Effective Pain Interventions for Veterans

A stepped-care intervention studied by researchers from the Richard L. Roudebush VA Medical Center in Indianapolis, the Regenstrief Institute and the Indiana University School of Medicine appears to statistically significantly improve pain-related disability among veterans of recent military operations. Published in the March 9 issue of JAMA Internal Medicine, the study involved 241 veterans of Operations Enduring Freedom, Iraqi Freedom, and New Dawn who suffered from chronic musculoskeletal pain of the back, knee, neck or shoulder.

Research has shown that US military veterans returning from Iraq or Afghanistan are more likely to suffer chronic pain than veterans of any other conflict in American history. The strategy utilized in the current study offers new hope for these veterans through the combination of analgesics, self-management strategies, and brief cognitive behavioral therapy. The combination resulted in statistically significant reductions in pain-related disability, pain interference, and pain severity in the study population.

“Pain is disabling and interferes with daily living as well as the ability to work,” said Matthew Bair, MD, Associate Professor of Medicine, Indiana University School of Medicine; Research Scientist, Center for Health Services Research, Regenstrief Institute, Inc; Core Investigator, VA HSR&D Center for Health Information and Communication; and lead author of the study, dubbed ESCAPE (Evaluation of Stepped Care for Chronic Pain). “It is a critical health issue among veterans, many of whom had multiple, often lengthy deployments…Many have significant long-term pain. We know that medications alone are only modestly successful in helping them; current pain treatments haven't made much of a dent. The decrease in pain severity and 30 percent improvement in pain-related disability we achieved in the ESCAPE study are clinically significant, and we found that improvement lasted for at least nine months.”

For the study, 241 veterans were randomized to the stepped care strategy or usual care from December 20, 2007 through June 30, 2011, with a 9-month follow-up completed by April 2012. Usual care consisted of education handouts on musculoskeletal pain and advices to discuss pain with a physician.

Step 1 of the intervention included 12 weeks of analgesic treatment and optimization according to an evidence-based algorithm coupled with pain self-management strategies, including goal setting, problem solving, positive self-talk, relaxation techniques, behavioral plans, and communication with their primary care physicians.

Following step 1, patients continued analgesics and self-management strategies and proceeded immediately to step 2, which included 12 weeks of cognitive behavioral therapy based on the concept that thoughts affect feelings that, in turn, affect behaviors. Therapy involved six, biweekly sessions delivered by telephone. These 45-minute sessions were provided by nurse cancer managers who conversed with veterans about thoughts and feelings about pain, previous pain treatments, identification of barriers to reducing functional limitations and pain severity, and cognitive restructuring after coaching from a psychologist. The nurse care managers also helped the veterans identify and overcome maladaptive thoughts by examining the accuracy and usefulness of these thoughts and developing more adaptive cognitions.

Patients who completed both steps experienced improvements in function as well as decreases in pain severity and the level with which pain interfered with mood, physical activity, work, social activity, relations with others, sleep and enjoyment of life.