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This Issue:The Aging Veteran | Table of Contents: Summer 2018 | Download this issue

A Chat with Our Experts

VA researcher is strong advocate for combining therapies for chronic pain

 Internal medicine physician and VA researcher Dr. Matthew Bair is working to improve pain management in the primary care setting. (Photo by Ricardo Ramirez))
Internal medicine physician and VA researcher Dr. Matthew Bair is working to improve pain management in the primary care setting. (Photo by Ricardo Ramirez)

Internal medicine physician and VA researcher Dr. Matthew Bair is working to improve pain management in the primary care setting. (Photo by Ricardo Ramirez)

Dr. Matthew Bair is a general internal medicine physician and VA health services researcher. He is a core investigator with the HSR&D Center for Health Information and Communication (CHIC) in Indianapolis. He is also an associate professor of medicine at Indiana University School of Medicine. His primary research interest is pain management in the primary care setting.

Over the last 15 years Bair has been part of a team of pain researchers that have worked to improve pain management in the primary care setting, particularly looking more at combining pharmacologic (the use of drugs) and non-pharmacologic treatment for Veterans.

Considered a leading expert in pain management, Bair recently gave a presentation on Capitol Hill as part of a conference sponsored by the National Association of Veterans' Research and Education Foundations (NAVREF). He and two other VA pain researchers, Dr. Erin Krebs and Dr. Sulayman Dib-Hajj, were invited to speak about their pain management research.

VARQU spoke with Bair about his presentation and his work to help Veterans better manage their chronic pain.

Welcome Dr. Bair. How prevalent is chronic pain in the Veteran population?

I think estimates for the prevalence of chronic pain in Veterans range from 50 percent in men to even higher in women Veterans. Dr. Robert Kerns and his team at West Haven, Connecticut, said that women Veterans have prevalence as high as 70 to 75 percent. At least one in two, or three out of four Veterans have chronic pain. That is higher than in the general population—about one in three people in the general population have chronic pain.

What are some of the unintended consequences of using opioid therapy?

Like any other pain treatment, the primary goals of opioid therapy are to reduce pain intensity and improve function. So if you take opioids away, there is the potential that you could actually increase pain intensity or worsen function.

I think there are also some associated issues that could potentially worsen quality of life. We know that patients with chronic pain and particularly patients on opioid therapy can be subject to stigmatization. I worry that if opioids are restricted significantly, that stigmatization could be heightened and, potentially, racial and ethnic disparities could widen. There is some data that suggests that opiates are less likely to be used in some clinical settings among African Americans relative to whites.

Besides opioid therapy, what evidence-based treatments are available to treat chronic pain?

There are multiple evidence-based treatments to treat chronic pain—opioids are just one, in terms of pharmacologic treatment. For example, non-steroidal anti-inflammatory drugs (like ibuprofen) are an evidence-based treatment for many chronic pain conditions, particularly osteoarthritis.

There are also many non-drug treatments that are evidence-based for the treatment of chronic pain. The strongest evidence is for cognitive behavioral therapy (CBT)—which is psychological therapy.

CBT provides patients with self-management strategies so they can better cope with their pain. It uses goal setting, which is a helpful strategy to help patients improve their quality of life and function. Some patients have what we call maladaptive thoughts related to their chronic pain; in those cases, CBT tries to substitute those negative thoughts with more positive, more helpful, more adaptive thoughts to better cope with their pain.

Physical therapy interventions—particularly a tailored exercise program—are also evidence-based. We have the whole suite of cognitive and integrative health treatments that are growing not only in popularity, but in evidence, from acupuncture treatment to massage therapy to spinal manipulation therapy, chiropractic therapy, yoga-based therapies, or tai chi.

So that's the good news. There are a lot of options to treat chronic pain. The downside is that each therapy individually has modest benefits. We don't have a treatment that is knocking it out of the park in terms of effectiveness. So the challenge is for an individual patient to find the right treatment or treatments. Usually what we need to do to get a stronger treatment effect is to combine treatments. And that's where I'm particularly interested: trying to find the right combination of pharmacologic treatment and non-pharmacologic treatment that improve treatment effects.

Research shows there is a relationship between pain and depression. Can you explain why?

We know that there is strong relationship between chronic pain and depression. There's an overlap between 30 and 50 percent—these go hand in hand, 30 to 50 percent of the time. So we know that there's a strong, reciprocal relationship—meaning that, if someone has a chronic pain condition they are more likely to develop depression. Because that would make sense, if you had pain and you are not able to do certain activities, recreational or sports, you might become depressed and socially isolated, which can make you more depressed. So we know that relationship is fairly strong—that chronic pain leads to depression.

The other relationship is that depression can lead to pain in the future. It's interesting that depression has been found to lower pain thresholds. Pain and depression share certain neurochemicals or neurotransmitters, and they share neuroanatomical pathways that are important in the regulation of pain and depression. So when I talk to my patients, I really talk to them about that cycle: that depression can lead to pain and pain can lead to depression. I feel that the most effective treatment is one where we address both at the same time.

Men are often characterized as less willing to talk about experiencing pain and depression than women. Do you find this to be true in your practice?

Absolutely, I think there are gender differences in how depression manifests, where women may be more likely to report depressive symptoms or physical symptoms that are a manifestation of depression. For men, their depression may manifest differently. They present more with anger and irritability, rather than a sad mood and anhedonia, or loss of interest.

There are gender differences in how depression might present and manifest, but there's also differences in how men and women may report symptoms, or the likelihood of reporting symptoms. I think another issue in the military and VA is the military culture. There is a saying in the military, particularly in the Marines, that says pain is weakness leaving the body. It is a tough image that, I think, perpetuates not reporting pain, not reporting depression. I think that inhibits those conditions from being recognized by clinicians, at times. And so, if they are not recognized, they are not treated.

Can you tell us about the work you did on SCAMP—a clinical trial that examined antidepressant therapy and pain self-management?

Stepped Care for Affective Disorders and Musculoskeletal Pain (SCAMP) was a clinical trial that was focused on primary care patients that had this comorbidity—meaning the coexistence of chronic pain and depression. So they had low back pain and depression. The idea of the SCAMP intervention was to try and address both conditions—to improve pain and depression outcomes. The intervention involved three months of treatment with antidepressant medications, according to an algorithm—a stepwise treatment sequencing—which would address depression symptoms.

It also included a pain self-management program that was largely based on cognitive behavioral therapy principles. So it helped in terms of educating Veterans about their pain condition, goal setting, problem solving, and strategies like deep-breathing techniques and relaxation strategies to better equip them to cope with their pain.

There were 250 patients who were involved in this study. We showed pretty significant improvements in depression symptoms and response rates in depression. The improvements in pain were more modest. They were important in terms of improving pain severity and function, but not as marked improvement as depression treatment.

Where would you like to see your research go from here?

I think we need to improve the evidence base for non-pharmacologic treatments, particularly in the complementary and integrative health area. We have an ongoing study that is looking at comparing yoga therapy versus a physical therapist-guided exercise program for Veterans with fibromyalgia. We are finishing up that trial.

We also have an ongoing clinical trial that's looking at Veterans with chronic neck pain, comparing two different types of massage interventions. One massage intervention is delivered by licensed massage therapists—what we view as the gold standard. We are comparing that to caregiver-delivered massage. Caregivers—spouses, children, or adult caregivers—will be trained in Swedish massage techniques so that they may apply them to Veterans with chronic neck pain.

I'm also interested in the overlap between chronic pain and PTSD and chronic pain and insomnia. Again, these are very common comorbidities—they go hand in hand. We see them a lot in patients with chronic pain, whether its anxiety symptoms, such as PTSD, or poor sleep, which can worsen their treatment response and worsen pain treatment outcomes. So we need to address those comorbidities.

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