Women Veterans’ Experiences with Integrated, Biopsychosocial Pain Care: A Qualitative Study

Pain Medicine ◽  
2021 ◽  
Author(s):  
Francesca M Nicosia ◽  
Carolyn J Gibson ◽  
Natalie Purcell ◽  
Kara Zamora ◽  
Jennifer Tighe ◽  
...  
Keyword(s):  
Chronic Pain ◽  
San Francisco ◽  
Women Veterans ◽  
Self Management ◽  
Veterans Health ◽  
Health Administration ◽  
Care Models ◽  
Va Health Care System ◽  
Pain Care ◽  
Gender Specific

Abstract Objectives Biopsychosocial, integrated pain care models are increasingly implemented in the Veterans Health Administration to improve chronic pain care and reduce opioid-related risks, but little is known about how well these models address women veterans’ needs. Design Qualitative, interview-based study. Setting San Francisco VA Health Care System Integrated Pain Team (IPT), an interdisciplinary team that provides short-term, personalized chronic pain care emphasizing functional goals and active self-management. Subjects Women with chronic pain who completed ≥3 IPT sessions. Methods Semistructured phone interviews focused on overall experience with IPT, perceived effectiveness of IPT care, pain care preferences, and suggested changes for improving gender-sensitive pain care. We used a rapid approach to qualitative thematic analysis to analyze interviews. Results Fourteen women veterans (mean age 51 years; range 33–67 years) completed interviews. Interviews revealed several factors impacting women veterans’ experiences: 1) an overall preference for receiving both primary and IPT care in gender-specific settings, 2) varying levels of confidence that IPT could adequately address gender-specific pain issues, 3) barriers to participating in pain groups, and 4) barriers to IPT self-management recommendations due to caregiving responsibilities. Conclusions Women veterans reported varied experiences with IPT. Recommendations to improve gender-sensitive pain care include increased provider training; increased knowledge of and sensitivity to women’s health concerns; and improved accommodations for prior trauma, family and work obligations, and geographic barriers. To better meet the needs of women veterans with chronic pain, integrated pain care models must be informed by an understanding of gender-specific needs, challenges, and preferences.

Flipping the Pain Care Model: A Sociopsychobiological Approach to High-Value Chronic Pain Care

Pain Medicine ◽  
2020 ◽  
Vol 21 (6) ◽  
pp. 1168-1180 ◽  
Author(s):  
Aram S Mardian ◽  
Eric R Hanson ◽  
Lisa Villarroel ◽  
Anita D Karnik ◽  
John G Sollenberger ◽  
...  
Keyword(s):  
United States ◽  
Chronic Pain ◽  
Clinical Care ◽  
The United States ◽  
Current Evidence ◽  
Veterans Health ◽  
Health Administration ◽  
Opioid Use ◽  
Practice Gap ◽  
Pain Care

Abstract Objective Much of the pain care in the United States is costly and associated with limited benefits and significant harms, representing a crisis of value. We explore the current factors that lead to low-value pain care within the United States and provide an alternate model for pain care, as well as an implementation example for this model that is expected to produce high-value pain care. Methods From the perspective of aiming for high-value care (defined as care that maximizes clinical benefit while minimizing harm and cost), we describe the current evidence practice gap (EPG) for pain care in the United States, which has developed as current clinical care diverges from existing evidence. A discussion of the biomedical, biopsychosocial, and sociopsychobiological (SPB) models of pain care is used to elucidate the origins of the current EPG and the unconscious factors that perpetuate pain care systems despite poor results. Results An interprofessional pain team within the Veterans Health Administration is described as an example of a pain care system that has been designed to deliver high-value pain care and close the EPG by implementing the SPB model. Conclusions Adopting and implementing a sociopsychobiological model may be an effective approach to address the current evidence practice gap and deliver high-value pain care in the United States. The Phoenix VA Health Care System’s Chronic Pain Wellness Center may serve as a template for providing high-value, evidence-based pain care for patients with high-impact chronic pain who also have medical, mental health, and opioid use disorder comorbidities.

scholarly journals Barriers to and Facilitators of Multimodal Chronic Pain Care for Veterans: A National Qualitative Study

Pain Medicine ◽  
2020 ◽  
Author(s):  
Chelsea Leonard ◽  
Roman Ayele ◽  
Amy Ladebue ◽  
Marina McCreight ◽  
Charlotte Nolan ◽  
...  
Keyword(s):  
Primary Care ◽  
Health Care ◽  
Chronic Pain ◽  
Pain Management ◽  
Health Care Providers ◽  
Veterans Health Administration ◽  
Veterans Health ◽  
Health Administration ◽  
Care Providers ◽  
Pain Care

Abstract Objective Chronic pain is more common among veterans than among the general population. Expert guidelines recommend multimodal chronic pain care. However, there is substantial variation in the availability and utilization of treatment modalities in the Veterans Health Administration. We explored health care providers’ and administrators’ perspectives on the barriers to and facilitators of multimodal chronic pain care in the Veterans Health Administration to understand variation in the use of multimodal pain treatment modalities. Methods  We conducted semi-structured qualitative interviews with health care providers and administrators at a national sample of Veterans Health Administration facilities that were classified as either early or late adopters of multimodal chronic pain care according to their utilization of nine pain-related treatments. Interviews were conducted by telephone, recorded, and transcribed verbatim. Transcripts were coded and analyzed through the use of team-based inductive and deductive content analysis. Results  We interviewed 49 participants from 25 facilities from April through September of 2017. We identified three themes. First, the Veterans Health Administration’s integrated health care system is both an asset and a challenge for multimodal chronic pain care. Second, participants discussed a temporal shift from managing chronic pain with opioids to multimodal treatment. Third, primary care teams face competing pressures from expert guidelines, facility leadership, and patients. Early- and late-adopting sites differed in perceived resource availability. Conclusions Health care providers often perceive inadequate support and resources to provide multimodal chronic pain management. Efforts to improve chronic pain management should address both organizational and patient-level challenges, including primary care provider panel sizes, accessibility of training for primary care teams, leadership support for multimodal pain care, and availability of multidisciplinary pain management resources.

scholarly journals Predictors of Veterans Health Administration utilization and pain persistence among soldiers treated for postdeployment chronic pain in the Military Health System

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Rachel Sayko Adams ◽  
Esther L. Meerwijk ◽  
Mary Jo Larson ◽  
Alex H. S. Harris
Keyword(s):  
Mental Health ◽  
Health Care ◽  
Chronic Pain ◽  
Veterans Health Administration ◽  
First Year ◽  
Veterans Health ◽  
Health Administration ◽  
Military Health System ◽  
Military Health ◽  
The Military

Abstract Background Chronic pain presents a significant burden for both federal health care systems designed to serve combat Veterans in the United States (i.e., the Military Health System [MHS] and Veterans Health Administration [VHA]), yet there have been few studies of Veterans with chronic pain that have integrated data from both systems of care. This study examined 1) health care utilization in VHA as an enrollee (i.e., linkage to VHA) after military separation among soldiers with postdeployment chronic pain identified in the MHS, and predictors of linkage, and 2) persistence of chronic pain among those utilizing the VHA. Methods Observational, longitudinal study of soldiers returning from a deployment in support of the Afghanistan/Iraq conflicts in fiscal years 2008–2014. The analytic sample included 138,206 active duty soldiers for whom linkage to VHA was determined through FY2019. A Cox proportional hazards model was estimated to examine the effects of demographic characteristics, military history, and MHS clinical characteristics on time to linkage to VHA after separation from the military. Among the subpopulation of soldiers who linked to VHA, we described whether they met criteria for chronic pain in the VHA and pain management treatments received during the first year in VHA. Results The majority (79%) of soldiers within the chronic pain cohort linked to VHA after military separation. Significant predictors of VHA linkage included: VHA utilization as a non-enrollee prior to military separation, separating for disability, mental health comorbidities, and being non-Hispanic Black or Hispanic. Soldiers that separated because of misconduct were less likely to link than other soldiers. Soldiers who received nonpharmacological treatments, opioids/tramadol, or mental health treatment in the MHS linked earlier to VHA than soldiers who did not receive these treatments. Among those who enrolled in VHA, during the first year after linking to the VHA, 49.7% of soldiers met criteria for persistent chronic pain in VHA. Conclusions The vast majority of soldiers identified with chronic pain in the MHS utilized care within VHA after military separation. Careful coordination of pain management approaches across the MHS and VHA is required to optimize care for soldiers with chronic pain.

Abstract 15444: Anticoagulation Treatment of Venous Thromboembolism Across the Weight Spectrum: Insights From the Veterans Health Administration

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Alexander C Perino ◽  
Jun Fan ◽  
Mitra Kothari ◽  
ATIF MOHAMMAD ◽  
Patrick Hlavacek ◽  
...  
Keyword(s):  
Venous Thromboembolism ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Treatment Strategies ◽  
Veterans Health ◽  
Health Administration ◽  
Mechanical Valves ◽  
Consensus Statements ◽  
Body Weights ◽  
Va Health Care System

Introduction: In seminal trials of venous thromboembolism (VTE) treatment with direct oral anticoagulants (DOAC), few patients were enrolled at low and high body weights to estimate treatment effects in these subgroups. Consensus statements have recommended against use of DOACs in VTE for patients ≥120 kg. We sought to describe real-world use of DOACs and other anticoagulants for VTE across the weight spectrum. Methods: We performed a retrospective cohort study of patients with first-time VTE that were treated with anticoagulants in the VA health care system from 2008 to 2018. We excluded patients with 1) additional indications for anticoagulation (atrial fibrillation and mechanical valves) and 2) no documented weight in the 90 days prior to 90 days after index VTE. We stratified patients by weight (<60, 60 to 119, ≥120 kg) and determined 1) index anticoagulation prescription in the 30 days after index VTE (DOAC, warfarin, and low molecular weight heparin or fondaparinux [LMWH/F] only) and 2) variables associated with DOAC prescription, as compared to warfarin, in those ≥120 kg. Results: After excluding 3,676 patients with missing weight, there were 111,774 patients with VTE (64±13 years, 6% female). The most common therapy was warfarin (66%), followed by DOAC (21%), and LMWH/F only (13%). Median weight was 92 kg (interquartile range: 28), with 13,753 patients (12%) with weight ≥120 kg. Across weight categories, proportion of patients receiving DOAC was similar. In patients ≥120 kg, after multivariate adjustment, multiple comorbidities were associated with warfarin prescription while chronic kidney disease was associated with DOAC prescription ( Table ). Conclusion: Weight ≥120 kg is common for VTE patients, with DOAC frequently prescribed despite consensus statements recommending DOAC avoidance. For patients ≥120 kg, comorbidities influence VTE treatment selection, and determination of optimal treatment strategies across the spectrum of comorbidities is needed.

Transforming Pain Management Through the Integration of Complementary and Conventional Care

2017 ◽  
Author(s):  
Heather Tick ◽  
Eric B. Schoomaker
Keyword(s):  
Healthcare Providers ◽  
Peripheral Sensitization ◽  
Veterans Health ◽  
Health Providers ◽  
Health Administration ◽  
Military Health ◽  
Current Program ◽  
The Military ◽  
Pain Care

This chapter discusses some of the assumptions behind the evolution of the current program of pain care and explores different strategies that could inform transformative changes to the system. It addresses the role of self-care, nutrition, mind-body strategies, and movement in improving function. The emerging scientific literature on neuroplasticity, central and peripheral sensitization, energy generation, and mitochondrial dysfunction, and the functional role of fascia is explored. Health providers in a transformed system will potentially work in more diverse settings, collaborate more broadly, and engage patients in conversations driven by patient priorities and emerging evidence-based modalities. The Veterans Health Administration and the Military Health System, acting on alarming increases in the incidence of chronic pain and associated comorbidities, have become the early adopters of transformative policies. Since pain is the most common cause for a healthcare visit, this chapter should be of interest to all healthcare providers, complementary, integrative, and conventional.

scholarly journals Gender Differences in Veterans Referred for Neuropsychological Evaluation in an Outpatient Neuropsychology Consultation Service

2020 ◽  
Vol 35 (5) ◽  
pp. 562-575
Author(s):  
Erin Sullivan-Baca ◽  
Kara Naylon ◽  
Andrea Zartman ◽  
Barry Ardolf ◽  
J Gregory Westhafer
Keyword(s):  
Gender Differences ◽  
Women Veterans ◽  
Neuropsychological Evaluation ◽  
Veterans Health ◽  
Performance Validity ◽  
Health Administration ◽  
Age Cohorts ◽  
Behavioral Observations ◽  
Validity Measures ◽  
Performance Validity Measures

Abstract Objective The number of women veterans seeking Veterans Health Administration services has substantially increased over the past decade. Neuropsychology remains an understudied area in the examination of gender differences. The present study sought to delineate similarities and differences in men and women veterans presenting for neuropsychological evaluation in terms of demographics, referral, medical conditions, effort, and outcome diagnosis. Method A database collected from an outpatient VA neuropsychology clinic from 2013 to 2019 was analyzed (n = 232 women, 2642 men). Additional analyses examined younger (n = 836 men, 155 women) and older (n = 1805 men, 77 women) age cohorts. Results Women veterans were younger and more educated than men, whereas men had higher prevalence of vascular risk factors. Both groups were most often referred from mental health clinics and memory was the most common referral question. Although men performed worse on performance validity measures, clinicians rated women as evidencing poorer effort on a cumulative rating based on formal and embedded performance validity measures, behavioral observations, and inconsistent test patterns. Older women reported more depressive symptoms than older men and were more commonly diagnosed with depression. Conclusions This exploratory study fills a gap in the understanding of gender differences in veterans presenting for neuropsychological evaluations. Findings emphasize consideration for the intersection of gender with demographics, medical factors, effort, and psychological symptoms by VA neuropsychologists. A better understanding of relationships between gender and these factors may inform neuropsychologists’ test selection, interpretation of behavioral observations, and diagnostic considerations to best treat women veterans.

Screening for homelessness among individuals initiating medication-assisted treatment for opioid use disorder in the Veterans Health Administration

2015 ◽  
Vol 11 (6) ◽  
pp. 459 ◽  
Author(s):  
Marcus A. Bachhuber, MD, MSHP ◽  
Christopher B. Roberts, MPH ◽  
Stephen Metraux, PhD ◽  
Ann Elizabeth Montgomery, PhD
Keyword(s):  
At Risk ◽  
Addiction Treatment ◽  
Women Veterans ◽  
Opioid Use Disorder ◽  
Treatment Programs ◽  
Veterans Health ◽  
Health Administration ◽  
Opioid Use ◽  
Medication Assisted Treatment ◽  
Male Veterans

Objective: To determine the prevalence of homelessness and risk for homelessness among veterans with opioid use disorder initiating treatment. Setting: Addiction treatment programs operated by the US Department of Veterans Affairs (VA).Participants: All veterans initiating treatment with methadone or buprenorphine for opioid use disorder between October 1, 2013 and September 30, 2014 (n = 2,699) who were administered the VA’s national homelessness screener. Main outcome measures: Self-reported homelessness or imminent risk of homelessness.Results: The prevalence of homelessness was 10.2 percent and 5.3 percent were at risk for homelessness. Compared to male veterans, women veterans were less likely to report homelessness (8.9 percent vs 10.3 percent) but more likely to be at risk (11.8 percent vs 4.9 percent). By age group, veterans aged 18-34 and 45-54 years most frequently reported homelessness (12.0 and 11.7 percent, respectively) and veterans aged 45-54 and 55-64 years most frequently reported risk for homelessness (6.5 and 6.8 percent, respectively).Conclusions: The prevalence of homelessness in this population is approximately 10 times that of the general veteran population accessing care at VA. Screening identified a substantial number of veterans who could benefit from VA housing assistance and had not received it recently. Programs to address veteran homelessness should engage with veterans seeking addiction treatment. Integration of homelessness services into addiction treatment settings may, in turn, improve outcomes.

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