Factors associated with participation in a walking intervention for veterans who smoke and have chronic pain.

This analysis was part of the Pain and Smoking Study (PASS), a randomized trial of a cognitive behavioral intervention (CBI) for Veterans with chronic pain who smoke. The objective of this study was to examine factors associated with participation in the walking component of the intervention. Demographics and clinical characteristics were obtained at baseline. Completion of two or more CBI counseling sessions was required to be included in analyses. Average daily step counts obtained via pedometer in the prior week were recorded in up to three telephone counseling sessions. Participants were then categorized as "sedentary" (≤ 4999 daily steps) or "not sedentary" (≥ 5000 daily steps). Multivariable logistic regression was used to model variance in activity categorization. Overall, 91.0% of participants were men, 70.5% were white, mean age was 58.4 years, mean BMI was 28.6, median pack years was 20.5, and 43.8% were depressed. Veterans reported moderate pain intensity (4.9/10) and pain interference (5.4/10). Pain locations included: lower extremity (67.4%), back (53.4%) and upper extremity (28.1%). Median daily steps were 2491 [IQR: 1720-3550] (sedentary) (n = 65), 7307 [IQR: 5952-8533] (not sedentary) (n = 24), and 3196 [IQR: 2237-5067] (overall) (n = 89). Veterans with older age (odds ratio (OR): 1.10, 95% confidence interval (CI): 1.04, 1.17) and presence of LE pain (OR: 5.98, 95% CI: 1.82, 19.65) had increased odds of being "sedentary." Integrated smoking cessation and chronic pain self-management interventions that include a walking component may need to consider the impact of age and pain location on participation.Trial registration: The trial is registered at www.ClinicalTrials.gov (NCT02971137). First posted on November 22, 2016.

Using Daily Ratings to Examine Treatment Dose and Response in Cognitive Behavioral Therapy for Chronic Pain: A Secondary Analysis of the Co-Operative Pain Education and Self-Management Clinical Trial.

BACKGROUND: Cognitive behavioral therapy for chronic pain (CBT-CP) has a strong evidence base, but little is known about when treatment benefits are achieved. The present study is a secondary analysis of individuals with chronic back pain recruited for a noninferiority trial comparing interactive voice response (IVR) CBT-CP with in-person CBT-CP. METHODS: On the basis of data from daily IVR surveys, a clinically meaningful change was defined as a 30% reduction in pain intensity (n = 108) or a 45% increase in daily steps (n = 104) compared with the baseline week. We identified individuals who achieved a meaningful change at any point during treatment, and then we compared those who maintained a meaningful change in their final treatment week (i.e., responders) with those who did not or who achieved a meaningful change but lapsed (i.e., nonresponders). RESULTS: During treatment, 46% of participants achieved a clinically meaningful decrease in pain intensity, and 66% achieved a clinically significant increase in number of steps per day. A total of 54% of patients were classified as responders in terms of decreases in pain intensity, and 70% were responders in terms of increases in step count. Survival analyses found that 50% of responders first achieved a clinically meaningful change by week 4 for pain intensity and week 2 for daily steps. Dropout and demographic variables were unrelated to responder status, and there was low agreement between the two measures of treatment response. CONCLUSIONS: Collectively, results suggest that most responders improve within 4 weeks. Evaluating treatment response is highly specific to the outcome measure, with little correlation across outcomes.

"It Made Me Not Want to See him ": The Role of Patient-Provider Communication in Influencing Rural-Dwelling Women Veterans' Motivation to Seek Health Care for Managing Chronic Pain.

Despite being high health care utilizers, many women Veterans perceive their pain condition to be poorly understood by their providers, which can be a strong demotivator for seeking care. We set out to understand the priorities rural-dwelling women Veterans have for using health care for their chronic pain, and interviewed participants about their experiences with (and priorities for seeking) health care for their chronic pain. Self-Determination Theory identifies three sources of motivation (autonomy, competence, relatedness), all of which were represented through two themes that reflect rural women Veterans' rationale for decision-making to obtain health care for chronic pain: role of trust and competing priorities. Women described their priorities for chronic pain management in terms of their competing priorities for work, education, and supporting their family, but most expressed a desire to function in their daily life and relationships. Second, women discussed the role of trust in their provider as a source of motivation, and the role of patient-provider communication skills and gender played in establishing trust. Rural women Veterans often discussed core values that stemmed from facets of their identity (e.g. gender, military training, ethnicity) that also influenced their decision-making. Our findings provide insight for how providers may use Motivational Interviewing and discuss chronic pain treatment options so that rural-dwelling women Veterans feel autonomous, competent, and understood in their decision-making about their chronic pain. We also discuss importance of acknowledging the effects of disenfranchising talk and perpetuating gendered stereotypes related to chronic pain and theoretical implications of this work.

Risk Factors Associated with Healthcare Utilization for Spine Pain.

OBJECTIVE: This study examined potential risk factors associated with healthcare utilization among patients with spine (i.e., neck and back) pain. METHODS: A two-stage sampling approach examined spine pain episodes of care among veterans with a yearly outpatient visit for six consecutive years. Descriptive and bivariate statistics, followed by logistic regression analyses, examined baseline characteristics of veterans with new episodes of care who either continued or discontinued spine pain care. A multivariable logistic regression model examined correlates associated with seeking continued spine pain care. RESULTS: Among 331,908 veterans without spine pain episodes of care during the 2-year baseline observation period, 16.5% (n = 54,852) had a new episode of care during the following 2-year observation period. Of those 54,852 veterans, 37,025 had an outpatient visit data during the final 2-year follow-up period, with 53.7% (n = 19,865) evidencing continued spine pain care. Those with continued care were more likely to be overweight or obese, non-smokers, Army veterans, have higher education, and had higher rates of diagnoses of all medical and mental health conditions examined at baseline. Among several important findings, women had 13% lower odds of continued care during the final 2-year observation period, OR 0.87 (0.81, 0.95). CONCLUSIONS: A number of important demographics and clinical correlates were associated with increased likelihood of seeking new and continued episodes of care for spine pain; however, further examination of risk factors associated with healthcare utilization for spine pain is indicated.

Co-Operative Pain Education and Self-management (COPES) Expanding Treatment for Real-World Access (ExTRA): Pragmatic Trial Protocol.

BACKGROUND: Given access barriers to cognitive behavioral therapy for chronic pain (CBT-CP), this pragmatic superiority trial will determine whether a remotely delivered CBT-CP intervention that addresses these barriers outperforms in-person and other synchronous forms of CBT-CP for veterans with musculoskeletal pain. DESIGN: This pragmatic trial compares an asynchronous form of CBT-CP that uses interactive voice response (IVR) to allow patients to participate from their home (IVR CBT-CP) with synchronous CBT-CP delivered by a Department of Veterans Affairs (VA) clinician. Veterans (n=764; 50% male) with chronic musculoskeletal pain throughout nine VA medical centers will participate. The primary outcome is pain interference after treatment (4 months). Secondary outcomes, including pain intensity, depression symptom severity, sleep, self-efficacy, and global impression of change, are also measured after treatment. Where possible, outcomes are collected via electronic health record extraction, with remaining measures collected via IVR calls to maintain blinding. Quantitative and qualitative process evaluation metrics will be collected to evaluate factors related to implementation. A budget impact analysis will be performed. SUMMARY: This pragmatic trial compares the outcomes, cost, and implementation of two forms of CBT-CP as delivered in the real-world setting. Findings from the trial can be used to guide future policy and implementation efforts related to these interventions and their use in the health system. If one of the interventions emerges as superior, resources can be directed to this modality. If both treatments are effective, patient preferences and health care system factors will take precedence when making referrals. Implications of COVID-19 on treatment provision and trial outcomes are discussed.

The Relationship Between Body Mass Index and Pain Intensity Among Veterans with Musculoskeletal Disorders: Findings from the MSD Cohort Study.

OBJECTIVE: To examine the relationship between body mass index (BMI) and pain intensity among veterans with musculoskeletal disorder diagnoses (MSDs; nontraumatic joint disorder; osteoarthritis; low back, back, and neck pain). SETTING: Administrative and electronic health record data from the Veterans Health Administration (VHA). SUBJECTS: A national cohort of US military veterans with MSDs in VHA care during 2001-2012 (N = 1,759,338). METHODS: These cross-sectional data were analyzed using hurdle negative binomial models of pain intensity as a function of BMI, adjusted for comorbidities and demographics. RESULTS: The sample had a mean age of 59.4, 95% were male, 77% were white/Non-Hispanic, 79% were overweight or obese, and 42% reported no pain at index MSD diagnosis. Overall, there was a J-shaped relationship between BMI and pain (nadir = 27 kg/m2), with the severely obese (BMI ≥ 40 kg/m2) being most likely to report any pain (OR vs normal weight = 1.23, 95% confidence interval = 1.21-1.26). The association between BMI and pain varied by MSD, with a stronger relationship in the osteoarthritis group and a less pronounced relationship in the back and low back pain groups. CONCLUSIONS: There was a high prevalence of overweight/obesity among veterans with MSD. High levels of BMI (>27 kg/m2) were associated with increased odds of pain, most markedly among veterans with osteoarthritis.

The feasibility of a group stress management Liver SMART intervention for patients with end-stage liver disease: A pilot study.

OBJECTIVE: Structured, empirically supported psychological interventions are lacking for patients who require organ transplantation. This stage IA psychotherapy development project developed and tested the feasibility, acceptability, tolerability, and preliminary efficacy of an 8-week group cognitive behavioral stress management intervention adapted for patients with end-stage liver disease awaiting liver transplantation. METHOD: Twenty-nine English-speaking United Network for Organ Sharing-registered patients with end-stage liver disease from a single transplantation center enrolled in 8-week, group cognitive-behavioral liver stress management and relaxation training intervention adapted for patients with end-stage liver disease. Patients completed pre- and postintervention surveys that included the Beck Depression Inventory II and the Beck Anxiety Inventory. Feasibility, acceptability, tolerability, and preliminary efficacy were assessed.ResultAttendance rate was 69.40%. The intervention was rated as "good" to "excellent" by 100% of participants who completed the postintervention survey in teaching them new skills to relax and to cope with stress, and by 94.12% of participants in helping them feel supported while waiting for a liver transplant. No adverse events were recorded over the course of treatment. Attrition was 13.79%. Anxious and depressive symptoms were not statistically different after the intervention.Significance of resultsThe liver stress management and relaxation training intervention is feasible, acceptable, and tolerable to end-stage liver disease patients within a transplant clinic setting. Anxious and depressive symptoms remained stable postintervention. Randomized controlled trials are needed to study the intervention's effectiveness in this population.

Use of Non-Pharmacological Pain Treatment Modalities Among Veterans with Chronic Pain: Results from a Cross-Sectional Survey.

BACKGROUND: Despite strong evidence for the effectiveness of non-pharmacological pain treatment modalities (NPMs), little is known about the prevalence or correlates of NPM use. OBJECTIVE: This study examined rates and correlates of NPM use in a sample of veterans who served during recent conflicts. DESIGN: We examined rates and demographic and clinical correlates of self-reported NPM use (operationalized as psychological/behavioral therapies, exercise/movement therapies, and manual therapies). We calculated descriptive statistics and examined bivariate associations and multivariable associations using logistic regression. PARTICIPANTS: Participants were 460 veterans endorsing pain lasting ≥ 3 months who completed the baseline survey of the Women Veterans Cohort Study (response rate 7.7%. MAIN MEASURES: Outcome was self-reported use of NPMs in the past 12 months. KEY RESULTS: Veterans were 33.76 years old (SD = 10.72), 56.3% female, and 80.2% White. Regarding NPM use, 22.6% reported using psychological/behavioral, 50.9% used exercise/movement and 51.7% used manual therapies. Veterans with a college degree (vs. no degree; OR = 2.51, 95% CI = 1.46, 4.30, p = 0.001) or those with worse mental health symptoms (OR = 2.88, 95% CI = 2.11, 3.93, p < 0.001) were more likely to use psychological/behavioral therapies. Veterans who were female (OR = 0.63, 95% CI = 0.43, 0.93, p = 0.02) or who used non-opioid pain medications (OR = 1.82, 95% CI = 1.146, 2.84, p = 0.009) were more likely to use exercise/movement therapies. Veterans who were non-White (OR = 0.57, 95% CI = 0.5, 0.94, p = 0.03), with greater educational attainment (OR = 2.11, 95% CI = 1.42, 3.15, p < 0.001), or who used non-opioid pain medication (OR = 1.71, 95% CI = 1.09, 2.68, p = 0.02) were more likely to use manual therapies. CONCLUSIONS: Results identified demographic and clinical characteristics among different NPMs, which may indicate differences in veteran treatment preferences or provider referral patterns. Further study of provider referral patterns and veteran treatment preferences is needed to inform interventions to increase NPM utilization. Research is also need to identify demographic and clinical correlates of clinical outcomes related to NPM use.

Patient Experiences Navigating Chronic Pain Management in an Integrated Health Care System: A Qualitative Investigation of Women and Men.

Background: Rates of pain among veterans are as high as 60%; rates approach 80% in women seeking Department of Veterans Affairs (VA) care. Prior studies examined experiences managing pain in community samples, with gender disparities observed. As the largest national integrated health care system in the country, the VA offers a unique environment to a) study perceptions of pain care among men and women and b) contrast experiences using an integrated health care setting with prior observations in the private sector. Methods: A purposive sample of chronic pain patients was recruited to qualitatively describe perceptions of managing pain in an integrated health care system (VA) and to explore gender differences. A constant comparative approach with sequential analysis was used to reach thematic consensus. Results: Ten focus groups (N = 48; six groups of women [N = 22]; four groups of men [N = 26]) revealed an overarching theme, "just keep plugging," which reflected pain as a constant struggle. Three subthemes emerged: "always a reacquaintance process" described frustration with the use of trainees in the medical center. The need to navigate "so many hoops" referred to frustrations with logistical barriers. "To medicate or not" reflected tensions around medication use. A distinct theme, "the challenges of being female," reflected women's perceptions of stigma and bias. Conclusions: Most of the identified challenges were not unique to the integrated setting. Findings revealed advantages to receiving pain care in this setting. Tensions between patient expectations and guidelines governing provider behavior emerged. Improved patient education, provider communication and sensitivity to the unique needs of women may optimize care.

A Brief, Integrated, Telephone-Based Intervention for Veterans Who Smoke and Have Chronic Pain: A Feasibility Study.

Objective: High rates of co-occurring smoking and chronic pain are observed in the veteran population. Individuals who smoke and have chronic pain report lower self-efficacy to quit and are less successful in their attempts. Design: In this pilot study, we assess the feasibility of a telephone-delivered intervention designed to integrate evidence-based smoking cessation and pain management components in a way that allows patients to understand the interplay between the two while attempting to have them build off each other and develop coping skills to address both concerns. Patients: Study participants (N = 7) were veterans who received primary care in the VA Healthcare System and reported current smoking and a worst pain intensity score of 4 or greater. Intervention: A five-session telephone intervention was delivered over eight weeks. Participants completed a survey at baseline and 10-week follow-up. Outcome Measures: Feasibility was assessed by examining engagement with the intervention. Results: Four out of seven participants completed all five sessions. Two out of seven veterans reported quitting smoking, and five out of seven reported clinically meaningful improvements in pain intensity and functional interference. Conclusions: Insights gained from this study were used to modify an intervention being examined in a randomized controlled trial to test its effectiveness on both smoking and pain outcomes.

Predictors of Participation in a Nonpharmacological Intervention for Chronic Back Pain.

Objective: Cognitive behavioral therapy for chronic pain (CBT-CP) has been identified as an evidence-based adjunct or alternative to opioid pain care. However, little is known about which patients participate in CBT-CP. This study examined predictors of enrollment in a noninferiority trial of in-person vs technology-based CBT-CP for patients with chronic back pain. Setting: A single Veterans Health Affairs (VHA) medical center. Subjects: Veterans with chronic back pain. Design and Methods: For eligible participants (N = 290), individual factors (demographics, distance from a VHA medical center, pain intensity, receipt of opioid prescription, and recruitment method) collected at trial screening were examined to identify predictors of enrollment (i.e., signed consent form). Of those who enrolled, duration of participation in the treatment portion of the study was examined. Results: Among eligible patients, 54% declined enrollment due to lack of interest. Regression analyses revealed that patients not in receipt of an opioid were more likely to enroll. The probability of being in the trial long enough to receive a "dose" of treatment (3 visits or more) was 0.76 (0.04). Conclusions: Overall, enrollment rates were low. However, most patients who enrolled in the study (102 of 134 signed consent) were retained and received a treatment dose. Patients not receiving opioids were more likely to enroll, suggesting that patients who are prescribed opioids, an important group for treatment outreach, are likely underengaged. Identifying predictors of enrollment in CBT-CP may help increase recruitment efficiency and assist in targeting patients who may benefit but are not currently interested in treatment.

Impact of Cigarette Smoking Status on Pain Intensity Among Veterans With and Without Hepatitis C.

Objective: Chronic pain is a significant problem in patients living with hepatitis C virus (HCV). Tobacco smoking is an independent risk factor for high pain intensity among veterans. This study aims to examine the independent associations with smoking and HCV on pain intensity, as well as the interaction of smoking and HCV on the association with pain intensity. Design/Particpants: Cross-sectional analysis of a cohort study of veterans of Operations Enduring Freedom/Iraqi Freedom/New Dawn (OEF/OIF/OND) who had at least one visit to a Veterans Health Administration (VHA) primary care clinic between 2001 and 2014. Methods: HCV was identified using ICD-9 codes from electronic medical records (EMRs). Pain intensity, reported on a 0-10 numeric rating scale, was categorized as none/mild (0-3) and moderate/severe (4-10). Results: Among 654,841 OEF/OIF/OND veterans (median age [interquartile range] = 26 [23-36] years), 2,942 (0.4%) were diagnosed with HCV. Overall, moderate/severe pain intensity was reported in 36% of veterans, and 37% were current smokers. The adjusted odds of reporting moderate/severe pain intensity were 1.23 times higher (95% confidence interval [CI] = 1.14-1.33) for those with HCV and 1.26 times higher (95% CI = 1.25-1.28) for current smokers. In the interaction model, there was a significant Smoking Status × HCV interaction (P = 0.03). Among veterans with HCV, smoking had a significantly larger association with moderate/severe pain (adjusted odds ratio [OR] = 1.50, P < 0.001) than among veterans without HCV (adjusted OR = 1.26, P < 0.001). Conclusions: We found that current smoking is more strongly linked to pain intensity among veterans with HCV. Further investigations are needed to explore the impact of smoking status on pain and to promote smoking cessation and pain management in veterans with HCV.

Developing a typology of patient-generated behavioral goals for cognitive behavioral therapy for chronic pain (CBT-CP): classification and predicting outcomes.

Patient-generated treatment goals describe what patients value, yet the content of these goals, and the relationship among goal types, goal accomplishment, and treatment outcomes has received little examination. We used inductive sorting to categorize patient-generated goals made by 147 adults receiving cognitive-behavioral therapy for chronic pain. The resulting goal categories were: Physical Activity (29.0%), Functional Status (24.6%), Wellness (16.3%), Recreational Activities (11.3%), House/Yard Work (9.7%), Socializing (7.1%), and Work/School (2.0%). Next, we examined associations between number of goals by category, goal accomplishment, and clinically meaningful improvements in pain-related interference, pain intensity and depressive symptoms. Improvement in all outcome domains was related to goal accomplishment. Additionally, depressive symptoms were related to number of Physical Activity, House/Yard Work, Recreational Activities, and Wellness goals, whereas improved pain-intensity was significantly related to House/Yard Work. Classifying patient-generated goals facilitates investigation of the relationships among goal type, goal accomplishment and treatment outcomes.

Examining Gender as a Correlate of Self-Reported Pain Treatment Use Among Recent Service Veterans with Deployment-Related Musculoskeletal Disorders.

OBJECTIVE: Women veterans with chronic pain utilize health care with greater frequency than their male counterparts. However, little is known about gender differences in the use of specialty pain care in this population. This investigation examined gender differences in self-reported use of opioids, interventional pain treatments, rehabilitation therapies, and complementary and integrative health (CIH) services for chronic pain treatment both within and outside of the Veterans Health Administration in a sample of veterans who served in support of recent conflicts. METHODS: Participants included 325 veterans (54% women) who completed a baseline survey as part of the Women Veterans Cohort Study and reported deployment-related musculoskeletal conditions and chronic pain. Measures included self-reported use of pain treatment modalities, pain severity, self-rated health, access to specialty care, disability status, and presence of a mental health condition. RESULTS: Men were more likely to report a persistent deployment-related musculoskeletal condition but were no more likely than women to report chronic pain. Overall, 21% of the sample reported using opioids, 27% used interventional strategies, 59% used rehabilitation therapies, and 57% used CIH services. No significant gender differences in use of any pain treatment modality were observed. CONCLUSIONS: Use of pain specialty services was common among men and women, particularly rehabilitative and CIH services. There were no gender differences in the self-reported use of different modalities. These results are inconsistent with documented gender differences in pain care. They encourage further examination of gender differences in preferences and other individual difference variables as predictors of specialty pain care utilization.

Cigarette Smoking Status and Receipt of an Opioid Prescription Among Veterans of Recent Wars.

Objective: Cigarette smokers seeking treatment for chronic pain have higher rates of opioid use than nonsmokers. This study aims to examine whether veterans of Operations Enduring Freedom/Iraqi Freedom/New Dawn (OEF/OIF/OND) who smoke are more likely to receive an opioid prescription than nonsmokers, adjusting for current pain intensity. Design: Cross-sectional analysis of a cohort study of OEF/OIF/OND veterans who had at least one visit to a Veterans Health Administration primary care clinic between 2001 and 2012. Methods: Smoking status was defined as current, former, and never. Current pain intensity (+/- 30 days of smoking status), based on the 0-10 numeric rating scale, was categorized as no pain/mild (0-3) and moderate/severe (4-10). Opioid receipt was defined as at least one prescription filled +/- 30 days of smoking status. Results: We identified 406,954 OEF/OIF/OND veterans: The mean age was 30 years, 12.5% were women (n = 50,988), 66.3% reported no pain or mild pain intensity, 33.7% reported moderate or severe pain intensity, 37.2% were current smokers, and 16% were former smokers. Overall, 33,960 (8.3%) veterans received one or more opioid prescription. Current smoking (odds ratio [OR] = 1.56, 95% confidence interval [CI] = 1.52-1.61) and former smoking (OR = 1.27, 95% CI = 1.22-1.32) were associated with a higher likelihood of receipt of an opioid prescription compared with never smoking, after controlling for other covariates. Conclusions: We found an association between smoking status and receipt of an opioid prescription. The effect was stronger for current smokers than former smokers, highlighting the need to determine whether smoking cessation is associated with a reduction in opioid use among veterans.

Psychosocial Vulnerability, Resilience Resources, and Coping with Infertility: A Longitudinal Model of Adjustment to Primary Ovarian Insufficiency.

BACKGROUND: The infertility associated with primary ovarian insufficiency (POI) presents significant emotional challenges requiring psychosocial adjustment. Few investigations have explored the longitudinal process of adaptation to POI. PURPOSE: This longitudinal investigation tests a model of adjustment to POI that includes separate psychosocial vulnerability and resilience resource factors. METHODS: Among 102 women with POI, personal attributes reflective of vulnerability and resilience were assessed at baseline. Coping strategies were assessed 4 months later and measures of distress and well-being 12 months later. RESULTS: As hypothesized, confirmatory factor analysis yielded separate, inversely correlated vulnerability and resilience resource factors at baseline, and distress and well-being factors at 12 months. Contrary to predictions, maladaptive and adaptive coping strategies were not bi-factorial. Moreover, a single stand-alone strategy, avoidance (i.e., refusing to acknowledge stress), mediated the association between baseline vulnerability and 12-month distress. CONCLUSIONS: For women with POI, interventional studies targeted to reduce avoidance are indicated.

Integrated, Team-Based Chronic Pain Management: Bridges from Theory and Research to High Quality Patient Care.

Chronic pain is a significant public health concern. For many, chronic pain is associated with declines in physical functioning and increases in emotional distress. Additionally, the socioeconomic burden associated with costs of care, lost wages and declines in productivity are significant. A large and growing body of research continues to support the biopsychosocial model as the predominant framework for conceptualizing the experience of chronic pain and its multiple negative impacts. The model also informs a widely accepted and empirically supported approach for the optimal management of chronic pain. This chapter briefly articulates the historical foundations of the biopsychosocial model of chronic pain followed by a relatively detailed discussion of an empirically informed, integrated, multimodal and interdisciplinary treatment approach. The role of mental health professionals, especially psychologists, in the management of chronic pain is particularly highlighted.

Trauma, social support, family conflict, and chronic pain in recent service veterans: does gender matter?

OBJECTIVE: Women veterans have a higher prevalence of chronic pain relative to men. One hypothesis is that differential combat and traumatic sexual experiences and attenuated levels of social support between men and women may differentially contribute to the development and perpetuation of pain. This investigation examined [1] gender differences in trauma, social support, and family conflict among veterans with chronic pain, and [2] whether trauma, social support, and family conflict were differentially associated with pain severity, pain interference, and depressive symptom severity as a function of gender. METHODS: Participants included 460 veterans (56% female) who served in support of recent conflicts, and who endorsed pain lasting 3 months or longer. Participants completed a baseline survey during participation in a longitudinal investigation. Self-report measures included pain severity, pain interference, depressive symptom severity, exposure to traumatic life events, emotional and tangible support, and family conflict. RESULTS: Relative to men, women veterans reporting chronic pain evidenced higher rates of childhood interpersonal trauma (51% vs 34%; P < 0.001) and military sexual trauma (54% vs 3%; P < 0.001), along with lower levels of combat exposure (10.00 vs 16.85, P < 0.001). Gender was found to be a moderator of the association of marital status, combat exposure, childhood interpersonal trauma, and family conflict with pain interference. It also moderated family conflict in the prediction of depressive symptoms. CONCLUSIONS: Results underscore the potential importance of developing and testing gender specific models of chronic pain that consider the relative roles of trauma, social support, and family conflict.

Smoking Status and Pain Intensity Among OEF/OIF/OND Veterans.

OBJECTIVE: Pain and smoking are highly prevalent among Veterans. Studies in non-Veteran populations have reported higher pain intensity among current smokers compared with nonsmokers and former smokers. We examined the association of smoking status with reported pain intensity among Veterans of Operations Enduring Freedom, Iraqi Freedom, and New Dawn (OEF/OIF/OND). DESIGN: The sample consisted of OEF/OIF/OND Veterans who had at least one visit to Veterans Affairs (2001-2012) with information in the electronic medical record for concurrent smoking status and pain intensity. The primary outcome measure was current pain intensity, categorized as none to mild (0-3); moderate (4-6); or severe (≥7); based on a self-reported 11-point pain numerical rating scale. Multivariable logistic regression analyses were used to assess the association of current smoking status with moderate to severe (≥4) pain intensity, controlling for potential confounders. RESULTS: Overall, 50,988 women and 355,966 men Veterans were examined. The sample mean age was 30 years; 66.3% reported none to mild pain; 19.8% moderate pain; and 13.9% severe pain; 37% were current smokers and 16% former smokers. Results indicated that current smoking [odds ratio (OR) = 1.29 (95% confidence intervals (CI) = 1.27-1.31)] and former smoking [OR = 1.02 (95% CI = 1.01-1.05)] were associated with moderate to severe pain intensity, controlling for age, service-connected disability, gender, obesity, substance abuse, mood disorders, and Post Traumatic Stress Disorder. CONCLUSIONS: We found an association between current smoking and pain intensity. This effect was attenuated in former smokers. Our study highlights the importance of understanding reported pain intensity in OEF/OIF/OND Veterans who continue to smoke.

STI diagnosis and HIV testing among OEF/OIF/OND veterans.

IMPORTANCE: Patients with sexually transmitted infection (STI) diagnosis should be tested for human immunodeficiency virus (HIV), regardless of previous HIV test results. OBJECTIVE: Estimate HIV testing rates among recent service Veterans with an STI diagnosis and variation in testing rates by patient characteristics. DESIGN, SETTING, AND PARTICIPANTS: The sample comprised 243,843 Veterans who initiated Veterans Health Administration (VHA) services within 1 year after military separation. Participants were followed for 2 years to determine STI diagnoses and HIV testing rates. We used relative risks regression to examine variation in testing rates. MAIN OUTCOMES AND MEASURES: We used VHA administrative data to identify STI diagnoses and HIV testing and results. RESULTS: Veterans with an STI diagnosis (n = 1815) had higher HIV testing rates than those without (34.9% vs. 7.3%, P<0.0001), but were not more likely to have a positive test result (1.1% vs. 1.4%, P = 0.53). Among Veterans with an STI diagnosis, testing increased from 25% to 45% over the observation period; older age was associated with a lower rate of testing, whereas race and ethnicity, multiple deployments, posttraumatic stress disorder, and substance abuse disorders were associated with a higher rate. CONCLUSIONS AND RELEVANCE: Since VHA implemented routine HIV testing, overall rates of testing have increased. However, among Veterans at significant risk for HIV because of an STI diagnosis, only 45% had an HIV test in the most recent year of observation. Other patient characteristics such as alcohol and drug abuse were associated with being tested for HIV. Providers should be reminded that an STI is a sufficient reason to test for HIV.