing chronic pain had a significantly lowered percent of EEG slow wave coherence during NREM sleep than subjects without chronic pain (p = 0.01). NREM EEG slow wave coherence did not correlate with SIQR scores in subjects without TBI (r = -0.03, p = 0.90), but was significantly negatively correlated in subjects with TBI (r = -0.32, p = 0.02). Conclusion EEG slow wave coherence during NREM sleep is correlated with chronic pain complaints in Veterans with a history of TBI, and could be indicative of neuronal dysfunction during sleep. Further research on slow wave coherence is warranted to understand the underlying mechanisms for the association between chronic pain and poor sleep following TBI. Support (if any) D01 W81XWH-17-1-0423

A mind-body program for pain and stress management in active duty service members and veterans.

The Mind-Body Medicine (MBM) program at the Naval Medical Center San Diego, created in collaboration with the Benson-Henry Institute for Mind Body Medicine and the Home Base Program at Massachusetts General Hospital, is a 7-week program designed to facilitate stress management habits into patient treatment plans. The aim of this study is to test the feasibility and acceptability of a mind-body program for service members and veterans. Participants (N = 239) were primarily active duty service members of the U.S. Navy and Marine Corps reporting significant perceived stress (Stress Resiliency (SR) group; n = 124), or meeting criteria for chronic pain (Pain Management (PM) group; n = 115). Participants completed measures at preprogram and post-program assessing for perceived stress, pain, functional impairment, quality of life, and psychological and somatic symptoms. Changes in self-reported psychological symptoms and knowledge and practice of mind-body principles were examined. Participants across groups had significant improvement in most outcomes (perceived stress, response to stressful experience, functional impairment, sleep disturbance, depression, PTSD, and anxiety symptoms; and each quality of life domain aside from social relationships), with p values < .0017 (Bonferroni corrected level of significance). The SR group demonstrated significant improvements in primary outcomes of perceived stress and response to stressful experience, and the PM group demonstrated significant improvement in pain severity, but not perceived stress. Significant change was observed in knowledge and practice of mind-body medicine principles, and high satisfaction was reported. Results suggest that a mind-body program may improve physical and psychological functioning for service members, including those facing significant perceived stress and chronic pain. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

586 Patient Satisfaction for the Use of DVPRS in the Assessment of Pain in the Burn and Surgical ICU

Abstract Introduction The assessment and treatment of pain has become increasingly important in light of the opioid epidemic. Inadequately managed pain can lead to increased risk of psychiatric illness. The numeric rating scale (NRS) is used in most ICUs and only assesses pain intensity. Although it is reliable, valid, and user-friendly, other publications have criticized this one-dimensional pain assessment tools as offering little information about the impact of the pain on the patient’s life. The defense and veterans pain rating scale (DVPRS) is a multi-dimensional tool designed to assess the patient’s pain intensity as well as how the pain interferes with the patient’s general activity, sleep, mood and stress. Studies have shown that it has good validity and reliability in the inpatient and outpatient military population with neuropathic and non-neuropathic pain. The DVPRS has not been evaluated in critical care patients. Thus, this study comparatively investigated ICU patients’ satisfaction with the DVPRS versus the NRS. Methods This was a prospective pilot study performed from September 2018 to July 2019 in a 10 bed burn intensive care unit (BICU) and 10 bed surgical intensive care unit (SICU) at a university teaching hospital. This was an IRB approved study. All enrolled patients were older than 18 years of age and were CAM-ICU negative. The participating staff members were educated on the use of the scales prior to the start of the study. Routine treatment of pain was not altered by the study. Pain was assessed by staff nurses randomly assigned to use the NRS or DVPRS tool. The selected tool was used on admission, during wound care and every 4 hours or upon patient need. The patients completed satisfaction surveys on the day of discharge. Results 42 patients participated and 32 completed the study. 18 patients were in the DVPRS arm and 14 were in the NRS arm. Our primary outcome was patient satisfaction, ranked on a scale from 0–10, where 0 was the lowest score and 10 was the highest. Overall, patients in the DVPRS cohort had higher median satisfaction scores (median score: 10, interquartile range: 8–10) than the NRS cohort (median score: 8, interquartile range 7–9), though this difference did not reach statistical significance (p=0.16). However, DVPRS patients were significantly more likely to be “completely satisfied” than NRS patients (55.6% in DVPRS patients versus 21.4% in NRS patients; p=0.04). Furthermore, upon multivariate logistic analysis adjusting for age, gender, and ICU using the NRS pain scale conferred lower odds of complete satisfaction with pain management (odds ratio: 0.19, p=0.04). Conclusions Our study showed that ICU patients preferred the DVPRS over the NRS. The DVPRS appeared to be as effective as the NRS in pain relief and gave providers more information about patients’ pain.

Sublingual Buprenorphine/Naloxone and Multi-Modal Management for High-Risk Chronic Pain Patients.

Patients with chronic pain managed with opioid medications are at high risk for opioid overuse or misuse. West Virginia University (WVU) established a High-Risk Pain Clinic to use sublingual buprenorphine/naloxone (bup/nal) plus a multimodal approach to help chronic pain patients with history of Substance Use Disorder (SUD) or aberrant drug-related behavior. The objective of this study was to report overall retention rates and indicators of efficacy in pain control from approximately six years of High-Risk Pain Clinic data. A retrospective chart review was conducted for a total of 78 patients who enrolled in the High-Risk Pain Clinic between 2014 and 2020. Data gathered include psychiatric diagnoses, prescribed medications, pain score, buprenorphine/naloxone dosing, time in clinic, and reason for dismissal. A linear mixed effects model was used to assess the pain score from the Defense and Veterans Pain Rating Scale (DVPRS) and daily bup/nal dose across time. The overall retention of the High-Risk Pain Clinic was 41%. The mean pain score demonstrated a significant downward trend across treatment time (p < 0.001), while the opposite trend was seen with buprenorphine dose (p < 0.001). With the benefit of six years of observation, this study supports buprenorphine/naloxone as a safe and efficacious component of comprehensive chronic pain treatment in patients with SUD or high-risk of opioid overuse or misuse.

Opioid-Free Anesthesia in the Perioperative Setting-A Preliminary Retrospective Matched Cohort Study.

Anesthesiologists have long used multimodal analgesia for effective pain control. Opioid-sparing anesthetics are gaining popularity among practitioners in light of increasing concerns for both immediate opioid side effects and the long-term opioid misuse among susceptible patients. Currently, there is a critical gap in knowledge regarding outcomes after an opioid-free anesthetic (OFA) during general anesthesia. We hypothesized that an opioid-free general anesthetic will not be inferior to a traditional opioid anesthetic (OA) as measured by the perioperative outcomes of postanesthesia care unit (PACU) duration, 12-hour postoperative summed pain intensity (SPI12) scores, total morphine equivalent doses (MEDs) utilized in the 12-hour postoperative inpatient (MED12) and total MEDs utilized in the 90-day outpatient periods (MED90). Patients were included if they were ≥18 years old, met criteria for American Society of Anesthesiologists classification I-IV, received general endotracheal anesthesia from a single anesthesia provider for a surgical operation in 2016, did not receive intraoperative administration of opioids, and were recovered in the PACU. A total of 25 patients were included in the OFA group and 29 control patients in the OA group (n = 54). A retrospective chart review of intraoperative records, perioperative pain scores, and medication utilization (inpatient and outpatient) was performed to obtain the data for the analysis of the primary outcomes. In both OFA and OA groups, the continuous outcomes were not normally distributed. Subsequent bivariate tests of the indicated OA versus OFA age (d = 0.58), surgery duration (d = 0.24), and preoperative pain score (d = 0.51) warranted inclusion in the multinomial regression. Surgical duration was not significantly associated with the primary outcomes. However, the continuous variables of age and preoperative Defense and Veterans Pain Rating Scale score were associated with differences in primary outcomes. Every 1-year increase in the age was associated with a 5.06 increase in SPI12 and 5.73 mg increase in MED12. Every 1-point increase in the preoperative Defense and Veterans Pain Rating Scale score was associated with an 8.45 minutes increase in PACU duration, 11.25 increase in SPI12, 17.85 mg increase in MED12, and 20.83 mg increase in MED90. In regard to the primary outcomes, there was a lack of significant differences between the OFA and OA groups in all outcomes (PACU duration, mean SPI12, MED12, and MED90). To our knowledge, this is the first matched cohort study directly comparing an OFA with a traditional anesthetic for general anesthesia in a wide range of surgical and clinical scenarios. There was no significant difference in SPI12 between the OFA group and OA group, suggesting that patients' subjective pain was similar immediately after surgery whether or not they received intraoperative opioids. Concurrently, no "catch-up" effect was observed as the PACU duration; MED12 and MED90 were not different between the OFA and OA groups. However, there were many covariates identified in this study because of the small sample size or each group. Additional research is needed to explore if these findings can be extrapolated to a larger more heterogeneous population. Our preliminary work suggests that eliminating patient exposure to opioids in the intraoperative period does not have a deleterious effect on perioperative patient outcomes.

Frequency and Severity of Phantom Limb Pain in Veterans with Major Upper Limb Amputation: Results of a National Survey.

To describe the frequency and severity of phantom limb pain (PLP) in veterans with major upper limb amputation and determine the association between PLP and person, amputation, and prosthesis characteristics. Cross-sectional design. National survey of veterans living in the community. U.S. military veterans (N = 776) with major upper limb amputations. Frequency and intensity of PLP, person characteristics such as age and gender, amputation characteristics such as level and etiology, and prosthesis characteristics such as type and intensity of prosthesis use. Respondents were 97% male with a mean age of 63 years and a mean time since amputation of 31 years. The most common amputation level was transradial (36%) and 62% reported accident as the amputation etiology. 73% of amputees reported PLP with a mean intensity score of 4.2 (standard deviation 3.4). PLP frequency in the daily to always category was reported in 42% of amputees. Weekly and more frequent residual limb pain was associated with having any PLP. Amputation at the shoulder (odds ratio [OR] 3.78 [1.93, 7.39]), amputation at the transhumeral level (OR 1.76 [1.10,2.81]), and amputation due to cancer (OR 5.33 [1.15, 24.81]) were also associated with any PLP. Moderate (β = 1.34, P = < .001) and severe (β = 3.31, P < .001) residual limb pain intensity was associated with higher PLP intensity among those with pain. Amputation at the shoulder level was associated with a 1.5 points higher average pain intensity score (P < .001) compared to the transradial level. Multivariable models failed to show an association between PLP prevalence and amputation of the dominant limb (P = .08) and PLP was not associated with intensity of daily prosthesis use in bivariate analyses. This study of a large cohort of veterans with major upper limb amputation highlights the long-term persistence of moderate frequency and intensity PLP.

Resolving the Burden of Low Back Pain in Military Service Members and Veterans (RESOLVE): Protocol for a Multisite Pragmatic Clinical Trial.

Physical therapy (PT) is frequently used for the management of low back pain (LBP) within the US Departments of Defense (DOD) and Veterans Affairs (VA). However, variations in PT practice patterns and use of ineffective interventions lower the quality and increase the cost of care. Although adherence to the clinical practice guidelines (CPGs) can improve the outcomes and cost-effectiveness of LBP care, PT CPG adherence remains below 50%. The Resolving the Burden of Low Back Pain in Military Service Members and Veterans (RESOLVE) trial will evaluate the effectiveness of an active PT CPG implementation strategy using an education, audit, and feedback model for reducing pain, disability, medication use, and cost of LBP care within the DOD and VA health care systems. The RESOLVE trial will include 3,300 to 7,260 patients with LBP across three DOD and two VA medical facilities using a stepped-wedge study design. An education, audit, and feedback model will be used to encourage physical therapists to better adhere to the PT CPG recommendations. The Oswestry Disability Index and the Defense and Veterans Pain Rating Scale will be used as primary outcomes. Secondary outcomes will include the LBP-related medication use, medical resource utilization, and biopsychosocial predictors of outcomes. Statistical analyses will be based on the intention-to-treat principle and will use linear mixed models to compare treatment conditions and examine the interactions between treatment and subgrouping status (e.g., limb loss). The RESOLVE trial will provide a pragmatic approach to evaluate whether better adherence to PT CPGs can reduce pain, disability, medication use, and LBP care cost within the DOD and VA health care systems.

Perceived partner responsiveness, pain, and sleep: A dyadic study of military-connected couples.

The health-promoting influence of supportive close relationships has been extensively documented, yet the mechanisms of this effect are still being clarified. Leading researchers have theorized that examining particular interpersonal interactions and the mediating intrapersonal processes they facilitate is the key to understanding how close relationships benefit health. The purpose of this study was to investigate the influence of perceived partner responsiveness (PPR) on pain and sleep quality via affect in a sample of veterans and spouses (collectively called military-connected couples). Military-connected couples (N = 162) completed 32 days of daily diaries. Mediated actor-partner interdependence models were conducted using multilevel structural equation modeling to assess the effects of PPR at baseline on the daily levels of positive affect, negative affect, pain, and sleep across the following 32 days. Indirect effects emerged such that affect mediated the association between PPR and pain for veterans only whereas affect mediated the association between PPR and sleep quality for both partners. Daily direct effects emerged as well; for example, positive affect was positively associated with higher sleep quality for both partners and lower pain for veterans. Partner effects were revealed such as veteran PPR was positively associated with spouse positive affect. Overall, greater PPR was associated with positive health outcomes for military-connected couples. The implications of this study include providing insights for couple-oriented interventions for preventing and treating pain and sleep problems in couples who are at high risk of these health problems such as military-connected couples. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Predicting Treatment Success with Facet Syndrome: An Algorithm to Predict Lumbar Radiofrequency Ablation Responders in a Military Population.

Radiofrequency ablation (RFA) of the medial branch nerve is a commonly performed procedure for patients with facet syndrome. RFA has previously been demonstrated to provide long-term functional improvement in approximately 50% of patients, including those who had significant pain relief after diagnostic medial branch block. We sought to identify factors associated with success of RFA for facet pain. Active-duty military patients who underwent lumbar RFA (L3, L4, and L5 levels) over a 3-year period were analyzed. Defense and Veterans Pain Rating Scale (DVPRS) and Oswestry Disability Index (ODI) scores were assessed the day of procedure and at the 2-month and 6-month follow-up. These data were analyzed to identify associations between patient demographics, pain, and functional status and patients' improvement after RFA, with a primary outcome of ODI improvement and a secondary outcome of pain reduction. Higher levels of starting functional impairment (starting ODI scores of 42.9 vs. 37.5; P = 0.0304) were associated with a greater likelihood of improvement in functional status 6 months after RFA, and higher starting pain scores (DVPRS pain scores of 6.1 vs. 5.1; P < 0.0001) were associated with a higher likelihood that pain scores would improve 6 months after RFA. A multivariate logistic regression was then used to develop a scoring system to predict improvement after RFA. The scoring system generated a C-statistic of 0.764, with starting ODI, pain scores, and both gender and smoking history as independent variables. This algorithm compares favorably to that of diagnostic medial branch block in terms of prediction accuracy (C-statistic of 0.764 vs. 0.57), suggesting that its use may improve patient selection in patients who undergo RFA for facet syndrome.