Veteran Experiences Seeking Non-pharmacologic Approaches for Pain.

Author: Giannitrapani K1, McCaa M1, Haverfield M1,2, Kerns RD3,4, Timko C1,2, Dobscha S5,6, Lorenz K1,2,7
1VA Palo Alto Health Care System, Center for Innovation to Implementation (Ci2i), Menlo Park, CA 94025.
2Stanford University, Palo Alto, CA 94305.
3Departments of Psychiatry, Neurology and Psychology, Yale University, New Haven, CT 06520.
4Pain Research, Informatics, Multimorbidities and Education (PRIME) Center of Innovation, VA Connecticut Healthcare System, West Haven, CT 06516.
5VA Portland Health Care System, Center to Improve Veteran Involvement in Care (CIVIC), Portland, OR 97239.
6Department of Psychiatry, Oregon Health and Science University, Portland, OR 97239-3098.
7RAND Corporation, Santa Monica, CA 90401.
Conference/Journal: Mil Med.
Date published: 2018 Mar 26
Other: Special Notes: doi: 10.1093/milmed/usy018. [Epub ahead of print] , Word Count: 489

Introduction: Pain is a longstanding and growing concern among US military veterans. Although many individuals rely on medications, a growing body of literature supports the use of complementary non-pharmacologic approaches when treating pain. Our objective is to characterize veteran experiences with and barriers to accessing alternatives to medication (e.g., non-pharmacologic treatments or non-pharmacologic approaches) for pain in primary care.

Materials and Methods: Data for this qualitative analysis were collected as part of the Effective Screening for Pain (ESP) study (2012-2017), a national randomized controlled trial of pain screening and assessment methods. This study was approved by the Veterans Affairs (VA) Central IRB and veteran participants signed written informed consent. We recruited a convenience sample of US military veterans in four primary care clinics and conducted semi-structured interviews (25-65 min) elucidating veteran experiences with assessment and management of pain in VA Healthcare Systems. We completed interviews with 36 veterans, including 7 females and 29 males, from three VA health care systems. They ranged in age from 28 to 94 yr and had pain intensity ratings ranging from 0 to 9 on the "pain now" numeric rating scale at the time of the interviews. We analyzed interview transcripts using constant comparison and produced mutually agreed upon themes.

Results: Veteran experiences with and barriers to accessing complementary non-pharmacologic approaches for pain clustered into five main themes: communication with provider about complementary approaches ("one of the best things the VA has ever given me was pain education and it was through my occupational therapist"), care coordination ("I have friends that go to small clinic in [area A] and I still see them down in [facility in area B] and they're going through headaches upon headaches in trying to get their information to their primary care docs"), veteran expectations about pain experience ("I think as a society we have shifted the focus to if this doctor doesn't relieve me of my pain I will find someone who does"), veteran knowledge and beliefs about various complementary non-pharmacologic approaches ("how many people know that tai chi will help with pain?… Probably none. I saw them doing tai chi down here at the VA clinic and the only reason I knew about it was because I saw it being done"), and access ("the only physical therapy I ever did… it helped…but it was a two-and-a-half-hour drive to get there three times a week… I can't do this"). Specific access barriers included local availability, time, distance, scheduling flexibility, enrollment, and reimbursement.

Conclusion: The veterans in this qualitative study expressed interest in using non-pharmacologic approaches to manage pain, but voiced complex multi-level barriers. Limitations of our study include that interviews were conducted only in five clinics and with seven female veterans. These limitations are minimized in that the clinics covered are diverse ranging to include urban, suburban, and rural residents. Future implementation efforts can learn from the veterans' voice to appropriately target veteran concerns and achieve more patient-centered pain care.

PMID: 29590422 DOI: 10.1093/milmed/usy018