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Background: Women experience chronic pain and use pain-related health care at higher rates than men. It is not known whether the pain-related health care female veterans receive is consistent with clinical practice guideline recommendations or whether receipt of this care differs between men and women., Objective: The aim of this study was to identify whether sex differences in chronic pain management care exist for patients served by the Veterans Health Administration (VHA)., Design: Data on patient demographics, diagnostic criteria, and health care utilization were extracted from VHA administrative databases for fiscal year 2010 (FY10)., Patients: Patients in this study included all VHA patients (excluding metastatic cancer patients) who received more than 90 days of a short-acting opioid medication or a long-acting opioid medication prescription in FY10 study., Measures: Multilevel logistic regressions were conducted to identify sex differences in receipt of guideline-recommended chronic pain management., Results: A total of 480,809 patients met inclusion criteria. Female patients were more likely to receive most measures of guideline-recommended care for chronic pain including mental health assessments, psychotherapy, rehabilitation therapy, and pharmacy reconciliation. However, women were more likely to receive concurrent sedative prescriptions, which is inconsistent with guideline recommendations. Most of the observed sex differences persisted after controlling for key demographic and diagnostic differences., Conclusions: Findings suggest that female VHA patients are more likely to receive an array of pain management practices than male patients, including both contraindicated and recommended polypharmacy. Quality improvement efforts to address underutilization of mental health and rehabilitative services for pain by male patients and polypharmacy in female patients should be considered., (Wiley Periodicals, Inc.)

In patients with HIV/AIDS, chronic pain is common and analgesics pose serious risks. Cognitive-behavioral therapies (CBT) provide an alternative. This study evaluated feasibility and impact of a CBT-based pain management program in three public primary care clinics for HIV patients. The program included a workbook and 12-weeks of group CBT sessions. HIV-positive patients with chronic moderate to severe pain were invited to participate in the program and were assessed at enrollment, 6, 12, and 24 weeks. Despite only moderate group attendance, program enrollment was associated with significant improvements in pain intensity, pain-related functioning, anxiety and acceptance, and mental health. At 24 weeks, effect sizes for pain outcomes were -0.83 for pain intensity and -0.43 for functioning. The pattern of change in outcomes was consistent with predictions based on cognitive-behavioral theory. Effects were observed at all clinics. Adding CBT-based pain management into primary care may provide important benefits for patients with HIV/AIDS.

Introduction: The primary aim of this study was to examine the role of patient characteristics in predicting response to treatment in a sample of HIV-positive patients receiving 12 weekly sessions of a CBT-based pain management protocol., Method: A pre/post test single group design was used. Pain-related functioning was assessed at baseline and 12 weeks post-treatment using the Pain Outcomes Questionnaire-VA. DATA ANALYSIS AND RESULTS: Multivariate regression analysis showed that higher baseline levels of pain-related anxiety were related to greater improvement in pain-related functioning at post-treatment, and non-Caucasian participants reported a greater response to treatment when compared to Caucasian participants. Attendance to CBT treatment sessions focused on progressive muscle relaxation and cognitive reconceptualization of pain were also related to treatment outcome., Conclusion: Non-Caucasian patients reporting higher levels of pain-related anxiety may respond particularly well to treatment. Treatment sessions focused on progressive muscle relaxation and cognitive reconceptualization of pain may be particularly helpful.

Veterans seeking care in VA medical facilities have high rates of chronic pain, which often co-occur with mental health and substance use disorders, including prescription opioid misuse. The overall goal of the Optimizing Pain Treatment Interventions (OPTI) study was to pilot a 12-week Collaborative Care intervention to improve opioid safety, chronic pain disability, and use of non-pharmacological pain management strategies in veterans in VA primary care. Between November 2014 and January 2017, 100 veteran patients with chronic pain and high-risk prescription opioid use (e.g., high-dose therapy, early refills, etc.) were enrolled and completed an initial one-hour study visit with a primary care provider (PCP) within 4 weeks of enrollment. Study PCPs were guided by a web-based opioid management decision support program and templated notes in the VA electronic medical record. After assessment and education, study PCPs used Shared Decision-Making to formulate a Pain Care Plan aligned with a participant's personal values and goals. After the initial visit, patients randomized to Collaborative Care received one Motivational Interviewing (MI) session with a Care Manager followed by 3 Care Manager-delivered brief telephone MI sessions at 6, 8, and 12 weeks to reinforce Pain Care Plans; patients randomized to an Attention Control condition met with a Care Manager briefly, followed by 3 brief scripted telephone psychoeducation sessions at 6, 8, and 12 weeks. Masked evaluators assessed outcomes at baseline, end of intervention (12 weeks), and after eight weeks of no contact (20 weeks). We present study rationale, detailed methods, preliminary results and lessons learned.

Background and Aims Chronic pain is difficult to treat in individuals with substance use disorders and, when not resolved, can have a negative impact on substance use disorder treatment outcomes. This study tested the efficacy of a psychosocial pain management intervention, ImPAT (improving pain during addiction treatment), that combines pain management with content related to managing pain without substance use. Design Single-site, parallel-groups randomized controlled trial comparing ImPAT to a supportive psychoeducational control (SPC) condition; follow-up assessments occurred at 3, 6 and 12 months. Setting The Ann Arbor VA Substance Use Disorder treatment program, USA. Participants Veterans Health Administration patients { n = 129; mean [standard deviation (SD)], age = 51.7 (9.5); 115 of 129 (89%) male; ImPAT ( n = 65); SPC ( n = 64)}. Intervention ImPAT combines principles of cognitive-behavioral therapy and acceptance-based approaches to pain management with content related to avoiding the use of substances as a coping mechanism for pain. The SPC used a psychoeducational attention control treatment for alcoholism modified to cover other substances in addition to alcohol. Measurements Primary: Pain intensity over 12 months; secondary: pain-related functioning, frequency of alcohol and drug use over 12 months. Findings Primary: randomization to the ImPAT intervention versus SPC predicted significantly lower pain intensity {β [standard error (SE)] = −0.71 (0.29); 95% confidence interval (CI) = −1.29, −0.12}; secondary: relative to the SPC condition, those who received ImPAT also reported improved pain-related functioning [β (SE) = 0.27 (0.11); 95% CI = 0.05, 0.49] and lower frequency of alcohol consumption [β (SE) = −0.77; 95% CI = −1.34, −0.20]. No differences were found between conditions on frequency of drug use over follow-up. Conclusions For adults with pain who are enrolled in addictions treatment, receipt of a psychological pain management intervention (improving pain during addiction treatment) reduced pain and alcohol use and improves pain-related functioning over 12 months relative to a matched-attention control condition. [ABSTRACT FROM AUTHOR]

Objective. The objective of this study was to explore the relationship between patterns of opioid use, pain severity, and pain-related mental health in chronic pain patients prescribed opioids. Design. The study was designed as a one-time patient interview with structured pain and opioid use assessments. Setting. The study was set in a tertiary care medical center in the United States Department of Veterans Affairs. Patients. Study participants were primary care patients with a pain condition for greater than 6 months who received at least one prescription for an opioid in the prior 12 months. Outcome Measures. The Prescription Drug Use Questionnaire was used to assess patterns of opioid use. The Pain Outcomes Questionnaire was used to assess pain-related functioning. Results. Symptomatic use of opioid medication (e.g., taking an opioid in response to increased pain) was more common than scheduled (i.e., taking an opioid at regular times) or strategic use of opioid medication (e.g., taking an opioid specifically to engage in activities). Symptomatic use of opioids was associated with poorer pain-related mental health, after controlling for pain duration and pain-related physical functioning. Use of opioids in a scheduled pattern was associated with better pain-related mental health. Patients rarely reported that they used opioids strategically to facilitate functional activities. Conclusions. The patterns in which patients use their opioid medications are associated with their psychological functioning. This is consistent with theory regarding the potential impact of reinforcing effects of opioid medication on functional outcomes. Interventions to encourage strategic or scheduled opioid use warrant investigation as methods to improve pain outcomes with opioids. [ABSTRACT FROM AUTHOR]

Background. With the growth in opioid therapy for the treatment of chronic pain, health care providers have focused their attention on avoiding over-use of opioid medications, specifically to avoid addiction, dependency, and other misuse. Qualitative and quantitative reviews of medication adherence, in contrast, focus primarily on why patients under-use or do not take their medications as prescribed and find nonadherence rates of approximately 25%. Objective. To identify the prevalence of under-use of opioid medications and the reasons and implications of under-use. Design. As part of a variety of structured assessments, subjects were asked detailed questions about how they used their opioid medication in their daily lives. Participants. One hundred ninety-one veterans who received an opioid prescription for any pain problem within the 12 months before the interview. Measures. We defined a patient who under-used his/her medication as one who took less than their prescribed dose of medication and reported that pain impaired their ability to engage in normal daily activities. Results. Under-use of opioids (20%) was more common than over-use (9%), consistent with research on medication adherence. Patients who under-used their opioids offered the same reasons for under-use that patients report for other medications. However, while under-users reported more pain than other opioid users they filled only slightly fewer opioid prescriptions. Communication problems between patients and providers about opioids were common. Conclusions. Improved communication between patients and providers and shared decision-making regarding opioid prescriptions may improve pain management and minimize the problems associated with over-prescription of opioids (i.e., diversion). [ABSTRACT FROM AUTHOR]

Objective. To develop and evaluate a clinical decision support system (CDSS) named Assessment and Treatment in Healthcare: Evidenced-Based Automation (ATHENA)-Opioid Therapy, which encourages safe and effective use of opioid therapy for chronic, noncancer pain. Design. CDSS development and iterative evaluation using the analysis, design, development, implementation, and evaluation process including simulation-based and in-clinic assessments of usability for providers followed by targeted system revisions. Results. Volunteers provided detailed feedback to guide improvements in the graphical user interface, and content and design changes to increase clinical usefulness, understandability, clinical workflow fit, and ease of completing guideline recommended practices. Revisions based on feedback increased CDSS usability ratings over time. Practice concerns outside the scope of the CDSS were also identified. Conclusions. Usability testing optimized the CDSS to better address barriers such as lack of provider education, confusion in dosing calculations and titration schedules, access to relevant patient information, provider discontinuity, documentation, and access to validated assessment tools. It also highlighted barriers to good clinical practice that are difficult to address with CDSS technology in its current conceptualization. For example, clinicians indicated that constraints on time and competing priorities in primary care, discomfort in patient-provider communications, and lack of evidence to guide opioid prescribing decisions impeded their ability to provide effective, guideline-adherent pain management. Iterative testing was essential for designing a highly usable and acceptable CDSS; however, identified barriers may limit the impact of the ATHENA-Opioid Therapy system and other CDSS on clinical practices and outcomes unless CDSS are paired with parallel initiatives to address these issues. [ABSTRACT FROM AUTHOR]

Abstract Veterans seeking care in VA medical facilities have high rates of chronic pain, which often co-occur with mental health and substance use disorders, including prescription opioid misuse. The overall goal of the Optimizing Pain Treatment Interventions (OPTI) study was to pilot a 12-week Collaborative Care intervention to improve opioid safety, chronic pain disability, and use of non-pharmacological pain management strategies in veterans in VA primary care. Between November 2014 and January 2017, 100 veteran patients with chronic pain and high-risk prescription opioid use (e.g., high-dose therapy, early refills, etc.) were enrolled and completed an initial one-hour study visit with a primary care provider (PCP) within 4 weeks of enrollment. Study PCPs were guided by a web-based opioid management decision support program and templated notes in the VA electronic medical record. After assessment and education, study PCPs used Shared Decision-Making to formulate a Pain Care Plan aligned with a participant's personal values and goals. After the initial visit, patients randomized to Collaborative Care received one Motivational Interviewing (MI) session with a Care Manager followed by 3 Care Manager-delivered brief telephone MI sessions at 6, 8, and 12 weeks to reinforce Pain Care Plans; patients randomized to an Attention Control condition met with a Care Manager briefly, followed by 3 brief scripted telephone psychoeducation sessions at 6, 8, and 12 weeks. Masked evaluators assessed outcomes at baseline, end of intervention (12 weeks), and after eight weeks of no contact (20 weeks). We present study rationale, detailed methods, preliminary results and lessons learned. [ABSTRACT FROM AUTHOR]