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Improving Healthcare for Veterans with Chronic Pain

July 2023


According to the Centers for Disease Control and Prevention, about 50 million U.S. adults have chronic pain [1]—ongoing pain that lasts longer than six months. Among Veterans, chronic pain is more prevalent and more intense than in the general population.[2] Chronic pain can contribute to depression, anxiety, poor sleep, decreased quality of life, and substance use disorders. It is also a risk factor for suicide.

VA offers help for Veterans who want to break the cycle of chronic pain. Available VA treatments include Cognitive Behavioral Therapy for Chronic Pain and complementary therapies such as yoga and acupressure.

In addition, HSR&D researchers at the Pain Research, Informatics, Multi-morbidities, and Education Center, the Center for Care Delivery and Outcomes Research, and the Center to Improve Veteran Involvement in Care are examining the science of pain and how best to treat it. The Pain/Opioid CORE strives to enhance collaboration and accelerate research related to pain (especially nondrug interventions for chronic pain), opioid prescribing, and opioid use disorder and promotes efforts to move research findings into wider use. And work within HSR&D’s Quality Enhancement Research Initiative includes study of pain care and opioid safety, with evaluation of the clinical impact of virtual interdisciplinary pain care teams, and a goal of improved access to effective care for Veterans who live with chronic pain.

Following are some recent HSR&D studies related to chronic pain.

Rage Against the Pain: Alternative Yoga for Chronic Low Back Pain

“The evidence base for yoga and its effects on low back pain is compelling, and it seems like a missed opportunity if we don’t do everything we can to have more Veterans benefit from this pain management approach.”—Bella Etingen, PhD


© iStock/Nenad Cavoski

Low back pain is a leading cause of disability among U.S. adults and can drive opioid use and associated adverse outcomes. Yoga is recommended as a frontline treatment for low back pain, but yoga adoption among Veterans is low. A potential barrier might be Veterans’ perceptions of yoga, which for some, encompass long-standing but often inaccurate beliefs of what yoga entails and how their participation will be viewed by others.

About This Study

To facilitate uptake and sustained use of yoga for low back pain among Veterans, this study sought to develop Rage Against the Pain (RAP) High Intensity Stretching, a program inspired by “metal yoga.” RAP promotes yoga as less of a meditative, introspective activity with quiet, calming music and more of an expressive, active practice set to music that many Veterans enjoy, such as rock and metal. RAP offers Veterans a yoga experience that imparts the same pain management benefits as traditional yoga but might better align with their preferences and interests.

This study’s overall goal was to develop and evaluate RAP’s ability to improve Veteran participation in yoga, and by extension, improve outcomes among Veterans with chronic low back pain. The researchers aimed to:

  • Develop RAP by finalizing the program curriculum, including music playlists, cues for self-expression, and yoga movements known to alleviate low back pain.
  • Examine the feasibility and acceptability of offering RAP for Veterans with chronic low back pain.
  • Gather preliminary data to provide the foundation for a future trial to examine the potential effectiveness of RAP on Veterans’ outcomes and medication use.

Veteran feedback was integral to study planning and execution. Veterans confirmed that many of their peers are not open to doing yoga but may be receptive to participating in alternatives to yoga. In the words of one Veteran, “I can’t tell my buddies that I’m going to yoga, but I can tell them that I’m doing a stretching program.”

Veterans with chronic low back pain were randomized into RAP or a Hatha yoga program. Classes were 60 minutes long, held once a week for 12 weeks, and taught by certified instructors. Program initiation and attrition were tracked and compared between groups, and baseline and follow-up data on outcomes (pain intensity, interference and behavior, function, quality of life, sleep, depression, medication use) were collected via survey. Veterans’ experiences with and perceptions of the programs were assessed through surveys and qualitative semi-structured interviews.

Findings are not yet available.

Expected Implications

RAP could provide an innovative approach to address a VA top priority: using complementary and integrative health therapies for pain management and opioid use reduction. If findings warrant, future research should test the effectiveness of RAP and examine aspects of its broader implementation in VA, with a long-term goal of developing a scalable and sustainable alternative yoga program to help Veterans with chronic pain who might not find other available pain management options to be appealing or effective.

Principal Investigator

Bella Etingen, PhDBella Etingen, PhD, is part of HSR&D’s Center of Innovation for Complex Chronic Healthcare in Hines, IL.

Healthcare Access and Delivery During the Pandemic for Black Veterans with Chronic Pain

“Our study highlights the need to understand the effects of the expansion of telehealth on all Veterans, including ensuring that increased reliance on telehealth does not exacerbate existing disparities.”—Marianne Matthias, PhD

 Shot of a doctor checking a patient's pulse

© iStock/PeopleImages

Chronic pain affects 40–70% of Veterans. Relative to White patients, Black patients experience greater pain severity, are more likely to be undertreated for pain, and report poorer quality communication with clinicians. In addition, studies have documented racial disparities in telehealth delivery.

About This Study

Following the onset of the COVID-19 pandemic, by June 2020, 58% of VA’s outpatient encounters were via phone or video, compared to 14% prior to the pandemic. The sudden decrease in in-person services, coupled with widespread, rapid implementation of telehealth, raises important questions about Veterans’ experiences with this shift. This is particularly true for Black patients, given documented disparities in pain care and telehealth delivery.

In this study, investigators sought to understand how Black Veterans with chronic pain experienced pandemic-related changes in VA healthcare delivery. Investigators conducted qualitative interviews with Black Veterans experiencing chronic pain who had completed the COOPERATE study, a randomized controlled trial of an intervention focused on communication and patient activation—providing patients with knowledge, confidence, and skills to manage their health. Researchers conducted telephone interviews lasting 45 to 60 minutes with 21 Veterans from October 2020 through January 2021. Participants received a $30 gift card for their time.


  • Black Veterans with chronic pain described mostly negative effects from the shift to telecare, including decreased ability to self-manage their chronic pain, difficulty obtaining non-pharmacological services such as physical therapy, difficulty seeing their primary care provider, and trouble scheduling surgery.
  • Many Veterans said phone and video visits were inadequate for complaints related to their pain.
  • Some Veterans were willing to accept the shortcomings of telehealth to avoid possible exposure to COVID-19. Others saw positive aspects of a virtual format. One Veteran said, “I know if I really need something, I’ll be taken care of.” He described the video visits as productive and even “kind of fun.”


Given existing disparities and the likely persistence of virtual care, research on the longer-term effects of virtual pain care is needed. Studies should examine disparities in patient experience and patient outcomes based on race, ethnicity, gender, and other factors.

Principal Investigator

Marianne Matthias, PhDMarianne Matthias, PhD, is part of HSR&D’s Center for Health Information and Communication in Indianapolis, IN.

Recent related publications by this investigator

Matthias MS, Adams J, Burgess DJ, et al. Communication and activation in pain to enhance relationships and treat pain with equity (COOPERATE): Rationale, study design, methods, and sample characteristics. Contemporary Clinical Trials. July 1, 2022;118:106790.

Matthias MS, Hirsh AT, Ofner S, et al. Exploring the relationships among social support, patient activation, and pain-related outcomes. Pain Medicine. April 8, 2022;23(4):676–685.

Matthias MS, Adams J, Burgess DJ, et al. Effects of the COVID-19 pandemic on Black Veterans’ mental health: A qualitative investigation. Journal of Health Care for the Poor and Underserved. January 1, 2022;33(3):1275–1290.

For more on this topic, check out a recent HSR&D Cyberseminar (or the related transcript) featuring Dr. Matthias.

Chronic Pain Management and Outcomes after Discontinuation of Opioid Therapy

“Some patients who discontinue opioids feel misheard. They don’t understand why they are being taken off opioid medications. This process of taper and discontinuation represents a missed opportunity for clinicians to help patients feel supported, rather than stigmatized and abandoned.”—Travis Lovejoy, PhD, MPH

 Senior elderly man touching his shoulder, suffering from shoulder pain, sciatica, sedentary lifestyle concept. shoulder health problems.

© iStock/stefanamer

Opioid medication was dispensed to nearly 900,000 Veterans at VA’s prescribing peak in 2012. By 2016, VA opioid medication was dispensed to fewer than 700,000 Veterans. The downward trend in VA opioid prescriptions is likely to continue, but little is known about the consequences of opioid discontinuation.

About This Study

This ongoing study (November 2018–September 2024) seeks to characterize patient experiences with opioid discontinuation, identify ways patients subsequently manage their pain through VA and non-VA resources, and examine outcomes such as quality of life, pain, substance use, and mental health symptom severity following opioid discontinuation. The study aims to:

  • Compare acute, six-month, and 12-month quality of life and pain outcomes between patients who discontinue versus those who remain on long-term opioid therapy (LTOT).
  • Test the moderating effects of gender, race, and ethnicity on changes in quality of life and pain outcomes between patients who discontinue versus those who remain on LTOT.
  • Use qualitative methods to augment quantitative findings on patient quality of life and pain outcomes, identify patient experiences with the opioid discontinuation process, and characterize the impact of discontinuation on patient-clinician relationships.

Researchers randomly selected 1,379 Veterans from the population of VA patients prescribed LTOT. Patients completed five mailed or online surveys, and clinical and pharmacy data will be extracted from electronic health records and merged with patient-reported data. Seventy-nine patients who discontinued opioid therapy participated in telephone interviews immediately following discontinuation, as well as at six and 12 months post-discontinuation.

Findings are not yet available.

Expected Implications

This study will provide VA operations administrators, hospital executives, and clinicians with information that characterizes Veterans’ perspectives of opioid discontinuation. Results can inform best practices for clinically indicated discontinuation of opioid therapy, while simultaneously mitigating negative consequences of discontinuation and engaging and empowering Veterans to manage chronic pain with evidence-based non-opioid treatment modalities available within VA and the community.

Principal Investigator

Travis Lovejoy, PhD, MPHTravis Lovejoy, PhD, MPH, is part of the Center to Improve Veteran Involvement in Care in Portland, OR.

Recent related publications by this investigator

Priest KC, King CA, Lovejoy TI, et al. Differences in the delivery of medications for opioid use disorder during hospitalization by racial categories: A retrospective cohort analysis. Substance Abuse. January 1, 2022;43(1):1251–1259.

Enhancing Geriatric Pain Care with Contextual Patient-Generated Data Profiles

“Care for chronic pain involves a partnership between clinicians and Veterans. Our work uses technology to help clinicians understand what matters to Veterans and what their lives are like. When the clinician and the Veteran together can view a photograph of the Veteran’s dog, along with knowing how the Veteran’s medications are stored and whether they have rugs in their home that can create fall risk can go a long way to determining what treatment might work for them, and it encourages patient involvement.”—Jorie Butler, PhD

VFX Joint and Knee Pain Augmented Reality Render. Close Up of a Person Experiencing Discomfort in a Result of Leg Trauma or Arthritis. Massaging the Muscles to Ease the Injury.

© iStock/gorodenkoff

Pain is not an inevitable or normal part of aging. However, chronic pain in geriatric patients is widespread, occurring in approximately 50% of community-dwelling adults age 65 or over. Ineffectively treated chronic pain patients are at risk for poorer quality of life and functional decline. Evidence suggests that pain in geriatrics patients is challenging to assess and requires a whole-person approach to diagnosis, treatment, and monitoring.

About This Study

This ongoing study (October 2020–September 2024) seeks to refine and test an approach to collect and display contextual Patient Generated Health Data (PGHD) to support primary care clinicians and geriatricians in caring for older adult Veterans with chronic pain. It aims to:

  • Prioritize content for contextual PGHD profiles to support patient-centered care for geriatric Veterans with chronic pain.
  • Develop a prototype mobile application for contextual PGHD display and evaluate its usability.
  • Examine, through a randomized trial, the impact of contextual PGHD profile displays on patient adherence, pain function, satisfaction, and shared decision-making in a clinical setting.

This study is using interviews with clinicians and Veteran patients and caregivers, along with evaluation of iterative contributions of contextual PGHD to develop and optimize methods for Veterans to contribute contextual PGHD. Patient-Aligned Care Team members will report in more detail on the relevance of contextual PGHD elements for clinical care. There will be a randomized, patient-level comparison of patient visits that include contextual PGHD and those that do not. Outcomes will include adherence to pain management and shared decision-making.

Findings are not yet available.

Expected Implications

This project’s innovative approach is expected to improve collection of contextual PGHD and inform future implementation, particularly as researchers work closely with operational partners, including the Offices of Healthcare Informatics, Connected Care, and Patient Centered Care & Cultural Transformation. Findings will contribute to effective pain management and patient-centered care for a vulnerable population.

Principal Investigator

Jorie Butler, PhDJorie Butler, PhD, is with HSR&D’s Informatics, Decision-Enhancement and Analytic Sciences Center in Salt Lake City, UT.


[1] Managing Chronic Pain | Self-Management Education Programs | Learn More. Feel Better. | CDC

[2] VA research on Pain Management

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