Original Article Journal of Addictions Nursing & Volume 25 & Number 2, 74Y80 & Copyright B 2014 International Nurses Society on Addictions
Measuring Chronic Pain Intensity Among Veterans in a Residential Rehabilitation Treatment Program Mary L. Randleman, MSN, RN m Mary E. Douglas, MSN, RN m Alice M. DeLane, MSN, RN, CNOR m Glen A. Palmer, PhD, ABN
The purpose of this study was to identify whether veterans with chronic pain, substance abuse, and posttraumatic stress disorder (PTSD) diagnoses residing in a Residential Rehabilitation Treatment Program (RRTP) perceived a higher level of pain than those veterans who had chronic pain but did not have active substance abuse issues or PTSD. A sample of veterans (n = 200) with chronic pain undergoing treatment for either chemical dependency and/or PTSD in an RRTP and a Surgical Specialty Care outpatient clinic at a Department of Veterans Affairs medical center took part in the study. Multiple analysis of variance and further univariate statistics were examined to determine the association between groups on the different scales. There was a considerable difference in terms of which group of veterans perceived a higher rate of pain even with the use of the same four pain assessment scales (i.e., Numeric Rating, Visual Analog, Faces, and Mankoski). Scores were significantly higher for the RRTP group than the Surgical Specialty Care group on all screening measures (p G .001). Veterans with chronic pain, substance abuse, and/or PTSD diagnoses residing in an RRTP tended to have a higher perception of chronic pain compared to those without substance abuse or PTSD diagnoses. Keywords: chronic pain, PTSD, residential treatment, substance abuse, veteran
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t is estimated that between 50,000 to 100,000 soldiers have been injured in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF; Gibson, 2012). Because of these nonmortal wounds, veterans may be left with
Mary L. Randleman, MSN, RN, Minneapolis VA Health Care System, Minnesota. Mary E. Douglas, MSN, RN, Fargo VA Health Care System, North Dakota. Alice M. DeLane, MSN, RN, CNOR, and Glen A. Palmer, PhD, ABN, St. Cloud VA Health Care System, Minnesota. The authors have no financial conflicts of interest to declare. Correspondence related to content to: Mary L. Randleman, MSN, RN, Mental Health, 7545 Veterans Drive, Ramsey, MN 55303. E-mail: [email protected] DOI: 10.1097/JAN.0000000000000027 74
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injuries that lead to the development of pain lasting greater than 6 months in length. Orthopedic injuries and amputations lead the list of injuries incurred as a result of the wars (Clark, Bair, Buckenmaier, Gironda, & Walker, 2007). In addition to physical injuries, many veterans are returning with long-term psychological trauma as well. These experiences contribute to the development of substance abuse and posttraumatic stress disorder (PTSD). Veterans are learning to live with both physical and psychological wounds. BACKGROUND The Veterans Health Administration is responsible for providing health care for veterans and military personnel who may be experiencing military-related medical issues, including chronic pain. A service available to veterans is a Mental Health Residential Rehabilitation Treatment Program (RRTP) that provides evidence-based, quality treatment for veterans with multiple and severe medical conditions including pain, mental illness, addiction, and psychosocial deficits. The RRTP is intended to address the patients’ goals of rehabilitation, recovery, health maintenance, improved quality of life, treatment of medical conditions, mental illnesses, addictive disorders, and homelessness (U.S. Department of Veterans Affairs, 2012). Veterans with chronic pain and psychological injuries, such as PTSD, often remark that they have little power over their pain (Gauntlett-Gilbert & Wilson, 2013). Studies show that individuals with substance abuse issues perceive a higher rate of pain, which may contribute to tolerance, that is, an adaptation in which a diminution of the medication effects requires an increase in the dosage to help alleviate the person’s pain (Morgan & White, 2009). There is limited research on chronic pain perception in veterans undergoing treatment in an RRTP as compared to other veterans with chronic pain. The purpose of this study is to identify whether veterans with chronic pain, substance abuse, and PTSD diagnoses residing in an RRTP perceive a higher level of pain than those veterans who have chronic pain but do not have active substance abuse issues or PTSD. The authors hypothesized that veterans in RRTP will, in fact, report higher levels of pain intensity compared to other veterans. Currently, there is limited research pertaining to the quality of pain assessment and management by clinicians working with a veteran population. If clinicians April/June 2014
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were to understand differences with reported pain intensity in the veteran population, it might contribute to changes in clinical practice, and this could improve overall pain management and general well-being for the patient.
LITERATURE REVIEW A literature search was carried out to ascertain the availability of current research describing the association of pain intensity in veterans who have chronic pain and diagnoses of either substance abuse or PTSD. The research databases of EBSCOhost and ProQuest were used to identify full-text, peer-reviewed articles related to veterans with substance abuse and PTSD. The keywords chronic pain, veterans, substance abuse, and PTSD were used. Chronic pain is common among the veteran population. Kern, Otis, Rosenberg, and Reid (2003) found that 50% of veterans receiving primary care experienced pain daily. This number is similar to the results identified in a study by Haskell et al. (2009), who found that pain was present in 59.7% of the veterans they assessed. Of those individuals, 63.2% described their pain as either moderate or severe. The American Pain Foundation (2009) found that 70% of respondents of an online survey of 753 veterans and members of the armed forces rated their pain intensity between 7 and 10 on a scale of zero to 10. The American Pain Foundation found that one third of the respondents also stated that they experienced PTSD in addition to having high pain intensity. This number is similar to other studies conducted comparing the link between pain and PTSD. In a study of veterans undergoing PTSD treatment, 66% of the population had comorbid chronic pain diagnoses (Shipherd et al., 2007). It has been reported that 81.5% of veterans returning from the OEF and OIF wars had chronic pain and 58.6% had both chronic pain and PTSD (Lew et al., 2009). Clark et al. (2007) explained that the development of psychosocial symptoms related to chronic pain from trauma sustained in the OEF and OIF campaigns may not be fully identified for many years. In addition to possessing the diagnosis of PTSD, substance abuse in veterans continues to be an issue with many individuals who experience chronic pain. Erbes, Westermeyer, Engdahl, and Johnsen (2007) discovered that 6% of returning veterans had both PTSD and alcohol use problems. Many individuals self-medicate with alcohol to treat their pain (Brennan, Schutte, & Moos, 2005; Chandragiri, Vael, King, & Hardy, 2000). Alcohol dependence creates physical changes within the body. These individuals metabolize medications and respond to pain stimuli differently, which affects pain medication response (D’Arcy, 2007). It is because of these physical changes that pain may be experienced at a higher level than an individual who does not experience alcohol dependence. Chandragiri et al. (2000) identify that symptoms of PTSD are intensified when there is a combined diagnoses of PTSD, substance abuse, and chronic pain. Gibson (2012) maintains that unhealthy lifestyle choices, such as substance abuse, can contribute to increased symptoms of chronic pain. Journal of Addictions Nursing
METHOD Participants Subjects (n = 200) were recruited from a Department of Veterans Affairs (VA) medical center in the Midwest. As previously described in Douglas, Randleman, DeLane, and Palmer (2014), the subjects were enrolled in the study from RRTP and Surgical Specialty Care (SSC) outpatient settings. Veteran computerized patient records were screened for study eligibility (n = 990). Of the 990 screened medical records, 487 individuals (49%) met the study criteria and 200 veterans agreed to participate in the study. Among the 200 veterans, the RRTP group (n = 100) served as our study group and the SSC group (n = 100) served as the standard level of care (i.e., control group) for comparison purposes. Veterans in the RRTP group were included in the study if they had diagnoses of chronic pain lasting more than 3 months as well as substance abuse and or PTSD. Participants in the SSC group all had report of chronic pain greater than 3 months but did not have the additional diagnoses of substance abuse or PTSD. Subjects were excluded from the study if they were VA employees, had active mental illness, were unable to read English at a basic level, or were at a cognitive level that prevented them from understanding the use of the pain scales. Veterans were contacted for participation by posted flyers advertising the study in the facility or by letter. The research protocol was reviewed and approved by the medical center’s affiliate institutional review board and a local research and development committee. A thorough review of the study was conducted with full consideration of human subjects’ protections for vulnerable populations. Informed consent and HIPAA authorization for this minimal risk prospective study were obtained in the patient care areas from all participants prior to participation in the study. Demographic characteristics of the sample are presented in Table 1. The sample of veterans was predominantly men (n = 189; about 95%). As previously described in Douglas et al. (2014), the mean age of the entire sample was 57.37 years (SD = 14.09 years), and ethnicity of the sample was predominantly Caucasian (n = 176; about 88%). All participants of the sample were reported to have chronic pain symptoms. The range of medical diagnoses included chronic pain syndrome, peripheral neuropathy, osteoarthritis, degenerative disc disease, fibromyalgia, and gout. Data also identified numerous pain-related injuries in multiple regions of the body such as neck, back, shoulder, knees, legs, arms, hands, and head. The RRTP group was the only group that had both a chronic pain condition along with a mental health condition such as depression, anxiety, PTSD, and a possible substance abuse diagnosis. Measurement Tools Several pain scales were used for comparison purposes (i.e., Numeric Rating, Visual Analog, Faces, and Mankoski). The pain scales were chosen for this study because the instruments were currently being administered as part of the standard level of care to assess pain in the RRTP and SSC patient care areas. The Numeric Rating scale is a tool used to rate pain on a scale www.journalofaddictionsnursing.com
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TABLE 1
Demographics of the Sample
Characteristic
RRTP Group SSC Group (n = 100) (n = 100)
Age
t /# 2 Value t (198) = 11.45***
M
48.50
66.24
SD
11.20
10.71 #2 (1) = .87
Gender Male Female
96 (96%)
93 (93%)
4 (4%)
7 (7%) # 2 (1) = 25.75***
Ethnicity Caucasian
77 (77%)
99 (99%)
African American
10 (10%)
V
Native American
10 (10%)
V
Asian American
V
1 (1%)
Other
2 (2%)
V
Unknown
1 (1%)
V
Note. RRTP = Residential Rehabilitation Treatment Program; SSC = Surgical Specialty Care. ***p G .001.
between 0 and 10. The Visual Analog scale is a 10-cm horizontal line that requires the patient to place a vertical line somewhere along the spectrum between ‘‘no pain’’ and ‘‘worst imaginable’’ pain. The Faces scale used five different faces to describe the level of pain a person is experiencing, and the Mankoski scale uses 10 different descriptors along with numbers to rate pain. All of the instruments used in this study have been found to be valid and reliable measures for pain (Douglas et al., 2014; Jaywant & Pai, 2003; Li, Herr, & Chen, 2009; Ware, Epps, Herr, & Packard, 2006; Williamson & Hoggart, 2005). The Numeric Rating scale and the Visual Analog scale had a very strong (r = .94) correlation according to Williamson and Hoggart (2005). Jaywant and Pai (2003) report that the Visual Analog scale has a .89 correlation with the Numeric Rating scale and a .82 correlation with the Faces scale. The Numeric Rating scale had a .78 correlation with the Faces scale (Jaywant & Pai, 2003). Douglas et al. (2014) found moderate to high validity correlation between the Mankoski pain scale and the Numeric Rating (r = .84), Visual Analog (r = .89), and Faces (r = .86) scales. The pain scales were presented to both groups in random order to eliminate possible confounds by administration of all measures in a specific order. Subjects were asked to rate their pain, while meeting with an investigator, in a private setting located within the patient care areas. Individuals rated current pain level, lowest pain for the previous week, highest pain for the previous week, and average pain for the previous week. 76
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Statistical Analysis Descriptive statistics were calculated with IBM SPSS Statistics (Version 20.0; IBM/SPSS, 2011). Data for this study was examined for skewness and kurtosis. Examination of the data revealed that all scales were within the recommended ranges for skewness and kurtosis. Therefore, there was no need for additional data transformation. There was no missing data for the variables analyzed in this particular study. Preliminary analyses were conducted to determine if there were differences between groups in areas of age (t test), gender (# 2 test), and ethnicity (# 2 test). Multiple analyses of variance (MANOVAs) and follow-up univariate statistics were conducted to determine differences between groups on the different scales. RESULTS Demographics from this study conveyed data consistent with the veteran sociodemographics for veterans being served within the Veteran Integrated System Network (VISN) serving a six-state area. For comparison purposes, the study group was representative with regional and national statistics relating to age, gender, and ethnicity (U.S. Department of Veterans Affairs, 2011). Veterans in the RRTP group were consistent with VISN data for age (M = 48.30; U.S. Department of Veterans Affairs, 2011). Gender categories for the sample of veterans were 98% men in the RRTP group and 93% in the SSC group, which is consistent with 94% male representation at the VISN level (U.S. Department of Veterans Affairs, 2011). Female representation in the RRTP group was 4% in comparison to 7% of women in the SSC group, which is consistent with the veteran population that is currently being served. Within the VISN, 5.4% of the veterans receiving services are women (U.S. Department of Veterans Affairs, 2011). The VISN demographics for race and ethnicity report that 74.8% of veterans are Caucasian compared to 77% found in the study group (U.S. Departments of Veterans Affairs, 2011). Data for the ethnicity of the veteran study groups do indicate a unique difference in the number of Caucasians. Veterans in the RRTP group were 77% Caucasian in comparison to the SSC group, which was 99%. These findings were consistent with the Midwest region and local demographics for this study and representative of the veterans being served in each unique care setting. Analyses were first conducted to determine differences between groups based on age, gender, and ethnicity. Table 1 provides demographic information regarding the sample. Mean age of the SSC group was 66.24 years (SD = 10.71), and the mean age of the RRTP group was 48.50 years (SD = 11.20). Mean age between groups was significant, t (198) = 11.45, p G .001, 95% CI [14.68, 20.80]. Because of significant differences between groups based on age, homogeneity of variance (i.e., Levene’s statistic) was carefully reviewed between groups. Findings were nonsignificant (p = .38), indicating equality of variances. For gender, there were no significant differences between groups, # 2(1) = 0.87, p = .35. For ethnicity, there was a significant difference between groups, # 2(4) = 25.75, p G .001. The SSC group was 99% Caucasian, whereas the RRTP group was 77% Caucasian. April/June 2014
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TABLE 2
Results of Multivariate Analyses
Variables
Covariate
Group Pain Scale
a
Group Pain Scale
b
Group Pain Scaleb
Wilks’ Lambda
MANOVA/MANCOVA
Effect Size
.78
F (4, 195) = 13.58***
)p2 = .22
Age
.88
F (4, 194) = 6.54***
)p2 = .12
Ethnicity
.81
F (4, 193) = 11.18***
)p2 = .19
RRTP Groups Pain Scalea
.68
F (20, 303) = 1.90*
)p2 = .09
Note. MANOVA = multiple analysis of variance; MANCOVA = multiple analysis of covariance; RRTP = Residential Rehabilitation Treatment Program. a MANOVA. bMANCOVA. *p G .05. ***p G .001.
A 2 4 MANOVA was conducted (group pain scale) to determine if there might be an overall main effect. Findings of MANOVA are presented in Table 2. Results of analysis revealed a significant overall main effect between variables (Wilks’ lambda = .78, F(4, 195) = 13.58, p G .001, )p2 = .22). Follow-up univariate statistics revealed significant differences between groups on all pain scales. Differences between groups on the pain scales are described in Table 3. Scores were significantly higher for the RRTP group than the SSC group on all screening measures. Given significant differences between group with age and ethnicity demographics, post hoc analyses were conducted to determine if effects of the two variables might have contributed significantly to overall main effects of MANOVA. Therefore, separate analyses were conducted with age and ethnicity each as covariates (i.e., MANCOVA) to determine if significant overall main effects could still be found (see Table 2). For age, findings were significant for overall main effects on pain scale scores despite accounting for age as the covariate (Wilks’ lambda = .88, F(4, 194) = 6.54, p G .001, )p2 = .12). For ethnicity, findings were also significant for overall main effects on pain scale scores despite accounting for ethnicity as the covariate (Wilks’ lambda = .81, F(4, 193) = 11.18, p G .001, )p2 = .19). Finally, post hoc analyses were conducted with the RRTP group to determine if there were significant differences between group pain scores based on diagnoses. Groups were divided into
TABLE 3
Results of Pain Scales Between Groups RRTP Group (n = 100)
SSC Group (n = 100)
M (SD)
M (SD)
F Value
Numeric Rating
5.32 (2.04)
3.40 (1.87)
48.39***
Visual Analog
5.33 (2.11)
3.48 (2.35)
34.28***
Faces
5.01 (2.20)
3.52 (2.33)
21.59***
Mankoski
5.27 (1.97)
3.57 (2.08)
35.23***
Pain Scale
Note. RRTP = Residential Rehabilitation Treatment Program; SSC = Surgical Specialty Care. ***p G .001.
Journal of Addictions Nursing
the following categories: (a) Alcohol only (n = 32); (b) Drug use only (i.e., opioids, cannabis, sedatives, inhalants, cocaine, and/or methamphetamine; n = 8); (c) Alcohol and PTSD (n = 15); (d) Drug use and PTSD (n = 8); (e) Alcohol, Drug use, and PTSD (n = 12); and (f) Alcohol and Drug use (n = 25). None of the participants in the RRTP group met criteria for PTSD alone. Because of the unequal sizes of the groups, preliminary analysis to check for possible violations of the homogeneity of variance was conducted with Box’s Test of Equality of Covariation of Matrices. This test showed these results were not significant, indicating that the variance between groups had sufficient normal distribution in order to conduct MANOVA. Analysis with MANOVA revealed a significant overall main effect (Wilks’ lambda = .68, F(20, 303) = 1.90, p G .05, partial )2 = .09). Results of post hoc analyses are provided in Table 4. Univariate statistics revealed significant differences between groups on the Numeric Rating (F(5, 94) = 2.54, p G .05, partial )2 = .12), Visual Analog (F(5, 94) = 3.22, p G .05, partial )2 = .15), Faces (F(5, 94) = 3.03, p G .05, partial )2 = .14), and Mankoski (F(5, 94) = 3.03, p G .05, partial )2 = .14) scales. Pairwise comparisons were then conducted with the Bonferroni posttest to help adjust for the problem of multiple comparisons. For the Numeric Rating scale, none of the pairwise comparisons were found to be noteworthy despite overall significance with univariate statistics. For the Visual Analog scale, scores were considerably higher for the Alcohol and Drugs group when compared to the Alcohol group (p G .05). Pairwise comparisons for Drug group on the Visual Analog scale were not significant when compared with the other groups despite the larger mean score, which was likely attributed to the small sample size for this group. For the Faces scale, comparisons revealed that scores were considerably lower for the Alcohol group when compared to the Drug group and the Alcohol and Drugs group. For the Mankoski scale, scores were significantly higher for the combination Alcohol, Drugs, and PTSD group when compared to the Alcohol group. DISCUSSION The aim of this study was to examine whether veterans with chronic pain, substance abuse, and PTSD diagnoses perceive a higher level of pain than those veterans who have chronic pain but do not have active substance abuse issues or PTSD. Results www.journalofaddictionsnursing.com
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TABLE 4
Pain Scale
Results of Post Hoc Analyses of Pain Scales Between RRTP Groups Alcohol
Drug
Alcohol and PTSD
Drugs and PTSD
Alcohol, Drugs, and PTSD
Alcohol and Drugs
(n = 32)
(n = 8)
(n = 15)
(n = 8)
(n = 12)
(n = 25)
M (SD)
M (SD)
M (SD)
M (SD)
M (SD)
M (SD)
6.25 (1.91)
5.73 (1.98)
5.75 (1.83)
5.92 (1.62)
5.62 (2.24)
2.54a*
4.20 (1.84)6*
6.33 (2.07)b
5.88 (2.21)
5.38 (1.78)
5.69 (1.43)
5.94 (2.30)1*
3.22*
2,6
1
Numeric Rating 4.33 (1.87) Visual Analog Faces
3.94 (2.23)
Mankoski
*
5
4.28 (1.82) *
6.50 (2.07) * 5.63 (2.00)
5.20 (1.97) 5.47 (1.96)
5.13 (1.81)
5.17 (1.80) 1
5.50 (1.41)
6.42 (1.51) * 1
2
3
F Value
1
5.68 (2.21) *
3.03*
5.68 (2.12)
3.03*
4
Note. RRTP = Residential Rehabilitation Treatment Program; PTSD = posttraumatic stress disorder. Alcohol. Drug. Alcohol and PTSD. Drugs and PTSD. 5 Alcohol, Drugs, and PTSD. 6Alcohol and Drugs. *p G .05. a Post hoc comparisons done with Bonferroni posttests to adjust for multiple comparisons. Although an overall significant difference was found between groups on the Numeric Rating scale, none of the post hoc comparisons were significant on the Bonferroni posttest. b Pairwise comparisons for this variable were not significant despite the larger mean score, which was likely attributed to the small sample for this group.
from the post hoc analyses of the pain scales in RRTP provided researchers with data that supported previous studies in relationship to reports of higher pain ratings for veterans experiencing pain and having PTSD. Psychiatric comorbidity, PTSD, and substance use disorders are twice as common with individuals with chronic moderate to severe pain (Gibson, 2012). In the current study, veterans experiencing chronic pain because of a medical condition and with no previous diagnoses of a psychiatric or substance abuse disorder often reported lower levels of pain. Each patient had a different pain management regimen that often included noncontrolled pharmacological and nonpharmacological interventions. Current research also indicates that veterans returning from combat often report symptoms of physical pain related to both physical and psychological conditions. Psychological trauma and ongoing stress related to combat also increases the likelihood for pain. Data from multiple studies have shown that individuals with PTSD tend to have increased levels of anxiety, which could impact the intensity of reported pain levels (Asmundson, Coons, Taylor, & Katz, 2002). Veterans with PTSD report having symptoms of irritability, traumatic memories, and physical injuries consistently describe higher levels of pain and difficulties with life adjustment (Caldeiro et al., 2008). According to this pain study, veterans in RRTP who have a PTSD diagnosis, chronic pain condition with or without a substance abuse disorder, report having higher pain levels. The data, in regard to the Alcohol group, reported the lowest pain rating (M = 3.94, SD = 2.23) in comparison to the other subgroups. Previous research on alcohol use and chronic pain conditions report findings of alcohol having a pain alleviating effect. Veterans in the RRTP who identified alcohol use did describe using alcohol as one method for pain management prior to admission to the treatment program. The alcohol often minimized their initial pain symptoms, but the pain reoccurred when drinking was discontinued. Data also suggest that individuals who experience chronic physical pain are at risk for developing alcohol dependence if alcohol remains the individ78
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ual’s choice for pain management (Elgi, Koob, & Edwards, 2012). It is unclear if veterans in RRTP with both alcohol and drug dependency increased their substance use in response to ineffective pain management. Although diagnosis was screened prior to inclusion in the study, the control group may have been using alcohol to manage pain symptoms but did not report any substance use. Furthermore, a portion of the control group could have undiagnosed and untreated mental health concerns. Findings indicate a higher rating of pain within the RRTP group, and this could indicate the importance of how the ‘‘perception of pain’’ influences the rating or scoring of the individuals’ experience of pain. Veterans in the RRTP group described how the Mankoski pain scale more accurately defined their experience of pain and preferred this pain scale over the other pain scales. Several RRTP veterans stated that the Mankoski scale, which includes more descriptors for their pain, communicated more clearly how their pain impacted their daily functioning. One veteran described how the Mankoski pain scale is more helpful for determining a pain rating for individuals experiencing chronic pain. This veteran described how the descriptors in the pain scale such as a pain level of 4, which is described as a pain level that can be ignored but allows for the ability to be involved with life activities, as being more reflective of his actual pain level. The veteran believed strongly about the need for his healthcare provider to clearly understand how his pain impacts his daily functioning and stated, ‘‘I want my provider to know how my pain is affecting my life.’’ Additional research by Lorenz et al. (2009) supports these findings and identified that Numeric Rating scales are insufficient in identifying the degree of pain the veteran is experiencing and how it is impacting their daily functioning. Their research also recognized the value in allowing the veteran time to discuss how pain impairs their ability to carry out their daily activities. Further consideration for having a more descriptive screening tool was to obtain quality information that would have an impact on the clinical picture or assessment of the pain condition. April/June 2014
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In addition, veterans in the current study described how important it is for healthcare providers to understand how pain ratings of 0Y10 do not adequately describe the pain level and pain-related problems experienced by the person. Several veterans reported that it has been difficult finding the ‘‘right’’ or ‘‘best’’ way to convey pain related to a physical injury to medical professionals without having the feeling as if they are ‘‘drug users.’’ Several veterans in the RRTP group also stated that they reported higher levels of pain in order to receive their pain medication. The Mankoski scale did have higher positive verbal reports for its use over the other three pain scales. A limitation of this study was that it was unclear if these veterans with chronic pain and medical conditions in the control group received more effective pain management for their conditions or if the actual pain level was reported to be lower. Future research should consider using a control group that does not receive medical intervention that could affect the pain scale rating at the time of inquiry. Other factors that could influence pain screening differences within the two study groups might be the individual veterans personality, social influences, and ability to express their concerns. One limitation of the study was the small sample size regarding specific drug use (i.e., opioids, cannabis, sedatives, inhalants, cocaine, and/or methamphetamine) in the Drug and Drug/ PTSD samples. The small sample sizes of these groups prohibited the exploration of differences that these individuals might experience with respect to pain. Further research investigating the differences on pain scale scores between different substance use groups would be beneficial. Another limitation of this study included the unique population of veterans who had chronic pain that could be influenced by cultural and ethnic backgrounds. The sample is representative of the veteran population in the Midwest but may not be representative of the overall veteran population of the United States. Further research is needed to compare the difference of pain scale scores of other ethnic and cultural backgrounds.
CONCLUSIONS The results of this research study show that those veterans with chronic pain, substance abuse, and PTSD diagnoses residing in an RRTP do perceive a higher level of pain than those veterans who also have chronic pain but do not have active substance abuse issues or PTSD. For future clinical practice, clinicians should be cognizant of the need for pain management techniques that address higher levels of pain for persons in residential treatment programs. This study further suggests the need for a more comprehensive pain assessment for veterans with substance abuse and PTSD diagnoses. Because of limited research performed on chronic pain perception in veterans undergoing treatment in an RRTP as compared to other veterans with chronic pain and the limited sample size of the RRTP group consisting of Drug use and Drug use with PTSD in this study, additional research is needed Journal of Addictions Nursing
to support the study findings. This would be reinforced with the use of a larger sample size. Outcomes of gender, age, and ethnicity regarding those experiencing chronic pain need further examination as variables influencing which groups of individuals perceive a higher level of pain. Acknowledgment: This study is the result of work supported with resources and the use of facilities at the St. Cloud VA Health Care System. The contents of this research do not represent the views of the Department of Veterans Affairs or the U.S. Government.
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Lew, H. L., Otis, J. D., Tun, C., Kerns, R. D., Clark, M. E., & Cifu, D. X. (2009). Prevalence of chronic pain, posttraumatic stress disorder, and persistent postconcussive symptoms in OIF/OEF veterans: Polytrauma clinical triad. Journal of Rehabilitation Research & Development, 46(6), 697Y702. Li, L., Herr, K., & Chen, P. (2009). Postoperative pain assessment with three intensity scales in Chinese elders. Journal of Nursing Scholarship, 41(3), 241Y249. Lorenz, K. A., Krebs, E. E., Bentley, T. G. K., Sherbourne, C. D., Goebel, J. R., Zubkoff, L., I Asch, S. M. (2009). Exploring alternative approaches to routine outpatient pain screening. Pain Medicine, 10(7), 1291Y1299. doi:10.1111/j.1526-4637.2009.00709x Morgan, B. D., & White, D. M. (2009). Managing pain in patients with co-occurring addictive disorders. Journal of Addictions Nursing, 20, 41Y48.
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Shiperd, J. C., Keyes, M., Jovanovic, T., Ready, D. J., Baltzell, D., Worley, V., I Duncan, E. (2007). Veterans seeking treatment for posttraumatic stress disorder: What about comorbid chronic pain? Journal of Rehabilitation Research & Development, 44(2), 153Y166. U.S. Department of Veterans Affairs. (2011). Northeast Program Evaluation Center (NEPEC). Retrieved from http://vaww.nepec.mentalhealth .med.va.gov/RRT/PRR/prrtp.htm U.S. Department of Veterans Affairs. (2012). National Center for PTSD. Retrieved from http://www.va.gov/health/aboutVHA.asp Ware, L. J., Epps, C. D., Herr, K., & Packard, A. (2006). Evaluation of the revised faces pain scale, verbal descriptor scale, numeric rating scale, and Iowa pain thermometer in older minority adults. Pain Management Nursing, 7(3), 117Y125. Williamson, A., & Hoggart, B. (2005). Pain: A review of three commonly used pain rating scales. Journal of Clinical Nursing, 14(7), 798Y804.
April/June 2014
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Measuring Chronic Pain Intensity Among Veterans in a Residential Rehabilitation Treatment Program Mary L. Randleman, MSN, RN m Mary E. Douglas, MSN, RN m Alice M. DeLane, MSN, RN, CNOR m Glen A. Palmer, PhD, ABN
The purpose of this study was to identify whether veterans with chronic pain, substance abuse, and posttraumatic stress disorder (PTSD) diagnoses residing in a Residential Rehabilitation Treatment Program (RRTP) perceived a higher level of pain than those veterans who had chronic pain but did not have active substance abuse issues or PTSD. A sample of veterans (n = 200) with chronic pain undergoing treatment for either chemical dependency and/or PTSD in an RRTP and a Surgical Specialty Care outpatient clinic at a Department of Veterans Affairs medical center took part in the study. Multiple analysis of variance and further univariate statistics were examined to determine the association between groups on the different scales. There was a considerable difference in terms of which group of veterans perceived a higher rate of pain even with the use of the same four pain assessment scales (i.e., Numeric Rating, Visual Analog, Faces, and Mankoski). Scores were significantly higher for the RRTP group than the Surgical Specialty Care group on all screening measures (p G .001). Veterans with chronic pain, substance abuse, and/or PTSD diagnoses residing in an RRTP tended to have a higher perception of chronic pain compared to those without substance abuse or PTSD diagnoses. Keywords: chronic pain, PTSD, residential treatment, substance abuse, veteran
I
t is estimated that between 50,000 to 100,000 soldiers have been injured in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF; Gibson, 2012). Because of these nonmortal wounds, veterans may be left with
Mary L. Randleman, MSN, RN, Minneapolis VA Health Care System, Minnesota. Mary E. Douglas, MSN, RN, Fargo VA Health Care System, North Dakota. Alice M. DeLane, MSN, RN, CNOR, and Glen A. Palmer, PhD, ABN, St. Cloud VA Health Care System, Minnesota. The authors have no financial conflicts of interest to declare. Correspondence related to content to: Mary L. Randleman, MSN, RN, Mental Health, 7545 Veterans Drive, Ramsey, MN 55303. E-mail: [email protected] DOI: 10.1097/JAN.0000000000000027 74
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injuries that lead to the development of pain lasting greater than 6 months in length. Orthopedic injuries and amputations lead the list of injuries incurred as a result of the wars (Clark, Bair, Buckenmaier, Gironda, & Walker, 2007). In addition to physical injuries, many veterans are returning with long-term psychological trauma as well. These experiences contribute to the development of substance abuse and posttraumatic stress disorder (PTSD). Veterans are learning to live with both physical and psychological wounds. BACKGROUND The Veterans Health Administration is responsible for providing health care for veterans and military personnel who may be experiencing military-related medical issues, including chronic pain. A service available to veterans is a Mental Health Residential Rehabilitation Treatment Program (RRTP) that provides evidence-based, quality treatment for veterans with multiple and severe medical conditions including pain, mental illness, addiction, and psychosocial deficits. The RRTP is intended to address the patients’ goals of rehabilitation, recovery, health maintenance, improved quality of life, treatment of medical conditions, mental illnesses, addictive disorders, and homelessness (U.S. Department of Veterans Affairs, 2012). Veterans with chronic pain and psychological injuries, such as PTSD, often remark that they have little power over their pain (Gauntlett-Gilbert & Wilson, 2013). Studies show that individuals with substance abuse issues perceive a higher rate of pain, which may contribute to tolerance, that is, an adaptation in which a diminution of the medication effects requires an increase in the dosage to help alleviate the person’s pain (Morgan & White, 2009). There is limited research on chronic pain perception in veterans undergoing treatment in an RRTP as compared to other veterans with chronic pain. The purpose of this study is to identify whether veterans with chronic pain, substance abuse, and PTSD diagnoses residing in an RRTP perceive a higher level of pain than those veterans who have chronic pain but do not have active substance abuse issues or PTSD. The authors hypothesized that veterans in RRTP will, in fact, report higher levels of pain intensity compared to other veterans. Currently, there is limited research pertaining to the quality of pain assessment and management by clinicians working with a veteran population. If clinicians April/June 2014
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were to understand differences with reported pain intensity in the veteran population, it might contribute to changes in clinical practice, and this could improve overall pain management and general well-being for the patient.
LITERATURE REVIEW A literature search was carried out to ascertain the availability of current research describing the association of pain intensity in veterans who have chronic pain and diagnoses of either substance abuse or PTSD. The research databases of EBSCOhost and ProQuest were used to identify full-text, peer-reviewed articles related to veterans with substance abuse and PTSD. The keywords chronic pain, veterans, substance abuse, and PTSD were used. Chronic pain is common among the veteran population. Kern, Otis, Rosenberg, and Reid (2003) found that 50% of veterans receiving primary care experienced pain daily. This number is similar to the results identified in a study by Haskell et al. (2009), who found that pain was present in 59.7% of the veterans they assessed. Of those individuals, 63.2% described their pain as either moderate or severe. The American Pain Foundation (2009) found that 70% of respondents of an online survey of 753 veterans and members of the armed forces rated their pain intensity between 7 and 10 on a scale of zero to 10. The American Pain Foundation found that one third of the respondents also stated that they experienced PTSD in addition to having high pain intensity. This number is similar to other studies conducted comparing the link between pain and PTSD. In a study of veterans undergoing PTSD treatment, 66% of the population had comorbid chronic pain diagnoses (Shipherd et al., 2007). It has been reported that 81.5% of veterans returning from the OEF and OIF wars had chronic pain and 58.6% had both chronic pain and PTSD (Lew et al., 2009). Clark et al. (2007) explained that the development of psychosocial symptoms related to chronic pain from trauma sustained in the OEF and OIF campaigns may not be fully identified for many years. In addition to possessing the diagnosis of PTSD, substance abuse in veterans continues to be an issue with many individuals who experience chronic pain. Erbes, Westermeyer, Engdahl, and Johnsen (2007) discovered that 6% of returning veterans had both PTSD and alcohol use problems. Many individuals self-medicate with alcohol to treat their pain (Brennan, Schutte, & Moos, 2005; Chandragiri, Vael, King, & Hardy, 2000). Alcohol dependence creates physical changes within the body. These individuals metabolize medications and respond to pain stimuli differently, which affects pain medication response (D’Arcy, 2007). It is because of these physical changes that pain may be experienced at a higher level than an individual who does not experience alcohol dependence. Chandragiri et al. (2000) identify that symptoms of PTSD are intensified when there is a combined diagnoses of PTSD, substance abuse, and chronic pain. Gibson (2012) maintains that unhealthy lifestyle choices, such as substance abuse, can contribute to increased symptoms of chronic pain. Journal of Addictions Nursing
METHOD Participants Subjects (n = 200) were recruited from a Department of Veterans Affairs (VA) medical center in the Midwest. As previously described in Douglas, Randleman, DeLane, and Palmer (2014), the subjects were enrolled in the study from RRTP and Surgical Specialty Care (SSC) outpatient settings. Veteran computerized patient records were screened for study eligibility (n = 990). Of the 990 screened medical records, 487 individuals (49%) met the study criteria and 200 veterans agreed to participate in the study. Among the 200 veterans, the RRTP group (n = 100) served as our study group and the SSC group (n = 100) served as the standard level of care (i.e., control group) for comparison purposes. Veterans in the RRTP group were included in the study if they had diagnoses of chronic pain lasting more than 3 months as well as substance abuse and or PTSD. Participants in the SSC group all had report of chronic pain greater than 3 months but did not have the additional diagnoses of substance abuse or PTSD. Subjects were excluded from the study if they were VA employees, had active mental illness, were unable to read English at a basic level, or were at a cognitive level that prevented them from understanding the use of the pain scales. Veterans were contacted for participation by posted flyers advertising the study in the facility or by letter. The research protocol was reviewed and approved by the medical center’s affiliate institutional review board and a local research and development committee. A thorough review of the study was conducted with full consideration of human subjects’ protections for vulnerable populations. Informed consent and HIPAA authorization for this minimal risk prospective study were obtained in the patient care areas from all participants prior to participation in the study. Demographic characteristics of the sample are presented in Table 1. The sample of veterans was predominantly men (n = 189; about 95%). As previously described in Douglas et al. (2014), the mean age of the entire sample was 57.37 years (SD = 14.09 years), and ethnicity of the sample was predominantly Caucasian (n = 176; about 88%). All participants of the sample were reported to have chronic pain symptoms. The range of medical diagnoses included chronic pain syndrome, peripheral neuropathy, osteoarthritis, degenerative disc disease, fibromyalgia, and gout. Data also identified numerous pain-related injuries in multiple regions of the body such as neck, back, shoulder, knees, legs, arms, hands, and head. The RRTP group was the only group that had both a chronic pain condition along with a mental health condition such as depression, anxiety, PTSD, and a possible substance abuse diagnosis. Measurement Tools Several pain scales were used for comparison purposes (i.e., Numeric Rating, Visual Analog, Faces, and Mankoski). The pain scales were chosen for this study because the instruments were currently being administered as part of the standard level of care to assess pain in the RRTP and SSC patient care areas. The Numeric Rating scale is a tool used to rate pain on a scale www.journalofaddictionsnursing.com
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TABLE 1
Demographics of the Sample
Characteristic
RRTP Group SSC Group (n = 100) (n = 100)
Age
t /# 2 Value t (198) = 11.45***
M
48.50
66.24
SD
11.20
10.71 #2 (1) = .87
Gender Male Female
96 (96%)
93 (93%)
4 (4%)
7 (7%) # 2 (1) = 25.75***
Ethnicity Caucasian
77 (77%)
99 (99%)
African American
10 (10%)
V
Native American
10 (10%)
V
Asian American
V
1 (1%)
Other
2 (2%)
V
Unknown
1 (1%)
V
Note. RRTP = Residential Rehabilitation Treatment Program; SSC = Surgical Specialty Care. ***p G .001.
between 0 and 10. The Visual Analog scale is a 10-cm horizontal line that requires the patient to place a vertical line somewhere along the spectrum between ‘‘no pain’’ and ‘‘worst imaginable’’ pain. The Faces scale used five different faces to describe the level of pain a person is experiencing, and the Mankoski scale uses 10 different descriptors along with numbers to rate pain. All of the instruments used in this study have been found to be valid and reliable measures for pain (Douglas et al., 2014; Jaywant & Pai, 2003; Li, Herr, & Chen, 2009; Ware, Epps, Herr, & Packard, 2006; Williamson & Hoggart, 2005). The Numeric Rating scale and the Visual Analog scale had a very strong (r = .94) correlation according to Williamson and Hoggart (2005). Jaywant and Pai (2003) report that the Visual Analog scale has a .89 correlation with the Numeric Rating scale and a .82 correlation with the Faces scale. The Numeric Rating scale had a .78 correlation with the Faces scale (Jaywant & Pai, 2003). Douglas et al. (2014) found moderate to high validity correlation between the Mankoski pain scale and the Numeric Rating (r = .84), Visual Analog (r = .89), and Faces (r = .86) scales. The pain scales were presented to both groups in random order to eliminate possible confounds by administration of all measures in a specific order. Subjects were asked to rate their pain, while meeting with an investigator, in a private setting located within the patient care areas. Individuals rated current pain level, lowest pain for the previous week, highest pain for the previous week, and average pain for the previous week. 76
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Statistical Analysis Descriptive statistics were calculated with IBM SPSS Statistics (Version 20.0; IBM/SPSS, 2011). Data for this study was examined for skewness and kurtosis. Examination of the data revealed that all scales were within the recommended ranges for skewness and kurtosis. Therefore, there was no need for additional data transformation. There was no missing data for the variables analyzed in this particular study. Preliminary analyses were conducted to determine if there were differences between groups in areas of age (t test), gender (# 2 test), and ethnicity (# 2 test). Multiple analyses of variance (MANOVAs) and follow-up univariate statistics were conducted to determine differences between groups on the different scales. RESULTS Demographics from this study conveyed data consistent with the veteran sociodemographics for veterans being served within the Veteran Integrated System Network (VISN) serving a six-state area. For comparison purposes, the study group was representative with regional and national statistics relating to age, gender, and ethnicity (U.S. Department of Veterans Affairs, 2011). Veterans in the RRTP group were consistent with VISN data for age (M = 48.30; U.S. Department of Veterans Affairs, 2011). Gender categories for the sample of veterans were 98% men in the RRTP group and 93% in the SSC group, which is consistent with 94% male representation at the VISN level (U.S. Department of Veterans Affairs, 2011). Female representation in the RRTP group was 4% in comparison to 7% of women in the SSC group, which is consistent with the veteran population that is currently being served. Within the VISN, 5.4% of the veterans receiving services are women (U.S. Department of Veterans Affairs, 2011). The VISN demographics for race and ethnicity report that 74.8% of veterans are Caucasian compared to 77% found in the study group (U.S. Departments of Veterans Affairs, 2011). Data for the ethnicity of the veteran study groups do indicate a unique difference in the number of Caucasians. Veterans in the RRTP group were 77% Caucasian in comparison to the SSC group, which was 99%. These findings were consistent with the Midwest region and local demographics for this study and representative of the veterans being served in each unique care setting. Analyses were first conducted to determine differences between groups based on age, gender, and ethnicity. Table 1 provides demographic information regarding the sample. Mean age of the SSC group was 66.24 years (SD = 10.71), and the mean age of the RRTP group was 48.50 years (SD = 11.20). Mean age between groups was significant, t (198) = 11.45, p G .001, 95% CI [14.68, 20.80]. Because of significant differences between groups based on age, homogeneity of variance (i.e., Levene’s statistic) was carefully reviewed between groups. Findings were nonsignificant (p = .38), indicating equality of variances. For gender, there were no significant differences between groups, # 2(1) = 0.87, p = .35. For ethnicity, there was a significant difference between groups, # 2(4) = 25.75, p G .001. The SSC group was 99% Caucasian, whereas the RRTP group was 77% Caucasian. April/June 2014
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TABLE 2
Results of Multivariate Analyses
Variables
Covariate
Group Pain Scale
a
Group Pain Scale
b
Group Pain Scaleb
Wilks’ Lambda
MANOVA/MANCOVA
Effect Size
.78
F (4, 195) = 13.58***
)p2 = .22
Age
.88
F (4, 194) = 6.54***
)p2 = .12
Ethnicity
.81
F (4, 193) = 11.18***
)p2 = .19
RRTP Groups Pain Scalea
.68
F (20, 303) = 1.90*
)p2 = .09
Note. MANOVA = multiple analysis of variance; MANCOVA = multiple analysis of covariance; RRTP = Residential Rehabilitation Treatment Program. a MANOVA. bMANCOVA. *p G .05. ***p G .001.
A 2 4 MANOVA was conducted (group pain scale) to determine if there might be an overall main effect. Findings of MANOVA are presented in Table 2. Results of analysis revealed a significant overall main effect between variables (Wilks’ lambda = .78, F(4, 195) = 13.58, p G .001, )p2 = .22). Follow-up univariate statistics revealed significant differences between groups on all pain scales. Differences between groups on the pain scales are described in Table 3. Scores were significantly higher for the RRTP group than the SSC group on all screening measures. Given significant differences between group with age and ethnicity demographics, post hoc analyses were conducted to determine if effects of the two variables might have contributed significantly to overall main effects of MANOVA. Therefore, separate analyses were conducted with age and ethnicity each as covariates (i.e., MANCOVA) to determine if significant overall main effects could still be found (see Table 2). For age, findings were significant for overall main effects on pain scale scores despite accounting for age as the covariate (Wilks’ lambda = .88, F(4, 194) = 6.54, p G .001, )p2 = .12). For ethnicity, findings were also significant for overall main effects on pain scale scores despite accounting for ethnicity as the covariate (Wilks’ lambda = .81, F(4, 193) = 11.18, p G .001, )p2 = .19). Finally, post hoc analyses were conducted with the RRTP group to determine if there were significant differences between group pain scores based on diagnoses. Groups were divided into
TABLE 3
Results of Pain Scales Between Groups RRTP Group (n = 100)
SSC Group (n = 100)
M (SD)
M (SD)
F Value
Numeric Rating
5.32 (2.04)
3.40 (1.87)
48.39***
Visual Analog
5.33 (2.11)
3.48 (2.35)
34.28***
Faces
5.01 (2.20)
3.52 (2.33)
21.59***
Mankoski
5.27 (1.97)
3.57 (2.08)
35.23***
Pain Scale
Note. RRTP = Residential Rehabilitation Treatment Program; SSC = Surgical Specialty Care. ***p G .001.
Journal of Addictions Nursing
the following categories: (a) Alcohol only (n = 32); (b) Drug use only (i.e., opioids, cannabis, sedatives, inhalants, cocaine, and/or methamphetamine; n = 8); (c) Alcohol and PTSD (n = 15); (d) Drug use and PTSD (n = 8); (e) Alcohol, Drug use, and PTSD (n = 12); and (f) Alcohol and Drug use (n = 25). None of the participants in the RRTP group met criteria for PTSD alone. Because of the unequal sizes of the groups, preliminary analysis to check for possible violations of the homogeneity of variance was conducted with Box’s Test of Equality of Covariation of Matrices. This test showed these results were not significant, indicating that the variance between groups had sufficient normal distribution in order to conduct MANOVA. Analysis with MANOVA revealed a significant overall main effect (Wilks’ lambda = .68, F(20, 303) = 1.90, p G .05, partial )2 = .09). Results of post hoc analyses are provided in Table 4. Univariate statistics revealed significant differences between groups on the Numeric Rating (F(5, 94) = 2.54, p G .05, partial )2 = .12), Visual Analog (F(5, 94) = 3.22, p G .05, partial )2 = .15), Faces (F(5, 94) = 3.03, p G .05, partial )2 = .14), and Mankoski (F(5, 94) = 3.03, p G .05, partial )2 = .14) scales. Pairwise comparisons were then conducted with the Bonferroni posttest to help adjust for the problem of multiple comparisons. For the Numeric Rating scale, none of the pairwise comparisons were found to be noteworthy despite overall significance with univariate statistics. For the Visual Analog scale, scores were considerably higher for the Alcohol and Drugs group when compared to the Alcohol group (p G .05). Pairwise comparisons for Drug group on the Visual Analog scale were not significant when compared with the other groups despite the larger mean score, which was likely attributed to the small sample size for this group. For the Faces scale, comparisons revealed that scores were considerably lower for the Alcohol group when compared to the Drug group and the Alcohol and Drugs group. For the Mankoski scale, scores were significantly higher for the combination Alcohol, Drugs, and PTSD group when compared to the Alcohol group. DISCUSSION The aim of this study was to examine whether veterans with chronic pain, substance abuse, and PTSD diagnoses perceive a higher level of pain than those veterans who have chronic pain but do not have active substance abuse issues or PTSD. Results www.journalofaddictionsnursing.com
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TABLE 4
Pain Scale
Results of Post Hoc Analyses of Pain Scales Between RRTP Groups Alcohol
Drug
Alcohol and PTSD
Drugs and PTSD
Alcohol, Drugs, and PTSD
Alcohol and Drugs
(n = 32)
(n = 8)
(n = 15)
(n = 8)
(n = 12)
(n = 25)
M (SD)
M (SD)
M (SD)
M (SD)
M (SD)
M (SD)
6.25 (1.91)
5.73 (1.98)
5.75 (1.83)
5.92 (1.62)
5.62 (2.24)
2.54a*
4.20 (1.84)6*
6.33 (2.07)b
5.88 (2.21)
5.38 (1.78)
5.69 (1.43)
5.94 (2.30)1*
3.22*
2,6
1
Numeric Rating 4.33 (1.87) Visual Analog Faces
3.94 (2.23)
Mankoski
*
5
4.28 (1.82) *
6.50 (2.07) * 5.63 (2.00)
5.20 (1.97) 5.47 (1.96)
5.13 (1.81)
5.17 (1.80) 1
5.50 (1.41)
6.42 (1.51) * 1
2
3
F Value
1
5.68 (2.21) *
3.03*
5.68 (2.12)
3.03*
4
Note. RRTP = Residential Rehabilitation Treatment Program; PTSD = posttraumatic stress disorder. Alcohol. Drug. Alcohol and PTSD. Drugs and PTSD. 5 Alcohol, Drugs, and PTSD. 6Alcohol and Drugs. *p G .05. a Post hoc comparisons done with Bonferroni posttests to adjust for multiple comparisons. Although an overall significant difference was found between groups on the Numeric Rating scale, none of the post hoc comparisons were significant on the Bonferroni posttest. b Pairwise comparisons for this variable were not significant despite the larger mean score, which was likely attributed to the small sample for this group.
from the post hoc analyses of the pain scales in RRTP provided researchers with data that supported previous studies in relationship to reports of higher pain ratings for veterans experiencing pain and having PTSD. Psychiatric comorbidity, PTSD, and substance use disorders are twice as common with individuals with chronic moderate to severe pain (Gibson, 2012). In the current study, veterans experiencing chronic pain because of a medical condition and with no previous diagnoses of a psychiatric or substance abuse disorder often reported lower levels of pain. Each patient had a different pain management regimen that often included noncontrolled pharmacological and nonpharmacological interventions. Current research also indicates that veterans returning from combat often report symptoms of physical pain related to both physical and psychological conditions. Psychological trauma and ongoing stress related to combat also increases the likelihood for pain. Data from multiple studies have shown that individuals with PTSD tend to have increased levels of anxiety, which could impact the intensity of reported pain levels (Asmundson, Coons, Taylor, & Katz, 2002). Veterans with PTSD report having symptoms of irritability, traumatic memories, and physical injuries consistently describe higher levels of pain and difficulties with life adjustment (Caldeiro et al., 2008). According to this pain study, veterans in RRTP who have a PTSD diagnosis, chronic pain condition with or without a substance abuse disorder, report having higher pain levels. The data, in regard to the Alcohol group, reported the lowest pain rating (M = 3.94, SD = 2.23) in comparison to the other subgroups. Previous research on alcohol use and chronic pain conditions report findings of alcohol having a pain alleviating effect. Veterans in the RRTP who identified alcohol use did describe using alcohol as one method for pain management prior to admission to the treatment program. The alcohol often minimized their initial pain symptoms, but the pain reoccurred when drinking was discontinued. Data also suggest that individuals who experience chronic physical pain are at risk for developing alcohol dependence if alcohol remains the individ78
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ual’s choice for pain management (Elgi, Koob, & Edwards, 2012). It is unclear if veterans in RRTP with both alcohol and drug dependency increased their substance use in response to ineffective pain management. Although diagnosis was screened prior to inclusion in the study, the control group may have been using alcohol to manage pain symptoms but did not report any substance use. Furthermore, a portion of the control group could have undiagnosed and untreated mental health concerns. Findings indicate a higher rating of pain within the RRTP group, and this could indicate the importance of how the ‘‘perception of pain’’ influences the rating or scoring of the individuals’ experience of pain. Veterans in the RRTP group described how the Mankoski pain scale more accurately defined their experience of pain and preferred this pain scale over the other pain scales. Several RRTP veterans stated that the Mankoski scale, which includes more descriptors for their pain, communicated more clearly how their pain impacted their daily functioning. One veteran described how the Mankoski pain scale is more helpful for determining a pain rating for individuals experiencing chronic pain. This veteran described how the descriptors in the pain scale such as a pain level of 4, which is described as a pain level that can be ignored but allows for the ability to be involved with life activities, as being more reflective of his actual pain level. The veteran believed strongly about the need for his healthcare provider to clearly understand how his pain impacts his daily functioning and stated, ‘‘I want my provider to know how my pain is affecting my life.’’ Additional research by Lorenz et al. (2009) supports these findings and identified that Numeric Rating scales are insufficient in identifying the degree of pain the veteran is experiencing and how it is impacting their daily functioning. Their research also recognized the value in allowing the veteran time to discuss how pain impairs their ability to carry out their daily activities. Further consideration for having a more descriptive screening tool was to obtain quality information that would have an impact on the clinical picture or assessment of the pain condition. April/June 2014
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In addition, veterans in the current study described how important it is for healthcare providers to understand how pain ratings of 0Y10 do not adequately describe the pain level and pain-related problems experienced by the person. Several veterans reported that it has been difficult finding the ‘‘right’’ or ‘‘best’’ way to convey pain related to a physical injury to medical professionals without having the feeling as if they are ‘‘drug users.’’ Several veterans in the RRTP group also stated that they reported higher levels of pain in order to receive their pain medication. The Mankoski scale did have higher positive verbal reports for its use over the other three pain scales. A limitation of this study was that it was unclear if these veterans with chronic pain and medical conditions in the control group received more effective pain management for their conditions or if the actual pain level was reported to be lower. Future research should consider using a control group that does not receive medical intervention that could affect the pain scale rating at the time of inquiry. Other factors that could influence pain screening differences within the two study groups might be the individual veterans personality, social influences, and ability to express their concerns. One limitation of the study was the small sample size regarding specific drug use (i.e., opioids, cannabis, sedatives, inhalants, cocaine, and/or methamphetamine) in the Drug and Drug/ PTSD samples. The small sample sizes of these groups prohibited the exploration of differences that these individuals might experience with respect to pain. Further research investigating the differences on pain scale scores between different substance use groups would be beneficial. Another limitation of this study included the unique population of veterans who had chronic pain that could be influenced by cultural and ethnic backgrounds. The sample is representative of the veteran population in the Midwest but may not be representative of the overall veteran population of the United States. Further research is needed to compare the difference of pain scale scores of other ethnic and cultural backgrounds.
CONCLUSIONS The results of this research study show that those veterans with chronic pain, substance abuse, and PTSD diagnoses residing in an RRTP do perceive a higher level of pain than those veterans who also have chronic pain but do not have active substance abuse issues or PTSD. For future clinical practice, clinicians should be cognizant of the need for pain management techniques that address higher levels of pain for persons in residential treatment programs. This study further suggests the need for a more comprehensive pain assessment for veterans with substance abuse and PTSD diagnoses. Because of limited research performed on chronic pain perception in veterans undergoing treatment in an RRTP as compared to other veterans with chronic pain and the limited sample size of the RRTP group consisting of Drug use and Drug use with PTSD in this study, additional research is needed Journal of Addictions Nursing
to support the study findings. This would be reinforced with the use of a larger sample size. Outcomes of gender, age, and ethnicity regarding those experiencing chronic pain need further examination as variables influencing which groups of individuals perceive a higher level of pain. Acknowledgment: This study is the result of work supported with resources and the use of facilities at the St. Cloud VA Health Care System. The contents of this research do not represent the views of the Department of Veterans Affairs or the U.S. Government.
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