Giannitrapani Karleen, McCaa Matthew, Haverfield Marie, Kerns Robert D, Timko Christine, Dobscha Steven, Lorenz Karl
VA Palo Alto Health Care System, Center for Innovation to Implementation (Ci2i), Menlo Park, CA.
Stanford University, Palo Alto, CA.
Mil Med. 2018 Nov 1;183(11-12):e628-e634. doi: 10.1093/milmed/usy018.
Pain is a longstanding and growing concern among US military veterans. Although many individuals rely on medications, a growing body of literature supports the use of complementary non-pharmacologic approaches when treating pain. Our objective is to characterize veteran experiences with and barriers to accessing alternatives to medication (e.g., non-pharmacologic treatments or non-pharmacologic approaches) for pain in primary care.
Data for this qualitative analysis were collected as part of the Effective Screening for Pain (ESP) study (2012-2017), a national randomized controlled trial of pain screening and assessment methods. This study was approved by the Veterans Affairs (VA) Central IRB and veteran participants signed written informed consent. We recruited a convenience sample of US military veterans in four primary care clinics and conducted semi-structured interviews (25-65 min) elucidating veteran experiences with assessment and management of pain in VA Healthcare Systems. We completed interviews with 36 veterans, including 7 females and 29 males, from three VA health care systems. They ranged in age from 28 to 94 yr and had pain intensity ratings ranging from 0 to 9 on the "pain now" numeric rating scale at the time of the interviews. We analyzed interview transcripts using constant comparison and produced mutually agreed upon themes.
Veteran experiences with and barriers to accessing complementary non-pharmacologic approaches for pain clustered into five main themes: communication with provider about complementary approaches ("one of the best things the VA has ever given me was pain education and it was through my occupational therapist"), care coordination ("I have friends that go to small clinic in [area A] and I still see them down in [facility in area B] and they're going through headaches upon headaches in trying to get their information to their primary care docs"), veteran expectations about pain experience ("I think as a society we have shifted the focus to if this doctor doesn't relieve me of my pain I will find someone who does"), veteran knowledge and beliefs about various complementary non-pharmacologic approaches ("how many people know that tai chi will help with pain?… Probably none. I saw them doing tai chi down here at the VA clinic and the only reason I knew about it was because I saw it being done"), and access ("the only physical therapy I ever did… it helped…but it was a two-and-a-half-hour drive to get there three times a week… I can't do this"). Specific access barriers included local availability, time, distance, scheduling flexibility, enrollment, and reimbursement.
The veterans in this qualitative study expressed interest in using non-pharmacologic approaches to manage pain, but voiced complex multi-level barriers. Limitations of our study include that interviews were conducted only in five clinics and with seven female veterans. These limitations are minimized in that the clinics covered are diverse ranging to include urban, suburban, and rural residents. Future implementation efforts can learn from the veterans' voice to appropriately target veteran concerns and achieve more patient-centered pain care.
疼痛一直是美国退伍军人长期且日益严重的问题。尽管许多人依赖药物治疗，但越来越多的文献支持在治疗疼痛时采用辅助性非药物方法。我们的目标是描述退伍军人在初级保健中使用替代药物治疗疼痛（如非药物治疗或非药物方法）的经历及障碍。
本定性分析的数据是作为疼痛有效筛查（ESP）研究（2012 - 2017年）的一部分收集的，该研究是一项关于疼痛筛查和评估方法的全国性随机对照试验。本研究经退伍军人事务部（VA）中央机构审查委员会批准，退伍军人参与者签署了书面知情同意书。我们在四个初级保健诊所招募了一个方便样本的美国退伍军人，并进行了半结构化访谈（25 - 65分钟），以阐明退伍军人在VA医疗系统中疼痛评估和管理的经历。我们对来自三个VA医疗系统的36名退伍军人进行了访谈，其中包括7名女性和29名男性。他们的年龄在28岁至94岁之间，在访谈时“当前疼痛”数字评分量表上的疼痛强度评分为0至9分。我们使用持续比较法分析访谈记录，并得出共同认可的主题。
退伍军人在使用辅助性非药物方法治疗疼痛方面的经历和障碍主要集中在五个主题：与提供者就辅助方法进行沟通（“VA给我的最好的事情之一就是疼痛教育，这是通过我的职业治疗师进行的”）、护理协调（“我有朋友在[A区]的小诊所看病，我仍在[B区的机构]看诊，他们在试图将自己的信息传达给初级保健医生时遇到了重重困难”）、退伍军人对疼痛体验的期望（“我认为作为一个社会，我们已经将焦点转移到如果这位医生不能缓解我的疼痛，我就会去找能缓解的人”）、退伍军人对各种辅助性非药物方法的知识和信念（“有多少人知道太极拳有助于缓解疼痛？……可能没有人知道。我在VA诊所看到他们打太极拳，我之所以知道，唯一原因就是我看到有人在打”）以及获取途径（“我唯一做过的物理治疗……有帮助……但每周要开车两个半小时去三次……我做不到”）。具体的获取障碍包括当地的可获得性、时间、距离、日程安排的灵活性、注册登记和报销。
在这项定性研究中的退伍军人表示有兴趣使用非药物方法来管理疼痛，但也表达了复杂的多层次障碍。我们研究的局限性包括仅在五个诊所进行了访谈，且只有七名女性退伍军人参与。不过，所涵盖的诊所具有多样性，包括城市、郊区和农村居民，这在一定程度上减少了这些局限性。未来的实施工作可以借鉴退伍军人的意见，以适当地关注退伍军人的关切，实现更以患者为中心的疼痛护理。
