Researchers Identify Factors That Make Amelioration Less Likely
By Brenda L. Mooney
PORTLAND, OR—Time is said to heal all wounds, and that might also be the case with older military veterans suffering from pain.
A report in The Journal of Pain notes that aging veterans frequently show improvements in pain intensity over time.1
Their likelihood of improvement is lowered, however, with use of opioids, certain mental health conditions and specific pain diagnoses, according to researchers from the VA’s Center to Improve Veterans Involvement in Care and Oregon Health & Science University. Overall, older adults have the highest prevalence of long-term use of pain medications, including opioids, study authors add.
The article points out that, while the older veteran population is at especially high risk for persistent pain, relatively little is known about factors linked with favorable and unfavorable outcomes over time.
To remedy that, the researchers sought to identify clinical and demographic factors associated with changes in pain scores over time in a national cohort of veterans 65 and older with chronic pain. Their original hypothesis was that older age and comorbid mental health disorders would be associated with less improvement in pain conditions over time.
Used in the study was a database of about 13,000 VA-treated veterans who had elevated numeric rating pain scores and had not been prescribed opioids. Researchers measured the percentage decrease over a year in average pain intensity scores, as well as the time to sustained improvement.
Nearly two-thirds of the patients met criteria for sustained improvement during the 12-month follow-up period, according to the results, which also linked initiation of opioid therapy with lower likelihood for sustained improvement. Service-connected disability and mental health problems, chronic low back pain, neuropathy and fibromyalgia/myofascial pain diagnoses also were associated with poor improvement.
Average relative improvement in pain intensity scores from baseline ranged from 25% to 29%, according to the report.
“We found that older veterans often show improvements in pain intensity, over time, and that opioid prescriptions, mental health conditions and certain pain diagnoses are associated with lower likelihood of improvement,” explained Steven K. Dobscha, MD, lead author and professor of psychiatry at Oregon Health and Sciences University. “Further, the oldest group of veterans within the sample demonstrated the most improvements in pain intensity. This supports prior research indicating that, as age increases, patterns and perceptions of pain may change and suggests that many older people with pain adjust and cope better over time.”
Despite the majority of the sample showing improvement in pain levels over time, the remainder had no reductions in discomfort and some even had exacerbated pain.
“Now interestingly, older adults are frequently excluded from clinical trials on pain treatments … at least traditionally that has been so,” Dobscha said last year in a cyberseminar on the research sponsored by the VA’s Health Services Research & Development (HSRD) department. “Even when they are not, trial results are often not stratified. … In general, we do not know quite as much about pain and the treatment of pain in older adults. We do not know as much about the course of pain over time really or its natural history. We do not know as much about effective pain therapies. Of relevance to this talk, we do not know as much about the factors that might be associated with positive or negative pain treatment outcomes.”
Further evaluation of pain outcomes in older adults is necessary, Dobscha said in an American Pain Society press release, emphasizing the need for more research to study the relationship between prescription opioids and treatment outcomes over time.
Yet, he cautioned at the cyberseminar, “We cannot assume that the opioid medication causes them to do more poorly over time. It is actually possible that opioid medications might have prevented them from doing even worse. I would encourage the group to keep that in mind as we look at some of these other findings related to opioid status.”
1 Dobscha SK, Lovejoy TI, Morasco BJ, Kovas AE, Peters DM, Hart K, Williams JL, McFarland BH. Predictors of Improvements in Pain Intensity in a National Cohort of Older Veterans With Chronic Pain. J Pain. 2016 Jul;17(7):824-35. doi:
10.1016/j.jpain.2016.03.006. Epub 2016 Apr 4. PubMed PMID: 27058162; PubMed Central PMCID: PMC4925248.
Legislation that would streamline VA’s community care programs into one program and expand VA’s caregiver program to veterans of all eras was signed into law earlier this month..
The good news from a recent consultant study is that, overall, the VA healthcare system is generally equal or better than others when inpatient and outpatient quality is measured.