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Pain Management


Introduction

Pain is one of the most common reasons Americans consult a physician. There are two types of pain: acute and chronic. Acute pain is caused by a specific condition like a broken bone or childbirth, and typically goes away once the underlying cause ends or is fixed. Chronic pain is ongoing pain that usually lasts longer than six months. It can stem from an injury, infection, or disease such as arthritis or cancer. Sometimes chronic pain has no known cause. Environmental and psychological factors can often make chronic pain worse.

According to a 2018 report by the Centers for Disease Control and Prevention (CDC), 50 million U.S. adults have chronic pain. Approximately 19.6 million American adults have high-impact chronic pain that limits at least one major life activity. One-third of people with high-impact chronic pain have difficulty with self-care activities like getting dressed.

Chronic pain is more prevalent and of greater intensity in the Veteran population than in the general population. It is often accompanied by co-existing mental health conditions. Unrelieved and persistent chronic pain can contribute to depression, anxiety, poor sleep patterns, decreased quality of life, and substance use disorder. It is also a risk factor for suicide. The consequences of chronic pain include lost work productivity, disability, and increased health care costs.

Joint and back pain and other musculoskeletal ailments are the most common diagnoses among Iraq and Afghanistan Veterans. In a 2017 report by the National Institutes of Health (NIH), 65.6% of American Veterans reported having pain in the three months before they were surveyed, with 9.1% classified as having severe pain. Severe pain was 40% greater in Veterans than non-Veterans, especially among those who served in recent conflicts.

VA's National Pain Management Strategy provides a system-wide standard of care to reduce suffering from preventable pain. As part of that strategy, the department's pain research portfolio covers a wide range of topics, from drug discovery, to complementary and integrative treatments, to the impact of pain on daily function and quality of life. The national program guides the direction of VA pain research, which in turn helps inform patient care.

Complementary and integrative health has been shown to be an effective alternative or addition to pain medication for many patients. A wide range of CIH therapies, such as acupuncture and yoga, are proving valuable in helping Veterans manage their pain.

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Selected Major Accomplishments in VA Research

  • 2000: Discovered that ion channels—specialized proteins in nerve cells—are heavily implicated in neuropathic pain
  • 2008: Established the VA Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center to study the interaction between pain and associated chronic conditions
  • 2014: Implemented the VA Overdose Education and Naloxone Distribution Program
  • 2015: Determined that VA's stepped-care model of pain management significantly reduced disability and pain interference and severity in Veterans with chronic pain
  • 2016Established the musculoskeletal diagnosis cohort, made up of more than 5 million Veterans in VA care, to characterize variations in pain, treatment, and outcomes
  • 2017Partnered with other federal agencies to fund $81 million in new research on nondrug treatment of pain for military personnel and Veterans
  • 2018: Published results from the Strategies for Prescribing Analgesics Comparative Effectiveness (SPACE) trial, which found no significant difference in function for Veterans receiving opioid or non-opioid medication for chronic back, hip, or knee pain

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New, Ongoing, and Published Research

VA researchers are working to develop new approaches to alleviate Veterans' pain, which may result from spinal cord injury, burns, amputations, traumatic brain injury, cancer, or musculoskeletal conditions. Some types of chronic pain, such as the nerve pain experienced by many people with spinal cord injury, are very difficult to treat.

VA investigators are conducting studies to find ways to decrease medical and behavioral harms related to opioid use and misuse, improve access to effective complementary approaches to pain care, and help Veterans select individualized treatment options to address pain and improve function, among other areas.

For more information on Pain Management, visit our  Afghanistan & Iraq Veterans Arthritis Gulf War Veterans Prosthetics PTSD Substance Use Disorders Suicide Prevention, and  Women's Health topic pages.

➤ Centers for pain research

Center for Neuroscience and Regeneration Research—Biomedical research conducted by VA investigators has contributed to the scientific understanding of pain, especially nerve pain. The  Center for Neuroscience and Regeneration Research is a collaboration among VA, the Yale School of Medicine, Paralyzed Veterans of America, and United Spinal Association. The center is a state-of-the-art research facility dedicated to molecular and cell-based discoveries targeting sodium channels that might lead to non-opioid analgesic development.

Pain, Research, Informatics, Medical comorbidities, and Education (PRIME) Center—VA's  Pain, Research, Informatics, Medical comorbidities, and Education (PRIME) Center, part of the VA Connecticut Healthcare System, conducts research to improve pain care and sponsors educational activities for Veterans and clinical staff. The PRIME Center's goals include advancing scientific knowledge and significantly impacting the care of Veterans living with pain and associated chronic conditions, such as depression or PTSD.

To meet these goals, the center studies the interactions between pain and associated chronic conditions and behavioral health factors to develop and implement effective interventions that can reduce pain, the negative impacts of pain on emotional and physical functioning, and the overall disease burden pain causes by employing principles of medical informatics, behavioral science, and health services research.

Tampa VAMC Chronic Pain Rehabilitation Program—VA's  Chronic Pain Rehabilitation Program, located at the James A. Haley Veterans Hospital in Tampa, Florida, is a nationally known center for chronic pain research, treatment, and education. The CPRP is the only Commission on Accreditation of Rehabilitation Facilities inpatient pain treatment center in the VA system.

The CPRP is a referral-based program for Veterans with chronic pain, including those living out-of-state. It offers inpatient and outpatient rehabilitation programs to help Veterans manage their chronic pain condition.

Center for Health Equity Research and Promotion—The  Center for Health Equity Research and Promotion (CHERP) is a VA Health Services Research and Development (HSR&D) Center of Innovation whose mission is to advance the quality and equity of health and health care for vulnerable Veteran populations. CHERP's research focuses on vulnerable Veteran populations, including those who face potential discrimination because of race, ethnicity, or social status, and those at risk for disparities in health or health care due to other physical or mental conditions.

CHERP is examining the associations of socio-economic status and geographic residence with pain management in Veterans. Researchers are:

  • Identifying and quantifying disparities in health care and health outcomes between vulnerable and non-vulnerable populations.
  • Identifying and understanding how multiple factors are associated with these disparities.
  • Designing and testing targeted interventions; assessing their efficacy, effectiveness, safety, and cost; and translating successful interventions into widespread clinical practice and policy.

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➤ Special programs and collaborations

CREATE: Pain Management and Patient Aligned Care—VA's Collaborative Research to Enhance and Advance Transformation and Excellence (CREATE) funding initiative encourages VA investigators to collaborate with other VA partners to conduct research on high-priority issues that affect the health and health care of Veterans.

VA's  Pain Management and Patient Aligned Care CREATE has three specific goals: to enhance Veterans' access to pain care, to use health information technology to promote better pain care for Veterans, and to build sustainable improvements in pain care. The program is anchored by three projects:

  • Longitudinal Musculoskeletal Cohort Study—This study examines variations in pain, pain treatment, the effects of co-existing conditions, and outcomes among Veterans receiving care from VA. Its results will be used to transform pain care and management within VA.
  • Effective Screening for Pain Study—This ongoing study aims to evaluate the effects of an enhanced, computer-aided pain screening and assessment tool to allow for the use of pain and function scores as an alternative to the currently used numerically based pain rating scale. The study's results will help improve the quality and clinical usefulness of the routine screenings for pain VA provides Veterans at every health encounter.
  • Comprehensive Opioid Management in Patient Aligned Care Teams (COMPACT)—The COMPACT study tests a telehealth-based self-management training system to promote improved care for Veterans receiving chronic opioid therapy. The primary aim of the study is to test the effectiveness of the system in improving physical and emotional functioning, the safe use of opioids, and quality of life. Because the COMPACT makes use of widely accessible automated telephone technology, researchers hypothesize the training system will broaden access to pain care and can be delivered with consistency, thereby reducing variability in care.

Pain/Opioid CORE—VA’s Pain/Opioid Consortium of Research (CORE) fosters high-quality, high-impact, and Veteran-centered research focused on improving care for and reducing opioid harms by building a network of researchers and promoting interdisciplinary-cross institutional research collaborations. Major themes of the CORE include:

  • Behavioral and self-management approaches for pain, including studies of complementary and integrative health approaches, exercise and movement, and psychological and behavioral interventions.
  • Pain management interventions and care delivery, including studies of VA practice and policy initiatives and pain care delivery approaches.
  • Long-term opioid therapy, opioid misuse, (the use of opioids in a manner other than directed by a doctor), and opioid use disorder (OUD), including studies of tapering strategies.

Improving Access to Opioid Use Disorder Treatment—This Quality Enhancement Research Initiative (QUERI) hopes to implement and evaluate the evidence-based practice of medication-assisted treatment of opioid use disorder (OUD) in primary care settings. QUERI researchers will evaluate the implementation and impact of a provider support initiative at two VA medical centers and four community-based clinics. They will create an interactive implementation toolkit with guidance on strategies and resources to treat OUD, and will broadly disseminate this toolkit throughout VA.

Improving Pain-Related Outcomes for Veterans ( IMPROVE)—This QUERI, based at VA medical centers in West Haven, Connecticut, and Palo Alto, California, strives to optimize safe and effective pain management through partnered implementation of personalized, patient-centered interventions that increase Veterans' access to care.

The Academic Detailing to Improve Pain Management (ADQI) project shares best practices with other VA pharmacy managers to help them implement opioid-related programs at their facilities. Academic detailing refers to the process of educating prescribers about the benefits and harms of medications like opioids.

A Primary Care-Integrated Pain Support project is looking at ways to implement a pharmacist-led pain care program. Its aim is to decrease the number of Veterans who are currently receiving high-dose opioid and/or combination opioid-benzodiazepine therapy.  

A third project, Cooperative Pain Education and Self-management (COPES), uses technology to provide cognitive behavioral therapy in Veterans’ homes. The goal of this project is to increase the number of Veterans with access to non-pharmacological care for chronic pain, and to enhance the geographic reach of these services.

Stepped Care Model for Pain Management and Patient Aligned Care Teams—VA's  Stepped Care Model for Pain Management (SCM-PM) gives clinicians the ability to assess and treat pain within a primary care setting while enabling them to use other treatment options, including specialized care and multidisciplinary approaches.

The model is designed to integrate with Patient Aligned Care Teams (PACT), providing quality and accessible primary care to Veterans. SCM-PM and PACT help Veterans by ensuring that VA clinicians are fully trained in pain management techniques; ensuring that pain assessment is performed in a consistent manner throughout VA; and placing the Veteran at the center of their health care team, facilitating prompt and appropriate pain treatment. The SCM-PM also stresses the importance of equitable access to health care and the effective use of resources to manage pain for enrolled Veterans.

Pain Management SOTA—VA State of the Art (SOTA) Conferences bring together VA and non-VA experts to synthesize what we know and what we need to know about topics critical to the health and well-being of Veterans. Their aim is to promote implementation of findings that improve quality of care and contribute to more effective management and research.

SOTA XV, was held Sept. 11–12, 2019, and dealt with opioid safety. The team identified three goals: to develop recommendations to improve pain management and opioid safety, to reach consensus on a research agenda, and to prioritize issues for future consideration. Three evidence reviews were conducted at the conference that reviewed barriers and facilitators for medication-assisted therapy (MAT) for opioid-use disorder, the benefits and harms of long-term opioid dose reduction, and managing acute pain in patients with opioid-use disorders on MAT.

SOTA XIII, was held Nov. 3–4, 2016, and dealt with non-pharmacological approaches to chronic musculoskeletal pain management. Researchers examined patient responses to psychological /behavioral therapies; exercise/movement therapies; manual therapies; and models for delivering multi-modal pain care. Several products were generated by the work groups, to include an evidence synthesis brief titled "Effectiveness of Models Used to Deliver Multimodal Care for Chronic Musculoskeletal Pain," a webinar to present findings from the SOTA, and a special supplement to the Journal of General Internal Medicine on pain management.

National Pain Strategy—The Interagency Pain Research Coordinating Committee (IPRCC) was created by the Department of Health and Human Services (HHS) to enhance pain research efforts and promote government collaboration. Based on recommendations from the Institute of Medicine (now the National Academy of Medicine), the IPRCC created the National Pain Strategy (NPS) in 2016, with input from VA clinicians, academic institutions, advocates, and other federal agencies. The NPS provided guidelines for the effective treatment of pain across a person's lifetime. It emphasized pain education and management and disparities in treatment, as well as continued pain research.

The  Federal Pain Research Strategy (FPRS) builds on the guidelines set out by the NPS and was created to oversee development of a long-term strategic plan for federal agencies that support pain research. The FPRS  final report was released to provide guidelines for federal agencies as they develop expanded pain research programs.

NIH, DOD, and VA collaborations—VA researchers are collaborating with NIH's  National Center for Complementary and Integrative Health to support studies on effective CIH approaches to pain management in Veterans.

In 2017, VA, the Department of Defense, and HHS  announced a multicomponent research project focusing on nondrug approaches for pain management in service members and Veterans. Twelve research projects, totaling approximately $81 million over six years, are focused on developing, implementing, and testing cost effective, large-scale research on nondrug approaches for pain management in military and Veteran health care settings. The types of approaches being studied include mindfulness and meditation, movement interventions, psychological and behavioral interventions, and integrative approaches that combine interventions.

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➤ Chronic back pain

Chronic back pain can change people's lives. The condition can be debilitating, making daily activities such as driving a car or sitting at a desk extremely difficult. As many as 40% of Veterans over 65 have chronic back pain.

Low back pain study underway—A team led by researchers at the Richard L. Roudebush VA Medical Center and Stanford University has begun a national study to find the best approach to manage low back pain. The 6-year clinical trial, called the Sequential and Comparative Evaluation of Pain Treatment Effectiveness Response (SCEPTER), aims to enroll more than 2,500 participants at 20 VA medical centers. Patients will be randomly assigned to one of three treatments: a web-based pain self-management program, a web-based intervention combined with a physical therapist-directed exercise program that includes face-to-face appointments, or usual care. The second phase of the trial will compare cognitive behavioral therapy, chiropractic care, and a yoga-based intervention.

Value of chiropractic care—In 2014, researchers at the Canandaigua VA Medical Center looked at whether chiropractic care could relieve the disability caused by chronic back pain. They  studied 136 Veterans aged 65 or older with lower back pain who had never received chiropractic care. Half received spinal manipulative therapy (SMT) from a chiropractor; the others received a sham treatment, similar to a placebo. After 12 weeks, the researchers found that there was a statistically significant improvement in the level of disability of those who received SMT, but no difference in the level of pain compared with those who received the sham treatment. The team believes that the concern they showed about the pain of all patients in the study changed the way the Veterans felt about pain, and made them feel better.

In 2017, a VA Western New York Healthcare System study  found that chiropractic care can improve outcomes for some female Veterans with low back pain. After an average of eight chiropractic treatments, women saw an average of 27% improvement in pain, based on a back-pain questionnaire. The researchers concluded that chiropractic care may be of value for pain management in this population.

Telehealth cognitive behavioral therapy as good as in-person treatment—Cognitive behavioral therapy (CBT) for low back pain delivered by phone had similar results to in-person treatment, according to a 2017  study by VA San Diego Healthcare System researchers. Patients with chronic low back pain participated in eight weeks of either CBT or in-person supportive care. Both groups showed similar levels of pain improvement, demonstrating that telehealth approaches to psychotherapy could be useful in treating pain.

Acceptance and commitment therapy (ACT) is a psychological approach to help people deal with chronic pain. In 2017, a team led by researchers with the VA San Diego Healthcare System  found that Veterans receiving the therapy both in person and by video teleconferencing showed significant improvements in pain interference, pain severity, mental and physical health-related quality of life, pain acceptance, activity level, depression, and pain-related anxiety.

A 2017  study by VA researchers at the PRIME Center in New Haven, Connecticut, and colleagues found that Veterans who received either interactive voice-response CBT or in-person CBT experienced statistically significant reductions in average pain intensity three and six months after their study had been completed, but not at nine months. They also found the treatment dropout rate was lower among Veterans receiving CBT by telephone.

The results suggest that teleconferencing is an acceptable way to deliver the therapy.

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➤ Opioid medications

Opioids are medications that relieve pain. They reduce the intensity of pain signals reaching the brain and affect those brain areas controlling emotion, which diminishes the effects of a painful stimulus. Medications that fall within this class include hydrocodone, oxycodone, morphine, codeine, and others.

In the 1980s, many specialists believed that opioids had a low incidence of addictive behavior, and use of the drugs to treat long-term pain increased. Today, they understand that these efforts to improve pain management contributed to a drastic rise in the prescription rate for opioids, leading to opioid dependence among many Americans. The prevalence of opioid dependence may be as high as 26% among patients in primary care who receive opioids for chronic pain. Several studies have shown that using opioids for chronic pain may actually worsen pain and functioning.

New drug may lead to safer pain treatment—Researchers with the Southeast Louisiana Veterans Health Care System and Tulane University have developed a new drug to treat pain that has less risk for addiction and overdose compared to currently available opioid medications. In a 2019 study, investigators found that a drug called ZH853 was as effective as morphine at relieving pain in rats. The new drug reduced the length of time animals felt pain and in some instances had anti-inflammatory effects.

Further research is needed, said the researchers, before ZH853 can be prescribed for pain, including clinical trials in human subjects.

VA and Medicare Part D dual users more likely to take high-dose opioids—Veterans who use both VA and Medicare Part D to fill prescriptions were at a two to three times higher risk of high-dose opioid exposure than those using one system, according to a 2018 study led by researchers at the VA Pittsburgh Healthcare System. The team found that 13% of Veterans who filled at least one opioid prescription in 2012 received care from both VA and Medicare Part D. The dual-use group was more likely than the VA-only group to receive greater than 100 morphine milligram equivalents for one or more days, and were more likely to have long-term high-dose opioid use.

Opioid doses and risk of suicide—In a 2016 study, researchers with the VA Ann Arbor Healthcare System and University of Michigan  found that Veterans receiving the highest doses of opioid painkillers were more than twice as likely to die by suicide, compared with those receiving the lowest doses.

The research team looked at nearly 124,000 Veterans who received VA care in 2004 and 2005. All had non-cancer chronic pain and received prescriptions for opioids. Using the National Death Index, the researchers found that 2,601 of the patients died by suicide during the observation period. Of those deaths, 532 were from an intentional overdose.

They found the risk for suicide by any means rose as opioid dosage increased. The association between opioid dose and risk of suicide by overdose was not higher than for other methods of suicide. The researchers could not tell, however, whether there was a direct causal link between the pain medications and suicide risk. Instead, the high doses may be a marker for other factors that drive suicide, including unresolved severe chronic pain.

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➤ Osteoarthritis

Opioid medications not superior to non-opioids—Veterans with chronic knee, hip, or back pain treated for 12 months or more did as well or better receiving non-opioid medications than opioids, according to a 2018 study led by researchers at the Minneapolis VA Health Care System.

The study, published in the Journal of the American Medical Association, looked at 240 Veterans with chronic pain. Half received opioid medications for 12 months; the other half received non-opioid medications. The team measured how much pain interfered with their functioning, the intensity of their pain, and the side effects of medication over the 12-month period.

Researchers found there was no significant difference in pain-related function between the two groups, and that those taking non-opioids had slightly lower pain intensity and significantly fewer side effects than those who took opioids. The results supported active non-opioid medication management in Veterans with moderate to severe pain.

Another study led by Minneapolis VA researchers, published in 2020, looked at prescribing data for more than 50,000 Veterans receiving care from VA who were taking opioids. They found patients who had their opioid dosage increased did not have meaningful improvements in pain, compared with patients who continued to take the same dose. There was also an increased risk of side effects from higher doses.

The authors warned clinicians should exercise extreme caution when embarking on a path of increasing opioid dosage to manage non-cancer pain.

Collaborative care and self-management lead to best pain management results—Adding collaborative care by nurses and doctors to an automated self-management program improves outcomes for Veterans with chronic musculoskeletal pain and mood disorders, according to a study published in 2019 led by researchers at the Richard J. Roudebush VA Medical Center in Indianapolis.

In the study, nearly 300 patients with both depression and anxiety were treated for 12 months. In addition to standard primary care, including medication as needed, one group received automated monitoring and web-based self-management modules. The other group received self-management information along with collaborative care by a team of nurses and physicians who provided regular phone contacts and optimized medication management.

While the symptoms of both groups declined, those in the collaborative care group were more likely to report overall improvements and were less likely to have worsening symptoms.

Link between body weight and pain—A study published in 2020, led by researchers with the VA Boston Healthcare System and Boston University, found that patients with a musculoskeletal disorder and higher body weight were more likely to report experiencing pain.

The researchers examined health record data on nearly 2 million Veterans with musculoskeletal disorders including osteoarthritis; non-traumatic joint disorder; and low back, back, and neck pain. About 79% of these Veterans were overweight or obese, and 42% of the group said they did not have any pain.

The higher the patients’ body mass index (BMI) the more likely they were to report pain. Patients with BMIs indicating moderate obesity were 9% more likely to report pain, and those with severe obesity had 23% higher odds of pain. According to the research team, more study is needed to understand the relationship between weight and pain, even though a link has been established.

Electrical brain stimulation and knee pain—Directly stimulating the brain with an electrical current may reduce pain in patients with knee osteoarthritis, according to a 2017  study that included a researcher with the South Central VA Health Care Network. The study team used transcranial direct current stimulation (tDCS), an electrical current applied to the head of participants once a day for five consecutive days.

Participants who received the electrical current indicated that they had significantly less knee pain than the control group, suggesting that electrical stimulation could be an alternative to medication for reducing osteoarthritis pain. 

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➤ Complementary and integrative health

Complementary and integrative health therapies can be used alongside standard medications for the relief of pain, and sometimes can even replace them. CIH therapies include tai chi, yoga, meditation, and acupuncture. In 2016, Congress passed the  Comprehensive Addiction and Recovery Act, which mandates that CIH therapies be made available in VA to provide nonpharmacological options to treat pain and related health conditions.

VA researchers are looking at trends in Veterans’ use of these therapies and are generating knowledge about which of these therapies are most effective for pain and other conditions.

Non-drug therapies can reduce negative outcomes—Non-drug therapies may help military service members with chronic pain and could reduce the risk of adverse outcomes like substance use disorders and suicide attempts later in life.

In a study published in 2020, a team led by investigators with the VA Palo Alto Health Care System reviewed the VA health records of more than 140,000 former Army soldiers, all of whom had reported chronic pain after their deployment to Iraq or Afghanistan.

Veterans who received non-drug therapies like acupuncture, biofeedback, or chiropractic care during their service had a significantly lower risk of new-onset alcohol or drug use disorders; poisoning with opioids, barbiturates, or sedatives; and suicidal thoughts and attempts while under VA care. The research team did not study death by suicide.

Evidence lacking for benefits of medical marijuana—In 2017, researchers from the VA Portland Health Care System and Oregon Health and Science University reviewed 75 publications on the effects of medical marijuana on many types of chronic pain.

They  found limited evidence that marijuana use might alleviate neuropathic pain in some patients, and that it might reduce spasticity associated with multiple sclerosis. There was insufficient evidence on the benefits of marijuana for all other pain types. Between 45% and 80% of those who seek medical marijuana do so for pain management.

Current federal law prohibits the use or dispensing of marijuana. As a federal agency, VA follows this prohibition and does not prescribe medical marijuana to any of its patients.

Benefits of massage for pain relief—A 2016  review by VA’s Evidence-based Synthesis program pointed to the potential benefits of massage to relieve neck pain and other types of pain, but concluded larger and more rigorous studies are needed.

In 2017, researchers from the Richard L. Roudebush VA Medical Center in Indianapolis and the Indiana University School of Health and Rehabilitation Sciences began a  study to determine whether massages provided by Veterans’ caregivers can relieve chronic neck pain. The study will recruit 468 Veterans. Participants will be randomized into one of three groups: Veterans receiving caregiver-assisted massage, Veterans treated by professional massage therapists, or waitlist control group. Researchers will compare changes in pain-related disability and examine secondary outcomes that include pain severity, quality of life, depression, anxiety, and stress. The study is scheduled to conclude in 2021.

Electroacupuncture can ease pain by releasing stem cells—Electroacupuncture is a modern version of the ancient Chinese technique of acupuncture. Researchers at a number of scientific institutions in the United States and South Korea  found, in 2017, that electroacupuncture can ease pain and promote tissue repair in humans, horses, and rodents.

The process of electroacupuncture (using needles that carry a mild electric current) triggers the release of mesenchymal stem cells (MSCs) into the blood stream. MSCs originate from a wide variety of tissue in adults, and are being widely studied for their healing potential. In the study, the MSCs originated from adipose or fat tissue in humans treated with electroacupuncture. The research team used functional brain scans, blood tests, artery imaging, gene sequencing, and other laboratory methods to trace electroacupuncture’s actions on the brain and nervous system, which resulted in the release of MSCs. These MSCs may have a wide variety of therapeutic effects like enhancing tissue repair and providing pain relief. 

Researchers are now looking at whether MSCs can be used as a therapeutic tool in their own right.

Yoga helps Veterans with back pain—In a 2017  study of Veterans with chronic low back pain, a team of researchers from the VA San Diego Healthcare System found that Veterans who completed a 12-week yoga program had better scores on a disability questionnaire, improved pain intensity scores, and a decline in opioid use.

The 12-week yoga intervention was based on hatha yoga, and consisted of two 60-minute, instructor-led yoga sessions per week. Home practice sessions were encouraged. The study is one of the first to demonstrate the effectiveness of yoga for chronic low back pain specifically in Veterans.

Practitioner-delivered CIH therapies combined with self-care—The APPROACH Trial is a large-scale clinical trial to assess the effectiveness of combined practitioner-delivered CIH (acupuncture, massage) and self-care CIH (yoga, tai chi, mindfulness). Investigators will compare combined CIH therapy against one type of therapy alone among Veterans with chronic musculoskeletal pain. The trial aims to improve Veterans pain, reduce several pain-related conditions, and decrease opioid use. This effort is being conducted in partnership with the VA Office of Patient Centered Care and Cultural Transformation and is funded through March 2024.

Effectiveness of CIH therapy in Veterans—The Complementary and Integrative Health Evaluation Center is conducting four projects to evaluate the effectiveness of CIH therapies in Veterans. CIHEC investigators will conduct an environmental scan that will examine delivery points for CIH, survey the Veterans Insight Panel on demand for and use of CIH therapies, improve data collection for patient-related outcomes for CIH therapies, and examine barriers and facilitators for implementation of battlefield acupuncture within VA.

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➤ Pain in Gulf War Veterans

Structural damage linked to musculoskeletal pain in Gulf War Veterans—Chronic musculoskeletal pain affects around 25 % of Veterans who were deployed during the Persian Gulf War, and Veterans deployed to Iraq and Afghanistan more recently have shown similar rates. A 2017  study done at the William S. Middleton Memorial Veterans Hospital in Madison, Wisconsin, showed that structural damage in the brain may be linked to this type of pain.

The research team used magnetic resonance imaging to determine that study participants with chronic pain had widespread disruptions in the structure of their white matter across several regions of the brain. (White matter is deep tissue within the brain that contains axons, nerve fibers that conduct electrical signals and connect different brain areas.) Their results showed that poorer white matter health was linked to higher pain levels and higher levels of fatigue. It was also linked to higher levels of depression, although to a lesser extent.

Previous studies have suggested that Gulf War illness symptoms are related to structural changes in the brain. (For more information on VA research into chronic multisymptom illness in Gulf War Veterans, see our topic page on  Gulf War Veterans.)

Study underway to evaluate mindfulness-based intervention in Gulf War Veterans—Mindfulness-based interventions teach meditation practices intended to enhance awareness of the present moment and to emphasize continued practices after the program is completed. The Seattle division of the VA Puget Sound Health Care System is  studying an eight-week program called Mindfulness-based Stress Reduction to see if the program can reduce symptoms of chronic multisymptom illness in Gulf War Veterans. The study will be completed in 2021.

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More on Our Website

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Selected Scientific Articles by Our Researchers

Outcomes of prescription opioid dose escalation from chronic pain: results from a prospective cohort study. Morasco BJ, Smith N, Dobscha SK, Deyo RA, Hyde S, Yarborough BJH. Patients prescribed stable doses of long-term opioid therapy may demonstrate small changes in key pain-related outcomes over time, but prescription opioid dose escalation status is unrelated to clinical outcomes. Pain. 2020 Jun;161(6):1332-1340.

Impact of opioid dose escalation on pain intensity: a retrospective cohort study. Hayes CJ, Krebs EE, Hudson T, Brown J, Li C, Martin BC. Increasing chronic pain patients’ opioid prescription doses does not seem to improve pain. Pain. 2020 May;161(5):979-988.

The relationship between body mass index and pain intensity among Veterans with musculoskeletal disorders; findings from the MSD cohort study. Higgins DM, Buta E, Heapy AA, Driscoll MA, Kerns RD, Masheb R, Becker WC, Hausmann LRM, Bair MJ, Wandner L, Janke EA, Brandt CA, Goulet JL. There was a high prevalence of overweight/obesity among more than 1.7 million Veterans with musculoskeletal disorders. High levels of body mass index were associated with increased odds of pain. Pain Med. 2020 Mar 18. Online ahead of print.

Nonpharmacological treatment of Army service members with chronic pain is associated with fewer adverse outcomes after transition to the Veterans Health Administration. Meerwijk EL, Larson MJ, Schmidt EM, Adams RS, Bauer MR, Ritter GA, Buckenmaier 3rd C, Harris AHS. Nonpharmacological treatment provided in the military health service to service members with chronic pain may reduce the risk of long-term adverse outcomes. J Gen Intern Med. 2020 Mar;35(3):775-783.

Regional and rural-urban variation in opioid prescribing in the Veterans Health Administration. Lund BC, Ohl ME, Hadlandsmyth K, Mosher HJ. There is substantial regional and rural-urban variation in opioid prescribing in VHA. Rural veterans receive over 30% more opioids than their urban counterparts. Mil Med. 2019 Dec 1;184(11-12):894-900.

Opioid exposure negatively affects antidepressant response to venlafaxine in older adults with chronic low back pain and depression. Stahl ST, Jung C, Weiner DK, Pecina M, Karp JF. Opioids are negatively associated with older adults' early analgesic response to lower-dose venlafaxine. Pain Med. 2019 Oct 21. Online ahead of print. 

Menopausal symptoms and higher risk opioid prescribing in a national sample of women Veterans with chronic pain. Gibson CJ, Li Y, Huang AJ, Rife T, Seal KH. Among midlife women Veterans with chronic pain, evidence of menopausal symptoms was associated with potentially risky long-term opioid prescription patterns, independent of known risk factors. J Gen Intern Med. 2019 Oct;34(10):2159-2166.

Automated self-management (ASM) vs. ASM-enhanced collaborative care for chronic pain and mood symptoms: the CAMMPS randomized clinical trial. Kroenke K, Baye F, Lourens SG, Evans E, Weitlauf S, McCalley S, Porter B, Matthias MS, Bair MJ. Two intervention models relying heavily on telecare delivery but differing in resource intensity both produced moderate improvements in pain and mood symptoms. However, the model combining collaborative care led by a nurse-physician team with web-based self-management was superior to self-management alone. J Gen Intern Med. 2019 Sep;34(9):1806-1814.

Buprenorphine treatment divide by race/ethnicity and payment. Lagisetty PA, Ross R, Bohnert A, Clay M, Maust DT. For every appointment in which a person of color received a prescription for buprenorphine, white patients had thirty-five such appointments. JAMA Psychiatry. 2019 May 8;76(9):979-981. 

Morphine immunomodulation prolongs inflammatory and postoperative pain while the novel analgesic ZH853 accelerates recovery and protects against latent sensitization. Feehan AK, Zadina JE. ZH853 is an excellent candidate for clinical development in humans for inflammatory and postoperative pain. J Neuroinflammation. 2019 May 21;16(1):100.

Dual receipt of prescription opioids from the Department of Veterans Affairs and Medicare Part D and prescription opioid overdose death among Veterans: a nested case-control study. Moyo P, Zhao X, Thorpe CT, Thorpe JM, Sileanu FE, Cashy JP, Hale JA, Mor MK, Radomski TR, Donohue JM, Hausman LRM, Hanlon JT, Good CB, Fine MJ, Gellad WF. Among veterans enrolled in VA and Medicare Part D, dual use of opioid prescriptions was independently associated with death from prescription opioid overdose. Ann Intern Med. 2019 Apr 2;170(7):433-442.

Noninvasive vagus nerve stimulation alters neural response and physiological autonomic tone to noxious thermal challenge. Lerman I, Davis B, Huang M, Huang C, Sorkin L, Proudfoot J, Zhong E, Kimball D, Rao R, Simon B, Spadoni A, Strigo I, Baker D, Simmons AN. Stimulating the vagus nerve in the neck might help ease pain associated with PTSD. PLoS One. 2019 Feb 13;14(2):e0201212.

High variability of opioid prescribing within and across emergency departments in the US Veterans Health Administration. Sowicz TJ, Gordon AJ, Gellad WF, Zhao X, Zhang H, Emmendorfer T, Good CB. Opioid prescribing rates vary widely in 118 VA emergency departments. J Gen Intern Med. 2018 Nov;33(11):1831-1832.

Battlefield acupuncture in the Veterans Health Administration: effectiveness in individual and group settings for pain and pain comorbidities. Federman DG, Zeliadt SB, Thomas ER, Carbone Jr. GF, Taylor ST. Battlefield acupuncture is effective for immediate relief of pain for the overwhelming majority of Veterans and holds promise as a nonpharmacologic pain-management intervention. Med Acupunct. 2018 Oct 1;30(5):273-278.

Decline in prescription opioids attributable to decreases in long-term use: a retrospective study in the Veterans Health Administration 2010-2016. Hadlandsmyth K, Mosher H, Vander Weg MW, Lund BC. Opioid prescribing trends followed similar trajectories in VHA and non-VHA settings, peaking around 2012 and subsequently declining. However, changes in long-term opioid prescribing accounted for most of the decline in the VHA. J Gen Intern Med. 2018 Jun;33(6):818-824.

Effect of opioid vs. nonopioid medications on pain related function in patients with chronic back pain or hip or knee osteoarthritis pain: the SPACE randomized clinical trial. Krebs EE, Gravely A, Nugent S, Jensen AC, DeRonne B, Goldsmith ES, Kroenke K, Bair MJ, Noorbaloochi S. Treatment with opioids was not superior to treatment with non-opioid medications for improving pain-related function over 12 months. Results do not support initiation of opioid therapy for moderate to severe chronic back pain or hip or knee osteoarthritis pain. JAMA. 2018 Mar 6;319(9):872-882.

Electronic medical record alert associated with reduced opioid and benzodiazepine coprescribing in high-risk Veteran patients. Malte CA, Berger D, Saxon AJ, Hagedorn HJ, Achtmeyer CE, Mariano AJ, Hawkins EJ. Medication alerts hold promise as a means of reducing opioid and benzodiazepine co-prescribing among certain high-risk groups. Med Care. 2018 Feb;56(2):171-178.

Impact of Dual Use of Department of Veterans Affairs and Medicare Part D Drug Benefits on Potentially Unsafe Opioid Use. Gellad WF, Thorpe JM, Zhao X, Thorpe CT, Sileanu FE, Cashy JP, Hale JA, Mor MK, Radomski TR, Hausmann LRM, Donohue JM, Gordon AJ, Suda KJ, Stroupe KT, Hanlon JT, Cunningham EF, Good CB, Fine MJ. Among Veterans dually enrolled in VA and Medicare Part D, dual use of opioids was associated with more than 2 to 3 times the risk of high-dose opioid exposure. Am J Public Health. 2018 Feb;108(2):248-255.

Interactive voice response-based self-management for chronic back pain: the COPES noninferiority randomized trial. Heapy AA, Higgins DM, Goulet JL, LaChapppelle KM, Driscoll MA, Cziapinski RA, Buta E, Piette JD, Krein SL, Kerns RD. Interactive voice response-based cognitive behavioral therapy is a low-burden alterative that shows promise as a nonpharmacologic treatment option for chronic pain. JAMA Intern Med. 2017 Jun 1;177(6):765-773.

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