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11 Articles in Volume 18, Issue #8
Challenges & Opportunities for Pain Management In Veterans
Chronic Pain and Psychopathology in the Veteran and Disadvantaged Populations
ESIs: Worth the Benefits?
Letters to the Editor: Recovery Centers Reject MAT, Cannabis for Chronic Headaches, Central Pain
Medication Management in the Aging
Pain Management in the Elderly
Pharmacists as Essential Team Members in Pain Management
Photobiomodulation for the Treatment of Fibromyalgia
Plantar Fasciitis: Diagnosis and Management
Slipping Rib Syndrome: A Case Report
What types of risk screening tests are available to clinicians prescribing opioid therapy?

Chronic Pain and Psychopathology in the Veteran and Disadvantaged Populations

A DSM-5 review highlights unique clinical comorbidities in Veterans and disadvantaged patient populations with chronic pain.
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The opioid epidemic reflects a serious unmet need for better recognition and treatment of common mental health problems in patients with chronic pain.1 Frontline practitioners may at times be faced with chronic pain patients suffering from undiagnosed mental health disorders when tapering opioid therapy. In most cultures, the majority of mental health cases go unrecognized in primary care settings.2 About 60% of previously undetected cases could have been recognized if the patients had been evaluated for mental health disorders.3

Complicating these assessments is the fact that patients attending pain specialty clinics often have more difficult-to-treat pain conditions and comorbid psychiatric disorders, use more outpatient services, and receive a greater number of opioid prescriptions.These data support the inclusion of mental healthcare in the specialized treatment of chronic pain.

Numerous studies have documented a strong association between chronic pain and psychopathology.5 Research has shown that chronic pain is most often associated with depression, anxiety, somatoform, personality, and substance use disorders, but less is known about pain’s relationship with other mental health conditions, such as schizophrenia spectrum/psychotic, sleep-wake, bipolar, neurocognitive, obsessive-compulsive, and dissociative disorders.

Mental Health in the Elderly(Source: 123RF)

One pivotal study in 1986 delineated the distribution of assigned diagnoses using the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III) published by the American Psychiatric Association for 283 male and female chronic pain patients.Each participant completed an extensive 3-day evaluation period as part of the admission to the Comprehensive Pain Center of the University of Miami School of Medicine. Subjects completed two hours of detailed, semi-structured psychiatric interviews based on DSM-III.

The results of the study found that anxiety and depressive disorders were the most frequently assigned diagnoses. Males were significantly over-represented with intermittent explosive disorders, adjustment disorders, and alcohol abuse and other drug dependence. Females were significantly over-represented with depressive and somatization disorders.6 See Table I for total prevalence.

Population Subgroups

It is well documented that chronic pain is more common in Veterans than the non-veteran US population, most often in the context of severity and comorbidities. Veterans are also at high-risk for harms from opioid medication. In fact, pain is one of the most common reasons Veterans consult with their primary care providers and one of the most prevalent symptoms reported by returning military personnel.7 Almost half of patients within Veterans Affairs (VA) healthcare settings experience pain on a regular basis.8 Previous research has found that past military service may contribute to “hypersensitivity” to pain symptoms.9-11 Pain severity and co-concurrence with mental health comorbidities result in high impact pain. Pain, medical, and/or mental comorbidities are often related to military service and/or require Veteran-specific expertise. Therefore, integrated care, or systematic coordination of medical, psychological, and social aspects of healthcare, is required for high quality pain care.

Chronic pain also disproportionately affects economically-disadvantaged persons, including minority groups, women, and older adults.12,13 Minority groups tend to have higher rates of chronic pain, and greater risk for pain-related disability.14 This demographic also has higher rates of major chronic physical and psychological comorbid conditions.15-17

The following section reviews a pilot study conducted by the author and his research team at the Jesse Brown VA Medical Center in Chicago, IL, between November 2013 and October 2014 that compared the APA’s 5th Edition of the DSM (DSM-5) disorders using emerging measures among Veterans who suffered from mixed, idiopathic chronic pain. These measures may potentially be useful tools to enhance clinical decision-making in a highly disadvantaged population of minorities and women. In addition, the study serves as a replication of previous studies using the most recent version of the DSM-5.18

Methods & Materials

Sample Characteristics

A sample of 272 Veterans ranging from 18- to 89-years-old with mixed, idiopathic conditions (ie, back, neck, extremity, head, and fibromyalgia) were recruited from the Pain Education School program at Jesse Brown VA Medical Center. Veterans voluntarily participated in the program and were free to withdraw at any time. Approximately 29 (11%) dropped before completing the pre-assessment. No exclusion criteria were used. As part of the introduction to the pain education program, all participants completed a pre-education assessment which included the World Health Organization Disability Assessment Schedule (WHODAS 2.0)19 and the DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure-Adult (CCSM-A).20

The WHODAS 2.0 is a 36-item, self-administered measure that assesses disability in adults across six domains (cognition, mobility, self-care, getting along, life activities, and social participation). Each item asks the individual to rate how much difficulty they had in the specific areas of functioning during the past 30 days. The CCSM-A is a 23-item, self-administered measure that assesses 12 psychiatric domains: depression, anger, mania, anxiety, somatic symptoms, psychosis, sleep problems, memory, repetitive behaviors, dissociation, personality, and substance use. Each item inquires about how much (or how often) the individual has been bothered by the specific symptom during the prior two weeks. Analysis of variance was used to evaluate sex differences among the aforementioned psychiatric domains using the GNU PSPP Statistical Analysis Software.21 The “N-1” chi-squared tests were computed as recommended by past studies to compare percentages using the MedCalc software.22-24

Last updated on: November 7, 2018
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Pain Management in the Elderly
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