Predictors of Veterans Health Administration utilization and pain persistence among soldiers treated for postdeployment chronic pain in the Military Health System

Abstract

Background Chronic pain presents a significant burden for both federal health care systems designed to serve combat Veterans in the United States (i.e., the Military Health System [MHS] and Veterans Health Administration [VHA]), yet there have been few studies of Veterans with chronic pain that have integrated data from both systems of care. This study examined 1) health care utilization in VHA as an enrollee (i.e., linkage to VHA) after military separation among soldiers with postdeployment chronic pain identified in the MHS, and predictors of linkage, and 2) persistence of chronic pain among those utilizing the VHA. Methods Observational, longitudinal study of soldiers returning from a deployment in support of the Afghanistan/Iraq conflicts in fiscal years 2008–2014. The analytic sample included 138,206 active duty soldiers for whom linkage to VHA was determined through FY2019. A Cox proportional hazards model was estimated to examine the effects of demographic characteristics, military history, and MHS clinical characteristics on time to linkage to VHA after separation from the military. Among the subpopulation of soldiers who linked to VHA, we described whether they met criteria for chronic pain in the VHA and pain management treatments received during the first year in VHA. Results The majority (79%) of soldiers within the chronic pain cohort linked to VHA after military separation. Significant predictors of VHA linkage included: VHA utilization as a non-enrollee prior to military separation, separating for disability, mental health comorbidities, and being non-Hispanic Black or Hispanic. Soldiers that separated because of misconduct were less likely to link than other soldiers. Soldiers who received nonpharmacological treatments, opioids/tramadol, or mental health treatment in the MHS linked earlier to VHA than soldiers who did not receive these treatments. Among those who enrolled in VHA, during the first year after linking to the VHA, 49.7% of soldiers met criteria for persistent chronic pain in VHA. Conclusions The vast majority of soldiers identified with chronic pain in the MHS utilized care within VHA after military separation. Careful coordination of pain management approaches across the MHS and VHA is required to optimize care for soldiers with chronic pain.

Racial and Ethnic Differences in Deaths by Suicide, Drug Overdose, and Opioid-Related Overdose in a National Sample of Military Members With Mild Traumatic Brain Injury, 1999-2019

“…For example, in comparing risk factors and health characteristics among veterans who did and did not receive VHA care, several studies show that VHA users report lower sociodemographic characteristics and higher comorbidities and disability than non-VA users. [35][36][37] In terms of risk for suicide among those with TBI by race/ethnicity, research among all cohorts (eg, military, general population) has been extremely limited. Our findings of significantly higher rates among AIAN individuals with mTBI are consistent with work by Mohatt et al, 38 who found a suicide rate of 66 per 100 000 person-years among AIAN veterans aged 18 to 39 years (2014-2018).…”

“…This is in part related to demographic differences among those who do and do not seek VHA care. For example, in comparing risk factors and health characteristics among veterans who did and did not receive VHA care, several studies show that VHA users report lower sociodemographic characteristics and higher comorbidities and disability than non-VA users 35–37…”

Associations of vulnerability to stressful life events with suicide attempts after active duty among high-risk soldiers: results from the Study to Assess Risk and Resilience in Servicemembers-longitudinal study (STARRS-LS)

“…Strikingly, 55.2% of the total sample and 72.6% of predicted high-risk respondents reported experiencing any 12-month SLE. This is likely to be an underestimate of significant stress exposure, though, given that we focused on commonly occurring acute stressors and did not assess either less-common acute stressors or chronic stressors known to occur to soldiers after leaving active duty (Adams, Meerwijk, Larson, & Harris, 2021; Kline, Ciccone, Falca-Dodson, Black, & Losonczy, 2011; Mansfield et al, 2011; Morin, 2011; Shen et al, 2016) and to be associated with elevated suicide risk (Hooley, Franklin, & Nock, 2014; Howarth et al, 2020; McFeeters et al, 2015; Nock et al, 2013). These results suggest that interventions to limit exposure to major stressors and, more importantly, to reduce vulnerability to these stressors might prevent a substantial proportion of the SAs that occur among high-risk soldiers after separation/deactivation.…”

Diagnostic profiles associated with long‐term opioid therapy in active duty servicemembers

“…[7][8][9] This hinders the implementation of evidence-based practice, as multimorbidity is the norm when managing chronic pain. [10][11][12] Thus a better understanding of high-risk presentations could help inform future policies and practice to ensure that those with the greatest clinical needs receive appropriate care without undue risk of addiction.…”