Pain and Psychological Outcomes Among Iraq and Afghanistan Veterans with Chronic Pain and PTSD: ESCAPE Trial Longitudinal Results

Matthew J Bair; Samantha D Outcalt; Dennis Ang; Jingwei Wu; Zhangsheng Yu

doi:10.1093/pm/pnaa007

Pain and Psychological Outcomes Among Iraq and Afghanistan Veterans with Chronic Pain and PTSD: ESCAPE Trial Longitudinal Results

Pain Med. 2020 Nov 7;21(7):1369-1376. doi: 10.1093/pm/pnaa007.

Authors

Matthew J Bair^{1

2

3}, Samantha D Outcalt^{1

2

4}, Dennis Ang⁵, Jingwei Wu⁶, Zhangsheng Yu⁷

Affiliations

¹ Center for Health Information and Communication, Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service, Indianapolis, Indiana.
² Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana.
³ Regenstrief Institute, Inc., Indianapolis, Indiana.
⁴ Department of Psychiatry, Indiana University School of Medicine, Indianapolis, Indiana.
⁵ Division of Rheumatology, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina.
⁶ Department of Biostatistics, Temple University, Philadelphia, Pennsylvania.
⁷ Center of Statistics Research, Research Department, School of Statistics, Shanghai Jiaotong University, Shanghai, China.

PMID: 32150258
DOI: 10.1093/pm/pnaa007

Abstract

Objective: To compare pain and psychological outcomes in veterans with chronic musculoskeletal pain and comorbid post-traumatic stress disorder (PTSD) or pain alone and to determine if veterans with comorbidity respond differently to a stepped-care intervention than those with pain alone.

Design: Secondary analysis of data from the Evaluation of Stepped Care for Chronic Pain (ESCAPE) trial.

Setting: Six Veterans Health Affairs clinics.

Subjects: Iraq and Afghanistan veterans (N = 222) with chronic musculoskeletal pain.

Methods: Longitudinal analysis of veterans with chronic musculoskeletal pain and PTSD or pain alone and available baseline and nine-month trial data. Participants randomized to either usual care or a stepped-care intervention were analyzed. The pain-PTSD comorbidity group screened positive for PTSD and had a PTSD Checklist-Civilian score ≥41 at baseline.

Results: T tests demonstrated statistically significant differences and worse outcomes on pain severity, pain cognitions, and psychological outcomes in veterans with comorbid pain and PTSD compared with those with pain alone. Analysis of covariance (ANCOVA) modeling change scores from baseline to nine months indicated no statistically significant differences, controlling for PTSD, on pain severity, pain centrality, or pain self-efficacy. Significant differences emerged for pain catastrophizing (t = 3.10, P < 0.01), depression (t = 3.39, P < 0.001), and anxiety (t = 3.80, P < 0.001). The interaction between PTSD and the stepped-care intervention was not significant.

Conclusions: Veterans with the pain-PTSD comorbidity demonstrated worse pain and psychological outcomes than those with chronic pain alone. These findings indicate a more intense chronic pain experience for veterans when PTSD co-occurs with pain. PTSD did not lead to a differential response to a stepped-care intervention.

Keywords: Chronic Pain; Pain Outcomes; Post-traumatic Stress Disorder; Psychological Outcomes; Veterans.

2020 American Academy of Pain Medicine. This work is written by US Government employees and is in the public domain in the US.

Publication types

Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

Afghan Campaign 2001-
Afghanistan
Chronic Pain* / epidemiology
Humans
Iraq
Iraq War, 2003-2011
Longitudinal Studies
Stress Disorders, Post-Traumatic* / epidemiology
Veterans*