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Pain Management

Introduction

Pain is one of the most common reasons Americans consult a physician. Joint and back pain and other musculoskeletal ailments are the most common diagnoses among Veterans of the wars in Iraq and Afghanistan.

According to a 2017 report by the National Institutes of Health (NIH), 65.6 percent of American Veterans reported having pain in the three months before they were surveyed by NIH, with 9.1 percent classified as having severe pain. Severe pain was 40 percent greater in Veterans than non-Veterans, especially among those who served in recent conflicts.

The consequences of chronic pain include lost work productivity, disability, and increased health care costs. Unrelieved and persistent chronic pain contributes to depression, anxiety, poor sleep patterns, decreased quality of life and substance use disorder. It is also a risk factor for suicide.

VA's National Pain Management Strategy provides a system-wide standard of care to reduce suffering from preventable pain. As part of that strategy, the department's pain research portfolio covers a wide range of topics, from drug discovery, to complementary and integrative treatments, to the impact of pain on daily function and quality of life. The strategy helps set the direction of VA pain research, which in turn helps inform and refine the strategy.

For patients interested in treatments other than medication, or in addition to medication, complementary and integrative medicine is a popular option. A wide range of these therapies and treatments, such as acupuncture and yoga, are proving valuable in helping Veterans manage their pain.

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Selected Major Accomplishments

• 2000: Discovered that ion channels—specialized proteins in the membrane of nerve cells—are heavily implicated in the biological mechanisms that generate and sustain neuropathic pain
• 2008: Established the VA Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center to study the interaction between pain and associated chronic conditions and behavioral health factors
• 2014:
• Announced, along with NIH, a five-year, $21.7 million quality-improvement initiative to research nondrug approaches to managing pain and related health conditions
• Implemented the VA Overdose Education and Naloxone Distribution Program
• 2015
• Determined that VA's stepped-care model of pain management for chronic pain resulted in significant reductions in pain-related disability, pain interference, and pain severity in Veterans with chronic musculoskeletal pain compared with usual care
• 2016: Established a musculoskeletal diagnosis cohort to characterize variation in pain, comorbidities, treatment, and outcomes among more than 5 million Veterans with musculoskeletal disorders receiving care from VA
• 2017: Partnered with other federal agencies to fund $81 million in new research on nondrug treatment of pain for military personnel and Veterans

New, Ongoing, and Published Research

VA researchers are working to develop new approaches to alleviate Veterans' pain, which may result from spinal cord injury, burns, amputations, traumatic brain injury, cancer, or musculoskeletal conditions. Some types of chronic pain, such as the nerve pain experienced by many people with spinal cord injury, are very difficult to treat.

Other investigators are conducting studies to determine which complementary and integrative pain therapies are truly effective, and for which conditions and populations they work.

➤ Centers for pain research

Center for Restoration of Nervous System Function—Biomedical research conducted by VA investigators has contributed to the scientific understanding of pain, especially nerve pain. The Center for Restoration of Nervous System Function is a collaboration among VA, the Yale School of Medicine, Paralyzed Veterans of America, and United Spinal Association.

The center is a state-of-the-art research facility dedicated to molecular and cell-based discoveries targeting sodium channels that might lead to non-opioid analgesic development.

Pain, Research, Informatics, Medical comorbidities, and Education (PRIME) Center—VA's Pain, Research, Informatics, Medical comorbidities, and Education (PRIME) Center, part of the VA Connecticut Healthcare System, conducts research to improve pain care and sponsors educational activities for Veterans and clinical staff. The PRIME Center's goals include advancing scientific knowledge and significantly impacting the care of Veterans living with pain and associated chronic conditions, such as depression or PTSD.

To meet these goals, the center studies the interactions between pain and associated chronic conditions and behavioral health factors to develop and implement effective interventions that can reduce pain, the negative impacts of pain on emotional and physical functioning, and the overall disease burden pain causes by employing principles of medical informatics, behavioral science, and health services research.

Tampa VAMC Chronic Pain Rehabilitation Program—VA's Chronic Pain Rehabilitation Program, located at the James A. Haley Veterans Hospital in Tampa, Florida, is a nationally known center for chronic pain research, treatment, and education. The CPRP is the only Commission on Accreditation of Rehabilitation Facilities inpatient pain treatment center in the VA system.

The CPRP is a referral-based program for Veterans with chronic pain, including those living out-of-state. It offers inpatient and outpatient rehabilitation programs to help Veterans manage their chronic pain condition.

Center for Health Equity Research and Promotion—The Center for Health Equity Research and Promotion (CHERP) is a VA Health Services Research and Development (HSR&D) Center of Innovation whose mission is to advance the quality and equity of health and health care for vulnerable Veteran populations. CHERP's research focuses on vulnerable Veteran populations, including those who face potential discrimination because of race, ethnicity, or social status, and those at risk for disparities in health or health care due to other physical or mental conditions.

CHERP is examining the associations of socio-economic status and geographic residence with pain management in Veterans. Researchers are:

• Identifying and quantifying disparities in health care and health outcomes between vulnerable and non-vulnerable populations;
• Identifying and understanding how multiple factors are associated with these disparities; and
• Designing and testing targeted interventions, assessing their efficacy, effectiveness, safety and cost, and translating successful interventions into widespread clinical practice and policy.

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➤ Special programs and collaborations

CREATE: Pain Management and Patient Aligned Care—VA's Collaborative Research to Enhance and Advance Transformation and Excellence (CREATE) funding initiative encourages VA investigators to collaborate with other VA partners to conduct research on high-priority issues that affect the health and health care of Veterans.

VA's Pain Management and Patient Aligned Care CREATE has three specific goals: to enhance Veterans' access to pain care, to use health information technology to promote better pain care for Veterans, and to build sustainable improvements in pain care. The program is anchored by three projects:

• Longitudinal Musculoskeletal Cohort Study—This study will examine variations in pain, pain treatment, the effects of co-existing conditions, and outcomes among Veterans receiving care from VA. The study's results will be used to transform pain care and management within VA.
• Effective Screening for Pain Study—This ongoing study aims to evaluate the effects of an enhanced, computer-aided pain screening and assessment tool to allow for the use of pain and function scores as an alternative to the currently used numerically based pain rating scale. The study's results will help improve the quality and clinical usefulness of the routine screenings for pain VA provides Veterans at every health encounter.
• Comprehensive Opioid Management in Patient Aligned Care Teams (COMPACT)—The COMPACT study is testing a telehealth-based self-management training system to promote improved care for Veterans receiving chronic opioid therapy. The primary aim of the study is to test the effectiveness of the system in improving physical and emotional functioning, the safe use of opioids, and quality of life. Because the COMPACT makes use of widely accessible automated telephone technology, researchers hypothesize that the training system will broaden access to pain care and can be delivered with consistency, thereby reducing variability in care.

Stepped Care Model for Pain Management and Patient Aligned Care Teams—VA's Stepped Care Model for Pain Management (SCM-PM) gives clinicians the ability to assess and treat pain within a primary care setting, while enabling them to use other treatment options, including specialized care and multidisciplinary approaches.

The model is designed to integrate with the Patient Aligned Care Team (PACT), providing quality and accessible primary care to Veterans. SCM-PM and PACT help Veterans by ensuring that VA clinicians are fully trained in pain management techniques; ensuring that pain assessment is performed in a consistent manner throughout VA; and placing the Veteran at the center of their health care team, facilitating prompt and appropriate pain treatment. The SCM-PM also stresses the importance of equitable access to health care and the effective use of resources to manage pain for enrolled Veterans.

SCOPE Study and Escape Trial—In 2009, researchers at the Indianapolis VA Medical Center began the Stepped Care to Optimize Pain Care Effectiveness (SCOPE) study. The study, which was completed in 2015, included 250 Veterans with persistent musculoskeletal pain (pain from both muscles and bones) who were receiving either usual forms of pain care or stepped care. Those receiving stepped care had their symptoms monitored by an automated system, and also received consults with a telephone-based pain specialist team to treat their pain.

The SCOPE study was followed by the Evaluation of Stepped Care for Chronic Pain (ESCAPE) clinical trial in 241 Veterans of the Afghanistan and Iraq conflicts. Results published in 2015 demonstrated that a stepped-care intervention that combined medication, self-management strategies, and brief cognitive behavioral therapy resulted in significant reductions in pain-related disability, pain interference, and pain severity in Veterans with chronic musculoskeletal pain.

Interagency Pain Research Coordinating Committee—The Interagency Pain Research Coordinating Committee (IPRCC) is a federal advisory committee created by the Department of Health and Human Services (HHS) to enhance pain research efforts and promote collaboration across the government.

Based on recommendations from the Institute of Medicine (now the National Academy of Medicine), the IPRCC created the National Pain Strategy (NPS) in 2016 with input from VA clinicians as well as academicians, advocates, and other federal agencies. The NPS provided guidelines for the effective treatment of pain across a person's lifetime. It emphasized pain education and management and disparities in treatment, as well as continued pain research.

The Federal Pain Research Strategy (FPRS) builds on the guidelines set out by the NPS, and was created to oversee development of a long-term strategic plan for federal agencies that support pain research. The FPRS final report was released to provide guidelines for federal agencies as they develop expanded pain research programs.

NIH, DoD, and VA collaborations—VA researchers are also collaborating with NIH's National Center for Complementary and Integrative Health (NCCIH, formerly NCCAM) to support studies on effective complementary and integrative approaches to pain management in Veterans with both physical and mental health conditions.

In 2014, VA and NCCIH jointly announced a $21.7 million research program focused on the use of complementary approaches to treat chronic pain in the Veteran population, and to determine whether treatments such as yoga, acupuncture, and meditation can help Veterans manage their chronic painful conditions.

In 2017, VA, the Department of Defense (DoD), and HHS announced a multicomponent research project focusing on nondrug approaches for pain management addressing the needs of service members and Veterans. Twelve research projects, totaling approximately $81 million over six years, will focus on developing, implementing, and testing cost effective, large-scale, real-world research on nondrug approaches for pain management and related conditions in military and Veteran health care delivery organizations.

Types of approaches being studied include mindfulness and meditative interventions, movement interventions, psychological and behavioral interventions, integrative approaches that involve more than one intervention, and integrated models of multimodal care. The projects will provide important information about the feasibility, acceptability, safety, and effectiveness of nondrug approaches in treating pain.

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➤ Chronic back pain

Chronic back pain can change people's lives. The condition can be debilitating, making daily activities such as driving a car or sitting at a desk extremely difficult. As many as 40 percent of Veterans over 65 years old have chronic back pain.

Value of chiropractic care—In 2014, researchers at the Canandaigua VA Medical Center looked at whether chiropractic care could relieve the disability caused by chronic back pain. They studied 136 Veterans aged 65 or older with lower back pain who had never received chiropractic care. Half received spinal manipulative therapy (SMT) from a chiropractor; the others received a sham treatment, similar to a placebo.

After 12 weeks, the researchers found that there was a statistically significant improvement in the level of disability of those who received SMT, but no difference in the level of pain compared with those who received the sham treatment. The team believes that the concern they showed about the pain of all patients in the study changed the way the Veterans felt about pain, and made them feel better.

In 2017, a VA Western New York Healthcare System study found that chiropractic care can improve outcomes for some female Veterans with low back pain. After an average of eight chiropractic treatments, women saw an average of 27 percent improvement in pain, based on a back pain questionnaire. The researchers concluded that chiropractic care may be of value for pain management in this population.

Spinal manipulation offers modest relief—A 2017 study led by a team at the West Los Angeles VA Medical Center found that spinal manipulative therapy for low back pain (the kind offered by chiropractors, physical therapists, and others) is associated with modest improvements in pain and function. The researchers reviewed and combined data from past studies on the topic.

Gabapentin no more effective than placebo—In 2016, researchers at the VA San Diego Healthcare System completed a study that indicated that the pain medication gabapentin, sold as Neurontin and under other brand names, is no more effective than placebo at treating chronic low back pain.

Following a 12-week study in which patients with chronic back pain received either gabapentin or a sugar pill placebo, results showed no significant differences in pain intensity scores between gabapentin and placebo groups either at the start or at the end of the study. Although a majority of study participants reported at least a 30 to 50 percent decrease in pain intensity, these differences did not differ significantly by group.

The researchers urged additional studies to test whether the drug may in fact be of some use for chronic low back pain, especially when the cause is nerve-related.

Telehealth cognitive behavioral therapy as good as in-person treatment—Cognitive behavioral therapy (CBT) for low back pain delivered by phone had similar results to in person treatment, according to a 2017 study by VA San Diego Healthcare System researchers. Patients with chronic low back pain participated in eight weeks of either cognitive behavioral therapy or in-person supportive care.

Both groups showed similar levels of pain improvement, demonstrating that telehealth approaches to psychotherapy could be useful in treating pain.

Another 2017 study from the PRIME Center found that Veterans receiving both forms of therapy experienced statistically significant reductions in average pain intensity three and six months after their study had been completed, but not at nine months. They also found the treatment dropout rate was lower among Veterans receiving CBT by telephone.

Video telehealth can be as effective as in-person therapy for a psychological treatment—Acceptance and commitment therapy (ACT) is a psychological approach to help people deal with chronic pain. In 2017, a research team led by researchers with the VA San Diego Healthcare System found that Veterans receiving the therapy both in person and by video teleconferencing showed significant improvements in pain interference, pain severity, mental and physical health-related quality of life, pain acceptance, activity level, depression, and pain-related anxiety.

The results suggest that teleconferencing is an acceptable way to deliver the therapy.

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➤ Genomic pain treatments

Personalized treatment approach for inherited erythromelalgia—Inherited erythromelalgia is a severe pain syndrome that occurs when genetic mutations to the sodium channel causes the body’s pain-sensing system to go into high gear, leading to flare-ups of pain and burning sensation in response to seemingly benign triggers like warm temperature and mild exercise.

In a study published in 2016, a team of researchers with the VA Connecticut Healthcare System and Yale University successfully tailored a personalized treatment approach to the syndrome, using molecular modeling and other techniques to find the most effective drug treatment plan for two patients from the same family. The drug carbamazepine was the most effective treatment, and its selection was guided by the exact location of a mutation in each patient’s genome.

According to the researchers, the study demonstrated that it is possible to use genomics and molecular modeling to guide pain treatment.

Genomic approaches have also been used with success in the clinic, as demonstrated in a case study published in the Journal of Pain Research. In this case study, pharmacogenetics—the study of how genes affect a person’s response to drugs—was used to develop a clinical course of action to manage the Veteran’s pain. The study credits VA for being a health care system willing to support the use of genetic testing to best treat its patients.

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➤ Over-prescription of opioids

Opioids are medications that relieve pain. They reduce the intensity of pain signals reaching the brain and affect those brain areas controlling emotion, which diminishes the effects of a painful stimulus. Medications that fall within this class include hydrocodones, such as Vicodin; oxycodones, such as OxyContin and Percocet; morphine, such as Kadian and Avinza; codeine; and related drugs.

Opioid prescription patterns—Most prescriptions for opioid painkillers are made by the broad swath of U.S. general practitioners, not by a limited group of specialists, according to a 2015 study by researchers at the Palo Alto VA Health Care System and the Stanford University School of Medicine.

The research team examined Medicare prescription drug claim data for 2013 and found that while the top 10 percent of opioid prescribers account for 57 percent of all opioid prescriptions, this prescribing pattern is comparable to that found in the Medicare data for prescribers of all drugs.

The team's findings contrast with previous studies by others that indicated the high levels of prescribing opioids in the United States is the result of a small population of prolific prescribers operating out of "corrupt pill mills." According to the authors of the new study, efforts to curtail national opioid overprescribing must address a broad swath of prescribers to be effective.

Opioid Safety Initiative—In 2011, the Minneapolis VA Medical Center began developing an Opioid Safety Initiative (OSI). The OSI was designed to decrease high-risk opioid prescribing practices and to improve the safety of opioid prescribing while providing high-quality pain care for Veterans.

A 2015 study found that the Minneapolis OSI, which emphasizes patient education, close patient monitoring with frequent feedback, and the use of complementary and integrative medicine practices like acupuncture and behavior therapy, can produce dramatic results.

Minneapolis researchers found that, from 2011 through 2014, the number of Veterans prescribed more than 200 morphine-equivalent milligrams worth of opioids decreased from 342 to 65. Overall, the number of unique pharmacy patients who received at least one opioid prescription decreased by almost 1,000 and the number of Veterans receiving oxycodone dropped from 292 to three.

Opioid doses and risk of suicide—In a 2016 study, researchers with the VA Ann Arbor Healthcare System and University of Michigan found that Veterans receiving the highest doses of opioid painkillers were more than twice as likely to die by suicide, compared with those receiving the lowest doses.

The research team looked at nearly 124,000 Veterans who received VA care in 2004 and 2005. All had non-cancer chronic pain and received prescriptions for opioids. Using the National Death Index, the researchers found that 2,601 of the patients died by suicide during the observation period. Of those deaths, 532 were from an intentional overdose.

They found the risk for suicide by any means rose as opioid dosage increased. The association between opioid dose and risk of suicide by overdose was not higher than for other methods of suicide. The researchers could not tell, however, whether there was a direct causal link between the pain medications and suicide risk. Instead, the high doses may be a marker for other factors that drive suicide, including unresolved severe chronic pain.

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➤ Knee osteoarthritis

Swedish massage an acceptable treatment—In 2015, researchers at the Durham (North Carolina) VA Medical Center and Duke University found, in a pilot study, that Swedish massage is an acceptable and feasible treatment for Veterans with osteoarthritis of the knee. The team looked at 25 Veterans, mostly men, with an average age of 57. The men also had an average body mass index of around 32, above the obesity threshold.

Of the original 25 Veterans in the study, 23 completed a regimen of eight weekly one-hour massage sessions. More than 90 percent of them said they wanted to continue to receive massage as part of their arthritis treatment plan, and nearly 90 percent thought other Veterans would try it if it were offered in VA.

They also reported, on average, about a 30 percent improvement in pain, stiffness, and function.

Electrical brain stimulation and knee pain—Directly stimulating the brain with electrical current may reduce pain in patients with knee osteoarthritis, according to a 2017 study that included a researcher with the South Central VA Health Care Network. The study team applied an electrical current through sponge electrodes placed on the head of experimental-group participants once a day for five consecutive days.

Participants who received the electrical current indicated that they had significantly less knee pain than the control group, suggesting that electrical stimulation could be an alternative to medication for reducing osteoarthritis pain. 

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➤ Complementary and integrative medicine

Complementary and integrative health therapies can be used along with standard pain medications, and sometimes can even replace them. They include techniques like tai chi, yoga, meditation, and acupuncture. In 2016, Congress passed the Comprehensive Addiction and Recovery Act, which mandates that complementary and integrative health therapies be provided in VA to provide nonpharmacological options to treat pain and pain’s related health conditions.

VA researchers are looking at trends in Veterans’ use of these therapies and are generating knowledge about which of these therapies are most effective for pain and other conditions.

Evidence lacking for benefits of medical marijuana—In 2017, researchers from the VA Portland Health Care System and Oregon Health and Science University reviewed 75 publications on the effects of medical marijuana for many types of chronic pain.

They found limited evidence that marijuana use might alleviate neuropathic pain in some patients, and that it might reduce spasticity associated with multiple sclerosis. There was insufficient evidence on the benefits of marijuana for all other pain types. Between 45 and 80 percent of those who seek medical marijuana do so for pain management.

Current federal law prohibits the use or dispensing of marijuana. As a federal agency, VA follows this prohibition and does not prescribe medical marijuana to any of its patients.

Benefits of massage for pain relief—A 2016 review by VA’s Evidence-based Synthesis program pointed to the potential benefits of massage to relieve neck and other types of pain based on past research, but concluded larger and more rigorous studies are needed.

In 2017, researchers from the Richard L. Roudebush VA Medical Center in Indianapolis and the Indiana University School of Health and Rehabilitation Sciences began a study to determine whether massages provided by Veterans’ caregivers can relieve chronic neck pain. There will be 468 Veterans enrolled, 156 of whom will receive massages from a caregiver; others will get messages from professional massage therapists or receive only the usual care for neck pain.

The study is scheduled to conclude in 2021.

Electroacupuncture can ease pain by releasing stem cells—Electroacupuncture is a modern version of the ancient Chinese healing art of acupuncture. Researchers at a number of scientific institutions in the United States and South Korea found, in 2017, that electroacupuncture can ease pain and promote tissue repair in humans, horses, and rodents, and explained the reason the technique works.

The process of electroacupuncture (acupuncture in which the needles carry a mild electric current) triggers the release of mesenchymal stem cells (MSCs) into the blood stream. MSCs originate from a wide variety of tissue in adults, and are being widely studied for their healing potential. In the study, the MSCs originated from adipose or fat tissue in humans treated with electroacupuncture. The research team used functional brain scans, blood tests, artery imaging, gene sequencing, and other lab methods to trace electroacupuncture’s actions on the brain and nervous system, which resulted in the release of MSCs. These MSCs may have a wide variety of therapeutic effects like enhancing tissue repair and providing pain relief. 

Researchers are now looking at whether MSCs can be used as a therapeutic tool in their own right.

Yoga helps Veterans with back pain—In a 2017 study of Veterans with chronic low back pain, a team of researchers from the VA San Diego Healthcare system found that Veterans who completed a 12-week yoga program had better scores on a disability questionnaire, improved pain intensity scores, and a decline in opioid use.

The 12-week yoga intervention was based on hatha yoga, and consisted of two 60-minute, instructor-led yoga sessions per week. Home practice sessions were encouraged. The study is one of the first to demonstrate the effectiveness of yoga for chronic low back pain, specifically in Veterans.

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➤ Pain in Gulf War Veterans

Structural damage linked to musculoskeletal pain in Gulf War Veterans—Chronic musculoskeletal pain affects around 25 percent of Veterans who were deployed during the Persian Gulf War, and Veterans deployed to Iraq and Afghanistan more recently have shown similar rates. A 2017 study done at the William S. Middleton Memorial Veterans Hospital in Madison, Wisconsin, showed that structural damage in the brain may be linked to this type of pain.

The research team used magnetic resonance imaging to determine that study participants with chronic pain had widespread disruptions in the structure of their white matter across several regions of the brain. (White matter is deep tissue within the brain that contains axons, nerve fibers that conduct electrical signals and connect different brain areas.) Their results showed that poorer white matter health was linked to higher pain levels and higher levels of fatigue. It was also linked to higher levels of depression, although to a lesser extent.

Previous studies have suggested that Gulf War illness symptoms are related to structural changes in the brain. (For more information on VA research into chronic multisymptom illness in Gulf War Veterans, see our topic page on Gulf War Veterans.)

Study underway to evaluate mindfulness-based intervention in Gulf War Veterans—Mindfulness-based interventions teach meditation practices intended to enhance awareness of the present moment and to emphasize continued practices after the program is completed. The Seattle Division of the VA Puget Sound Health Care System is studying an eight-week program called Mindfulness-based Stress Reduction to see if the program can reduce symptoms of chronic multisymptom illness in Gulf War Veterans. The study will be completed in 2021.

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More on Our Website

• White matter damage linked to chronic musculoskeletal pain in Gulf War Veterans, VA Research Currents, Oct. 26, 2017
• Interagency grant to study non-drug approaches to treat pain, VA Research Quarterly Update, Fall 2017
• Brief screening key to referral for VA chronic pain treatment, VA Research Quarterly Update, Fall 2017
• Study data lacking on benefits and risks of medical marijuana for chronic pain and PTSD, VA Research Currents, Aug. 24, 2017
• Study: yoga helps back pain among Veterans, VA Research Currents, July 25, 2017
• Pain in the neck? Caregiver-assisted massage might pose solution, VA Research Currents, June 22, 2017
• Early-life pain may contribute to obesity risk, finds rat study, VA Research Currents, June 7, 2017
• Collaboration on research into complementary approaches to chronic pain, VA Research Quarterly Update, Spring 2017
• Study: Spinal manipulation offers modest relief for back pain, VA Research Quarterly Update, Spring 2017
• Study: Electroacupuncture eases pain through stem-cell release, VA Research Currents, March 16, 2017
• Yale-VA study yields promising results from genetically tailored pain treatment, VA Research Currents, July 11, 2016
• Study questions effectiveness of commonly used medication for back pain, VA Research Currents, April 6, 2016
• How VA is combating pain, VA Research Quarterly Update, Spring 2016

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Selected Scientific Articles by Our Researchers

Cerebral white matter structure is disrupted in Gulf War Veterans with chronic musculoskeletal pain. Van Riper SM, Alexander AL, Koltyn KF, Stegner AJ, Ellingson LD, Destiche DJ, Dougherty RJ, Lindheimer JB, Cook DB. Widespread white matter microstructure disruption across brain regions is implemented in pain processing and modulation in chronic pain. Pain. 2017 Dec;158(12):2364-2375.

Yoga for military Veterans with chronic low back pain: a randomized clinical trial. Groessl EJ, Liu L, Chang DG, Wetherell JK, Bormann JE, Atkinson JH, Baxi S, Schmalzl L. Yoga improved health outcomes among veterans despite evidence they had fewer resources, worse health, and more challenges attending yoga sessions than community samples studied previously. Am J Prev Med. 2017 Nov;53(5):599-608.

Chiropractic management for U.S. female Veterans with low back pain: a retrospective study of clinical outcomes. Corcoran KL, Dunn AS, Formolo LR, Beehler GP. Chiropractic care may be of value in contributing to the pain management needs of this unique patient population. J Manipulative Physiol Ther. 2017 Oct;40(8):573-579.

Efficacy of transcranial direct current stimulation over primary motor cortex (anode) and contralateral supraorbital area (cathode) on clinical pain severity and mobility performance in persons with knee osteoarthritis: an experimenter and participant-blinded, randomized, sham-controlled pilot clinical study. Ahn H, Woods AJ, Kunik ME, Bhattacharjee A, Chen Z, Choi E, Fillingim RB. Direct current stimulation has promising clinical efficacy for reduction in pain perception for older adults with knee osteoarthritis. Brain Stimul. 2017 Sep-Oct;10(5):902-905.

Randomized controlled trial of telephone-delivered cognitive behavioral therapy versus supportive care for chronic back pain. Rutledge T, Atkinson JH, Chircop-Rollick T, D’Andrea J, Garfin S, Patel S, Penzien DB, Wallace M, Weickgenant AL, Slater M. Home-based, telephone-delivered cognitive behavioral therapy or supportive care treatments did not differ in their benefits for back pain severity and disability. Clin J Pain, 2017 Sep 1. (epub ahead of print)

The effects of Cannabis among adults with chronic pain and an overview of general harms: a systematic review. Nugent SM, Morasco BJ, O’Neil ME, Freeman M, Low A, Kondo K, Elven C, Zakher B, Motu’apuaka M, Paynter R, Kansagara D. Limited evidence suggests that cannabis may alleviate neuropathic pain in some patients, but insufficient evidence exists for other types of chronic pain. Ann Intern Med. 2017 Sep 5;167(5):319-331.

Management of chronic pain in the aftermath of the opioid backlash. There are select patients for whom opioid pain management works well, given the limited effectiveness of analgesics like acetaminophen and NSAIDs for lower-back pain. Kroenke K, Cheville A. JAMA. 2017 Jun 20;317(23)2365-2366.

Interactive voice response-based self-management for chronic back pain: the COPES noninferiority randomized trial. Heapy AA, Higgins DM, Goulet JL, LaChappelle KM, Driscoll MA, Czlapinski RA, Buta E, Piette JD, Krein SL, Kerns RD. Interactive voice response cognitive behavioral therapy is a low-burden alternative that can increase access to the therapy for chronic pain and shows promise as a nonpharmacologic treatment option. JAMA Intern Med. 2017 Jun 1;177(6):765-773.

Electroacupuncture promotes central nervous system-dependent release of mesenchymal stem cells. Salazar TE et al. Electroacupuncture-activated sensory ganglia and sympathetic nervous system centers can mediate the release of mesenchymal stem cells that can enhance tissue repair, increase anti-inflammatory cytokine production, and provide pronounced analgesic relief. Stem Cells. 2017 May;35(5):1303-1315.

Association of spinal manipulative therapy with clinical benefit and harm for acute low back pain: systematic review and meta-analysis. Paige NM, Miake-Lye IM, Booth MS, Beroes JM, Mardian AS, Dougherty P, Branson R, Tang B, Morton SC, Shekelle PG. Among patients with acute low back pain, spinal manipulative therapy was associated with modest improvements in pain and function at up to 6 weeks. JAMA. 2017 Apr 11;317(14):1451-1460.

Telehealth versus in-person acceptance and commitment therapy for chronic pain: a randomized noninferiority trial. Herbert MS, Arari N, Liu L, Heppner P, Rutledge T, Williams K, Eraly S, VanBuskirk K, Nguyen C, Bondi M, Atkinson JH, Golshan S, Wetherell JL. Acceptance and commitment therapy for chronic pain can be implemented through video teleconferencing with reductions in pain interference comparable with in person delivery. J Pain. 2017 Feb;18(2):200-211.

Pharmacology for pain in a family with inherited erythromelagia guided by genomic analysis and functional profiling. Geha P, Yang Y, Estacion M, Schulman BR, Tokuno H, Apkarian AV, Dib-Hall SD, Waxman SG. Pharmacotherapy guided by genomic analysis, molecular modeling, and functional profiling can attenuate neuropathic pain in patients carrying the S241T mutation. JAMA Neurol. 2016 Jun 1;73(6):659-687.

A randomized controlled trial of gabapentin for chronic low back pain with and without a radiating component. Atkinson JH, Slater MA, Capparelli EV, Patel SM, Wolfson T, Gamst A, Abramson IS, Wallace MS, Funk SD, Rutledge TR, Wetherell JL, Matthews SC, Zisook S, Garfin SR. Gabapentin appears to be ineffective for analgesia in chronic low back pain with or without a radiating component. Pain. 2016 Jul;157(7):1499-1507.