Advertisement

Predictors of Improvements in Pain Intensity in a National Cohort of Older Veterans With Chronic Pain

      Highlights

      • Most older veterans with elevated pain intensity improved over time.
      • Higher baseline scores and age were associated with greater likelihood of improvement.
      • Mental health diagnoses were associated with lower likelihood of improvement.
      • Opioid prescription initiation was associated with lower likelihood of improvement.
      • Further study of heterogeneity in pain outcomes in older adults is needed.

      Abstract

      Little is known about the factors associated with pain-related outcomes in older adults. In this observational study, we sought to identify patient factors associated with improvements in pain intensity in a national cohort of older veterans with chronic pain. We included 12,924 veterans receiving treatment from the Veterans Health Administration with persistently elevated numeric rating scale scores in 2010 who had not been prescribed opioids in the previous 12 months. We examined: 1) percentage decrease over 12 months in average pain intensity scores relative to average baseline pain intensity score; and 2) time to sustained improvement in average pain intensity scores, defined as a 30% reduction in 3-month scores compared with baseline. Average relative improvement in pain intensity scores from baseline ranged from 25% to 29%; almost two-thirds met criteria for sustained improvement during the 12-month follow-up period. In models, higher baseline pain intensity and older age were associated with greater likelihood of improvement in pain intensity, whereas Veterans Affairs service-connected disability, mental health, and certain pain-related diagnoses were associated with lower likelihood of improvement. Opioid prescription initiation during follow-up was associated with lower likelihood of sustained improvement. The findings call for further characterization of heterogeneity in pain outcomes in older adults as well as further analysis of the relationship between prescription opioids and treatment outcomes.

      Perspective

      This study identified factors associated with improvements in pain intensity in a national cohort of older veterans with chronic pain. We found that older veterans frequently show improvements in pain intensity over time, and that opioid prescriptions, mental health, and certain pain diagnoses are associated with lower likelihood of improvement.

      Key words

      To read this article in full you will need to make a payment
      Subscribe to The Journal of Pain
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

      1. American College of Surgeons National Surgical Quality Improvement Program: ACS NSQIP Participant Use Data File. Available at: https://www.facs.org/quality-programs/acs-nsqip/program-specifics/participant-use. Accessed March 16, 2016

        • Andersson H.I.
        • Ejlertsson G.
        • Leden I.
        • Rosenberg C.
        Chronic pain in a geographically defined general population: Studies of differences in age, gender, social class, and pain localization.
        Clin J Pain. 1993; 9: 174-182
        • Angst M.S.
        • Clark J.D.
        Opioid-induced hyperalgesia: A qualitative systematic review.
        Anesthesiology. 2006; 104: 570-587
        • Ashworth J.
        • Green D.J.
        • Dunn K.M.
        • Jordan K.P.
        Opioid use among low back pain patients in primary care: Is opioid prescription associated with disability at 6-month follow-up?.
        Pain. 2013; 154: 1038-1044
        • Atlas S.J.
        • Chang Y.
        • Keller R.B.
        • Singer D.E.
        • Wu Y.A.
        • Deyo R.A.
        The impact of disability compensation on long-term treatment outcomes of patients with sciatica due to a lumbar disc herniation.
        Spine. 2006; 31: 3061-3069
        • Bair M.J.
        • Robinson R.L.
        • Katon W.
        • Kroenke K.
        Depression and pain comorbidity: A literature review.
        Arch Intern Med. 2003; 163: 2433-2445
        • Bellville J.W.
        • Forrest Jr., W.H.
        • Miller E.
        • Brown Jr., B.W.
        Influence of age on pain relief from analgesics. A study of postoperative patients.
        JAMA. 1971; 217: 1835-1841
        • Bland J.M.
        • Altman D.G.
        Statistics notes: Some examples of regression towards the mean.
        BMJ. 1994; 309: 780
        • Braden J.B.
        • Young A.
        • Sullivan M.D.
        • Walitt B.
        • Lacroix A.Z.
        • Martin L.
        Predictors of change in pain and physical functioning among post-menopausal women with recurrent pain conditions in the women’s health initiative observational cohort.
        J Pain. 2012; 13: 64-72
        • Campbell C.I.
        • Weisner C.
        • Leresche L.
        • Ray G.T.
        • Saunders K.
        • Sullivan M.D.
        • Banta-Green C.J.
        • Merrill J.O.
        • Silverberg M.J.
        • Boudreau D.
        • Satre D.D.
        • Von Korff M.
        Age and gender trends in long-term opioid analgesic use for noncancer pain.
        Am J Public Health. 2010; 100: 2541-2547
        • Chou R.
        • Shekelle P.
        Will this patient develop persistent disabling low back pain?.
        JAMA. 2010; 303: 1295-1302
        • Clark J.D.
        Chronic pain prevalence and analgesic prescribing in a general medical population.
        J Pain Symptom Manage. 2002; 23: 131-137
        • Cleeland C.S.
        • Reyes-Gibby C.C.
        • Schall M.
        • Nolan K.
        • Paice J.
        • Rosenberg J.M.
        • Tollett J.H.
        • Kerns R.D.
        Rapid improvement in pain management: The Veterans Health Administration and the Institute for Healthcare Improvement Collaborative.
        Clin J Pain. 2003; 19: 298-305
        • Cook A.J.
        • Chastain D.C.
        The classification of patients with chronic pain: age and sex differences.
        Pain Res Manag. 2001; 6: 142-151
        • Copeland L.A.
        • Zeber J.E.
        • Wang C.P.
        • Parchman M.L.
        • Lawrence V.A.
        • Valenstein M.
        • Miller A.L.
        Patterns of primary care and mortality among patients with schizophrenia or diabetes: A cluster analysis approach to the retrospective study of healthcare utilization.
        BMC Health Serv Res. 2009; 9: 127
        • Crofford L.J.
        Adverse effects of chronic opioid therapy for chronic musculoskeletal pain.
        Nat Rev Rheumatol. 2010; 6: 191-197
        • Crosby F.E.
        • Colestro J.
        • Ventura M.R.
        • Graham K.
        Survey of pain among veterans in Western New York.
        Pain Manag Nurs. 2006; 7: 12-22
        • Department of Veterans Affairs and Department of Defense
        VA/DoD Clinical Practice Guideline for Assessment and Management of Patients at Risk for Suicide.
        U.S. Department of Veterans Affairs, Washington, DC2013
        • Deyo R.A.
        • Bryan M.
        • Comstock B.A.
        • Turner J.A.
        • Heagerty P.
        • Friedly J.
        • Avins A.L.
        • Nedeljkovic S.S.
        • Nerenz D.R.
        • Jarvik J.G.
        Trajectories of symptoms and function in older adults with low back disorders.
        Spine (Phila Pa 1976). 2015; 40: 1352-1362
        • Dobscha S.K.
        • Morasco B.J.
        • Duckart J.P.
        • Macey T.A.
        • Deyo R.A.
        Correlates of prescription opioid initiation and long-term opioid use in Veterans with persistent pain.
        Clin J Pain. 2013; 29: 102-108
        • Dobscha S.K.
        • Morasco B.J.
        • Kovas A.E.
        • Peters D.M.
        • Hart K.
        • McFarland B.H.
        Short-term variability in outpatient pain intensity scores in a national sample of older veterans with chronic pain.
        Pain Med. 2015; 16: 855-865
        • Dorflinger L.
        • Moore B.
        • Goulet J.
        • Becker W.
        • Heapy A.A.
        • Sellinger J.J.
        • Kerns R.D.
        A partnered approach to opioid management, guideline concordant care and the stepped care model of pain management.
        J Gen Intern Med. 2014; 29: 870-876
        • Dunn K.M.
        • Campbell P.
        • Jordan K.P.
        Long-term trajectories of back pain: Cohort study with 7-year follow-up.
        BMJ Open. 2013; 3: e003838
        • Dworkin R.H.
        • Turk D.C.
        • Wyrwich K.W.
        • Beaton D.
        • Cleeland C.S.
        • Farrar J.T.
        • Haythornthwaite J.A.
        • Jensen M.P.
        • Kerns R.D.
        • Ader D.N.
        • Brandenburg N.
        • Burke L.B.
        • Cella D.
        • Chandler J.
        • Cowan P.
        • Dimitrova R.
        • Dionne R.
        • Hertz S.
        • Jadad A.R.
        • Katz N.P.
        • Kehlet H.
        • Kramer L.D.
        • Manning D.C.
        • McCormick C.
        • McDermott M.P.
        • McQuay H.J.
        • Patel S.
        • Porter L.
        • Quessy S.
        • Rappaport B.A.
        • Rauschkolb C.
        • Revicki D.A.
        • Rothman M.
        • Schmader K.E.
        • Stacey B.R.
        • Stauffer J.W.
        • von Stein T.
        • White R.E.
        • Witter J.
        • Zavisic S.
        Interpreting the clinical importance of treatment outcomes in chronic pain clinical trials: IMMPACT recommendations.
        J Pain. 2008; 9: 105-121
        • Edlund M.J.
        • Martin B.C.
        • Devries A.
        • Fan M.Y.
        • Braden J.B.
        • Sullivan M.D.
        Trends in use of opioids for chronic noncancer pain among individuals with mental health and substance use disorders: The TROUP study.
        Clin J Pain. 2010; 26: 1-8
        • El-Shormilisy N.
        • Strong J.
        • Meredith P.J.
        Associations between gender, coping patterns and functioning for individuals with chronic pain: a systematic review.
        Pain Res Manag. 2015; 20: 48-55
        • Eriksen J.
        • Sjogren P.
        • Bruera E.
        • Ekholm O.
        • Rasmussen N.K.
        Critical issues on opioids in chronic non-cancer pain: An epidemiological study.
        Pain. 2006; 125: 172-179
        • Goulet J.L.
        • Brandt C.
        • Crystal S.
        • Fiellin D.A.
        • Gibert C.
        • Gordon A.J.
        • Kerns R.D.
        • Maisto S.
        • Justice A.C.
        Agreement between electronic medical record-based and self-administered pain numeric rating scale: Clinical and research implications.
        Med Care. 2013; 51: 245-250
        • Grambsch P.M.
        • Therneau T.M.
        Proportional hazards tests and diagnostics based on weighted residuals.
        Biometrika. 1994; 81: 515-526
        • Gureje O.
        • Simon G.E.
        • Von Korff M.
        A cross-national study of the course of persistent pain in primary care.
        Pain. 2001; 92: 195-200
        • Hayden J.A.
        • Chou R.
        • Hogg-Johnson S.
        • Bombardier C.
        Systematic reviews of low back pain prognosis had variable methods and results: Guidance for future prognosis reviews.
        J Clin Epidemiol. 2009; 62: 781-796.e1
        • Heapy A.
        • Dziura J.
        • Buta E.
        • Goulet J.
        • Kulas J.F.
        • Kerns R.D.
        Using multiple daily pain ratings to improve reliability and assay sensitivity: How many is enough?.
        J Pain. 2014; 15: 1360-1365
        • Jakobsson U.
        The epidemiology of chronic pain in a general population: Results of a survey in southern Sweden.
        Scand J Rheumatol. 2010; 39: 421-429
        • Jensen M.P.
        • Karoly P.
        • Braver S.
        The measurement of clinical pain intensity: A comparison of six methods.
        Pain. 1986; 27: 117-126
        • Jensen M.P.
        • Karoly P.
        • O’Riordan E.F.
        • Bland Jr., F.
        • Burns R.S.
        The subjective experience of acute pain. An assessment of the utility of 10 indices.
        Clin J Pain. 1989; 5: 153-159
        • Kazis L.E.
        • Miller D.R.
        • Clark J.
        • Skinner K.
        • Lee A.
        • Rogers W.
        • Spiro 3rd, A.
        • Payne S.
        • Fincke G.
        • Selim A.
        • Linzer M.
        Health-related quality of life in patients served by the Department of Veterans Affairs: Results from the Veterans Health Study.
        Arch Intern Med. 1998; 158: 626-632
        • Kerns R.D.
        • Otis J.
        • Rosenberg R.
        • Reid M.C.
        Veterans’ reports of pain and associations with ratings of health, health-risk behaviors, affective distress, and use of the healthcare system.
        J Rehabil Res Dev. 2003; 40: 371-379
        • Krebs E.E.
        • Carey T.S.
        • Weinberger M.
        Accuracy of the pain numeric rating scale as a screening test in primary care.
        J Gen Intern Med. 2007; 22: 1453-1458
        • Lorenz K.A.
        • Sherbourne C.D.
        • Shugarman L.R.
        • Rubenstein L.V.
        • Wen L.
        • Cohen A.
        • Goebel J.R.
        • Hagenmeier E.
        • Simon B.
        • Lanto A.
        • Asch S.M.
        How reliable is pain as the fifth vital sign?.
        J Am Board Fam Med. 2009; 22: 291-298
        • Macedo L.G.
        • Maher C.G.
        • Latimer J.
        • McAuley J.H.
        • Hodges P.W.
        • Rogers W.T.
        Nature and determinants of the course of chronic low back pain over a 12-month period: A cluster analysis.
        Phys Ther. 2014; 94: 210-221
        • Magni G.
        • Marchetti M.
        • Moreschi C.
        • Merskey H.
        • Luchini S.R.
        Chronic musculoskeletal pain and depressive symptoms in the National Health and Nutrition Examination. I. Epidemiologic follow-up study.
        Pain. 1993; 53: 163-168
        • Mallen C.D.
        • Peat G.
        • Thomas E.
        • Dunn K.M.
        • Croft P.R.
        Prognostic factors for musculoskeletal pain in primary care: A systematic review.
        Br J Gen Pract. 2007; 57: 655-661
        • McWilliams L.A.
        • Goodwin R.D.
        • Cox B.J.
        Depression and anxiety associated with three pain conditions: Results from a nationally representative sample.
        Pain. 2004; 111: 77-83
        • Morasco B.J.
        • Corson K.
        • Turk D.C.
        • Dobscha S.K.
        Association between substance use disorder status and pain-related function following 12 months of treatment in primary care patients with musculoskeletal pain.
        J Pain. 2011; 12: 352-359
        • Morasco B.J.
        • Gritzner S.
        • Lewis L.
        • Oldham R.
        • Turk D.C.
        • Dobscha S.K.
        Systematic review of prevalence, correlates, and treatment outcomes for chronic non-cancer pain in patients with comorbid substance use disorder.
        Pain. 2011; 152: 488-497
      2. National Center for Veterans Analysis and Statistics: Profile of Veterans: 2009 Data from the American Community Survey. 2011. Available at: http://www.va.gov/vetdata/docs/SpecialReports/Profile_of_Veterans_2009_FINAL.pdf. Accessed April 28, 2016.

        • National VA Pain Outcomes Working Group, National VA Pain Management Coordinating Committee Veterans Health Administration
        VHA Pain Outcomes Toolkit.
        Department of Veterans Affairs, Washington, DC, U.S.2003
        • Otis J.D.
        • Keane T.M.
        • Kerns R.D.
        An examination of the relationship between chronic pain and post-traumatic stress disorder.
        J Rehabil Res Dev. 2003; 40: 397-405
        • Papaleontiou M.
        • Henderson C.R.
        • Turner B.J.
        • Moore A.A.
        • Olkhovskaya Y.
        • Amanfo L.
        • Reid M.C.
        Outcomes associated with opioid use in the treatment of chronic noncancer pain in older adults: A systematic review and meta-analysis.
        J Am Geriatr Soc. 2010; 58: 1353-1369
        • Patel K.V.
        • Guralnik J.M.
        • Dansie E.J.
        • Turk D.C.
        Prevalence and impact of pain among older adults in the United States: Findings from the 2011 National Health and Aging Trends Study.
        Pain. 2013; 154: 2649-2657
        • Paulose-Ram R.
        • Hirsch R.
        • Dillon C.
        • Losonczy K.
        • Cooper M.
        • Ostchega Y.
        Prescription and non-prescription analgesic use among the US adult population: Results from the third National Health and Nutrition Examination Survey (NHANES III).
        Pharmacoepidemiol Drug Saf. 2003; 12: 315-326
        • Reid M.C.
        • Bennett D.A.
        • Chen W.G.
        • Eldadah B.A.
        • Farrar J.T.
        • Ferrell B.
        • Gallagher R.M.
        • Hanlon J.T.
        • Herr K.
        • Horn S.D.
        • Inturrisi C.E.
        • Lemtouni S.
        • Lin Y.W.
        • Michaud K.
        • Morrison R.S.
        • Neogi T.
        • Porter L.L.
        • Solomon D.H.
        • Von Korff M.
        • Weiss K.
        • Witter J.
        • Zacharoff K.L.
        Improving the pharmacologic management of pain in older adults: Identifying the research gaps and methods to address them.
        Pain Med. 2011; 12: 1336-1357
        • Riley 3rd, J.L.
        • Cruz-Almeida Y.
        • Glover T.L.
        • King C.D.
        • Goodin B.R.
        • Sibille K.T.
        • Bartley E.J.
        • Herbert M.S.
        • Sotolongo A.
        • Fessler B.J.
        • Redden D.T.
        • Staud R.
        • Bradley L.A.
        • Fillingim R.B.
        Age and race effects on pain sensitivity and modulation among middle-aged and older adults.
        J Pain. 2014; 15: 272-282
        • Selim A.J.
        • Fincke G.
        • Ren X.S.
        • Lee A.
        • Rogers W.H.
        • Miller D.R.
        • Skinner K.M.
        • Linzer M.
        • Kazis L.E.
        Comorbidity assessments based on patient report: Results from the Veterans Health Study.
        J Ambul Care Manage. 2004; 27: 281-295
        • Sullivan M.D.
        • Edlund M.J.
        • Fan M.Y.
        • Devries A.
        • Brennan Braden J.
        • Martin B.C.
        Risks for possible and probable opioid misuse among recipients of chronic opioid therapy in commercial and Medicaid insurance plans: The TROUP Study.
        Pain. 2010; 150: 332-339
        • Therneau T.M.
        • Grambsch P.M.
        Modeling Survival Data: Extending the Cox Model.
        Springer-Verlag, New York2000
        • Thomas E.
        • Peat G.
        • Harris L.
        • Wilkie R.
        • Croft P.R.
        The prevalence of pain and pain interference in a general population of older adults: Cross-sectional findings from the North Staffordshire Osteoarthritis Project (NorStOP).
        Pain. 2004; 110: 361-368
        • Tian T.Y.
        • Zlateva I.
        • Anderson D.R.
        Using electronic health records data to identify patients with chronic pain in a primary care setting.
        J Am Med Inform Assoc. 2013; 20: e275-e280
        • Turk D.C.
        • Dworkin R.H.
        • Allen R.R.
        • Bellamy N.
        • Brandenburg N.
        • Carr D.B.
        • Cleeland C.
        • Dionne R.
        • Farrar J.T.
        • Galer B.S.
        • Hewitt D.J.
        • Jadad A.R.
        • Katz N.P.
        • Kramer L.D.
        • Manning D.C.
        • McCormick C.G.
        • McDermott M.P.
        • McGrath P.
        • Quessy S.
        • Rappaport B.A.
        • Robinson J.P.
        • Royal M.A.
        • Simon L.
        • Stauffer J.W.
        • Stein W.
        • Tollett J.
        • Witter J.
        Core outcome domains for chronic pain clinical trials: IMMPACT recommendations.
        Pain. 2003; 106: 337-345
      3. United States Department of Veterans Affairs. National Center for Veterans Analysis and Statistics: Veteran population. Available at: http://www.va.gov/vetdata/Veteran_Population.asp. Accessed March 16, 2016

        • Verhaak P.F.
        • Kerssens J.J.
        • Dekker J.
        • Sorbi M.J.
        • Bensing J.M.
        Prevalence of chronic benign pain disorder among adults: A review of the literature.
        Pain. 1998; 77: 231-239
        • West N.A.
        • Severtson S.G.
        • Green J.L.
        • Dart R.C.
        Trends in abuse and misuse of prescription opioids among older adults.
        Drug Alcohol Depend. 2015; 149: 117-121
        • Yang Z.
        • Lowe A.J.
        • de la Harpe D.E.
        • Richardson M.D.
        Factors that predict poor outcomes in patients with traumatic vertebral body fractures.
        Injury. 2010; 41: 226-230