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Perspectives from the Department of Veterans Affairs Pain/Opioid Consortium on Research Veteran Engagement Panel

INTRODUCTION

The National Academy of Sciences, Engineering, and Medicine (National Academies) Committee on Evaluating the Effects of Opioids and Benzodiazepines on All-Cause Mortality sought perspectives of veterans who obtained pain care management and treatment from the Veterans Health Administration (VHA). The committee collaborated with the Department of Veterans Affairs (VA) Health Systems Research (HSR) Pain/Opioid Consortium on Research (Pain/Opioid CORE) Veteran Engagement Panel (VEP) to obtain these perspectives. A summary of the input obtained follows.

Background

The Pain/Opioid CORE is one of the four VA HSR-funded COREs. The goal of the COREs is to help and enhance collaborative research to improve care provided to veterans, especially by prioritizing research areas. The Pain/Opioid CORE focuses on research on pain, especially nonpharmacological interventions, opioid prescribing, and opioid use disorder.¹ One aspect of the Pain/Opioid CORE is the VEP, composed of 13 veterans who have experience with chronic pain and/or opioids and help provide guidance to VA researchers from a veteran’s perspective.

To help formulate and prepare for the panel discussion, per National Academies policies, National Academies project staff met and provided VEP staff and members with the statement of task, the committee’s purpose in hearing from veterans, and how the findings would be shared with the committee and used in the final report. VEP staff sought consent from veterans on the panel on behalf of the National Academies. The National Academies does not provide an honorarium to participants or volunteers. However, these VEP members were compensated for their time through COREs. National Academies staff worked with the committee to develop a focus group discussion facilitation guide, which was shared with the VA Pain/Opioid CORE staff for their approval. After a joint review and approval process, a final guide was approved by the committee and VA Pain/Opioid CORE staff for use during the VEP discussion.

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¹ https://www.hsrd.research.va.gov/centers/core (accessed September 17, 2024).

SUMMARY

VEP staff helped facilitate a panel discussion with eight veterans from the Pain/Opioid CORE VEP: six women and two men who served from the early 1970s to 2015; about half served in the Army, with the remainder serving in the Navy or Air Force.

Several themes emerged through the panel discussion. First, VEP veterans reported that pain management differed by service era. For example, they reported that opioid pharmacotherapy to manage pain was more readily available during the Vietnam campaign, compared to later campaigns, such as post-9/11, when nonopioid medications, such as ibuprofen and acetaminophen, were more readily available. Second, during active duty, veterans were encouraged to shorten their breaks so as to return to active service sooner, especially when staffing was short. Third, continuation of care when transitioning from active duty to post-military care varied, with some veterans reporting a lack of continuity in care. Fourth, opioid prescribing policies changed over time—although prescribing became more restrictive, some panel members noted that pain management shifted toward a participatory process that prioritized joint decision making between provider and veteran. Fifth, multiple VEP veterans mentioned that the Mission Act provided more options for pain management and treatment, especially nonpharmacological strategies, such as acupuncture and physiotherapy. The veterans noted, though, that options varied by VHA facilities, and their availability was not always guaranteed. In addition, the onus of finding providers and obtaining referrals for treatment was often left to the veteran. Sixth, the VEP veterans felt that both VHA and civilian providers often refused to prescribe opioid pharmacotherapy, even when warranted. Veterans reported feeling that they had not been listened to and were inadequately treated to help manage pain. Seventh, they mentioned that many of those prescribing opioid pharmacotherapy were averse to tapering or discontinuation. The veterans reported that these could lead to the following: (a) “provider shopping” to find ones who would be willing to continue to prescribe opioids; (b) turning to nonprescribed alternatives, such as alcohol and cannabis for pain management, especially given easier access to those substances; (c) feeling neglected when experiencing unmanaged pain; and (d) seeking care out of the VHA.