Abstract
Purpose
In the context of increased access to multidisciplinary pain team care in the veterans health administration (VHA) in recent years, the current study sought to determine whether continuity of pain clinic care varied for rural compared to urban veterans, following an initial pain clinic visit. Specifically, the frequency of general pain clinic visits and pain clinic psychology visits were contrasted between rural and urban veterans in 2015 and 2022.
Methods
National VHA administrative data were used to build two cohorts of veterans with an initial pain clinic visit in 2015 or 2022. Number of pain clinic visits and number of pain clinic psychology visits in the following year were calculated. Multivariable regression models examined rural/urban differences in receipt of follow‐up pain clinic visits and receipt of follow‐up pain psychology visits in both 2015 and 2022, after adjusting for demographic characteristics and psychiatric comorbidity.
Findings
Veterans with an initial pain clinic visit increased by 22.5% from 2015 (n = 95,549) to 2022 (n = 117,044) and included about one‐third rural veterans in both years. Rural veterans had lower rates of follow‐up pain clinic visits in 2015 (adjusted odds ratio [aOR]: 0.85; 95% confidence interval [CI]: 0.82–0.87) and this gap remained, but narrowed, by 2022 (aOR: 0.92; 95% CI: 0.90–0.95). The gap in pain psychology follow‐up visits, however, disappeared between 2015 (adjusted incidence rate ratio [aIRR]: 0.88; 95% CI: 0.81–0.95) and 2022 (aIRR: 1.00; 95% CI: 0.93–1.08).
Conclusions
The rural gap in continuity of specialty pain clinic services for veterans has improved across time, particularly in relation to pain clinic psychology visits.
Keywords: chronic pain, pain clinic, pain psychology, rural, veteran
INTRODUCTION
Chronic pain is prevalent among US Military Veterans, who can benefit from a multidisciplinary management approach, including specialty pain care. 1 , 2 , 3 , 4 Rural veterans may experience barriers to accessing multidisciplinary and specialty pain care and are more likely to be prescribed long‐term opioids, relative to their urban counterparts. 5 , 6 Rural barriers, such as lack of providers and travel burden, can impact both initiation and continuation of pain management services. 7 , 8 , 9
The veterans health adminsitration (VHA) has made concerted efforts in the last decade to increase veteran access to multidisciplinary pain management teams 10 , 11 ; however, it is currently unknown whether access has improved for rural veterans with chronic pain. Specifically, in 2016, the Comprehensive Addiction and Recovery Act (CARA) mandated multidisciplinary pain management teams at all VHA facilities. In 2017, the VHA Pain Management Team Memorandum provided guidance on implementation of multidisciplinary pain management teams and in 2021, the Assistant Under Secretary for Health for Clinical Services released a memorandum that provided guidance to Veterans Integrated Network Directors about releasing field funding to enhance access to pain management services. 12 As such, in recent years, the VA has increased multidisciplinary staffing and services in pain clinics across the VA. 12
One important component of multidisciplinary pain management is pain psychology. 2 Pain psychology interventions, such as cognitive behavioral therapy (CBT) for chronic pain (CBT‐CP) and acceptance and commitment therapy (ACT) have demonstrated efficacy in reducing pain severity and increasing function among persons with chronic pain. 13 , 14 , 15 , 16 While pain psychology can include multiple approaches (e.g., CBT, ACT, mindfulness, biofeedback, hypnosis, emotional awareness, and expression therapy 16 ), CBT‐CP, has been broadly disseminated across the VA, via a VA‐developed CBT‐CP protocol and implementing widespread training of this modality. 17 Pain psychology interventions typically require multiple sessions; however, there are varying perspectives on the exact number required for treatment. Three sessions of CBT‐CP has been identified as a minimum dose of treatment. 18
The current study sought to investigate continuation of services among rural and urban veterans who were new to VA pain clinic specialty care. Specifically, this study sought to understand whether, in the setting of the recent roll‐out of increased multidisciplinary pain team staffing, rural veterans with an initial pain clinic visit in 2022 received follow‐up pain clinic visits at similar rates to urban veterans. The current study also investigated whether there was a rural gap in continuation of pain clinic services in 2015, prior to the CARA mandate. Further, the rural/urban comparison was investigated both in relation to general pain clinic visits and specifically in relation to a service that was designed to require multiple appointments: pain psychology.
METHODS
Data sources
National administrative data from the VHA were accessed from the VA Corporate Data Warehouse using the VA Informatics and Computing Infrastructure. Outpatient encounter data were used to identify pain clinic visits, receipt of pain psychology services, and psychiatric diagnoses. Geocoded enrollee files were used to determine patient residence (urban vs. rural). This study was reviewed by the local institutional review board and determined not to constitute human subjects research and classified as exempt.
Patients
Patients were veterans in receipt of an initial VHA pain clinic visit during calendar years 2015 or 2022, defined as an outpatient pain clinic encounter during that calendar year (primary or secondary stop code of 420), with no pain clinic visits in the prior 2 years. The first visit during the target calendar year (2015 or 2022) was defined as the index pain clinic visit. Patient residence was classified based on the designation established by the VA Office of Rural Health specifies Rural‐Urban Commuting Areas 1.0 and 1.1 as urban, and all other codes as rural. 19
Demographic characteristics included age, sex, race, and ethnicity. Psychiatric comorbidities, including posttraumatic stress disorder, depressive disorder, substance use disorder, anxiety disorder, bipolar disorder, psychotic disorder, and sleep disorder, were assessed using previously established methods by the presence of an inpatient hospitalization or outpatient encounter with an associated ICD10 code (see Ref. [20] for a full list of codes). Pain severity was quantified for each year (2015 and 2022) by the mean of all outpatient numeric pain rating scales observed during the prior year.
Pain clinic metrics
Pain clinic utilization metrics for each patient were ascertained for the 365 days following their index pain clinic visit. The primary metric was the count of total pain clinic visits during this 1‐year follow‐up period, including the index visit. A dichotomized variable was also created to indicate whether the patient received at least one follow‐up pain clinic visit after the index visit. Receipt of pain psychology (i.e., pain‐related behavioral health) services was identified from among pain clinic visits based on current procedural codes for diagnostic evaluation (90791), psychotherapy (90832, 90834, 90837, 90853), or health behavior assessment and intervention (for CY2015 cohort: 96150, 96151, 96152, 96153; for CY2022 cohort: 96156, 96158, 96159, 96164, 96165). Specific metrics related to pain psychology services included a dichotomous indicator for receipt of any pain psychology visit, the discrete count of follow‐up pain psychology visits, and a dichotomous indicator for any follow‐up pain psychology visits. A final metric for receipt of a minimum dose of pain psychology treatment was defined by a dichotomous indicator for having at least three follow‐up visits (four total visits). 18
Analysis
Baseline demographic variables, psychiatric comorbidities, and average pain severity were compared in bivariate analyses between rural versus urban veterans in both 2015 and 2022. The count of pain clinic visits was contrasted between urban and rural residing veterans using a Wilcoxon rank sum test in bivariate analyses and negative binomial regression in multivariable analyses. Dichotomous utilization metrics were contrasted between urban and rural residence using logistic regression. Multivariable models were adjusted for demographic characteristics psychiatric comorbidities, and pain severity. Separate analyses were conducted for the 2015 and 2022 cohorts and contrasts in findings over time were interpreted in terms of clinical significance. All statistical analyses were two‐tailed at the α = 0.05 significance level and conducted using SAS version 9.4.
RESULTS
The number of veterans with an initial pain clinic visit increased by 22.5% from 2015 (n = 95,549) to 2022 (n = 117,044) and included about one‐third rural veterans in both 2015 (33.1%) and 2022 (29.8%; Table 1). In both years, rural veterans were older on average and more likely to be male, White, and non‐Hispanic or Latino (Table 1). In both 2015 and 2022, urban veterans had higher rates of substance use disorders and bipolar disorders, and lower rates of sleep disorders. In 2022 only, urban veterans had higher rates of depressive disorders, anxiety, disorders, and psychotic disorders (Table 1).
TABLE 1.
Characteristics of veterans with an initial pain clinic visit in 2015 or in 2022.
| 2015 a , N = 95,549 | 2022 b , N = 117,044 | |||
|---|---|---|---|---|
| Characteristic | Rural, n = 31,599, n (%) or M (SD) | Urban, n = 63,950, n (%) or M (SD) | Rural, n = 34,855, n (%) or M (SD) | Urban, n = 82,189, n (%) or M (SD) |
| Age | 58.2 (13.9) | 56.3 (14.4) | 60.0 (14.9) | 57.9 (15.4) |
| Female | 2800 (8.9) | 8010 (12.5) | 4164 (11.9) | 13,310 (16.2) |
| Race | ||||
| Asian American | 96 (0.3) | 797 (1.2) | 171 (0.5) | 1517 (1.8) |
| Black or African American | 2560 (8.1) | 15,343 (24.0) | 2523 (10.1) | 21,900 (26.6) |
| White American | 26,923 (85.2) | 43,342 (67.8) | 28,547 (81.9) | 5181 (63.1) |
| Other | 808 (2.6) | 1386 (2.2) | 862 (2.5) | 1834 (2.2) |
| Unknown | 1212 (3.8) | 3092 (4.8) | 1752 (5.0) | 5087 (6.2) |
| Hispanic or Latino ethnicity | 841 (2.7) | 5115 (8.0) | 1339 (3.8) | 8206 (10.0) |
| Mean pain severity score | 5.8 (2.3) | 6.0 (2.3) | 5.3 (2.7) | 5.5 (2.7) |
| Posttraumatic stress disorder | 7347 (23.3) | 14,485 (22.7) | 9290 (26.7) | 21,922 (26.7) |
| Depressive disorder | 11,588 (36.7) | 23,852 (37.3) | 1277 (34.6) | 31,088 (37.8) |
| Substance use disorder | 4533 (14.3) | 11,228 (17.6) | 4748 (13.6) | 13,380 (16.3) |
| Anxiety disorder | 1930 (6.1) | 3943 (6.2) | 2828 (8.1) | 7175 (8.7) |
| Bipolar disorder | 1255 (4.0) | 3014 (4.7) | 1413 (4.1) | 3717 (4.5) |
| Psychotic disorder | 1458 (4.6) | 3194 (5.0) | 551 (1.6) | 1990 (2.4) |
| Sleep Disorder | 8833 (28.0) | 16,941 (26.5) | 13,974 (40.1) | 31,753 (38.6) |
All urban versus rural comparisons were significantly different in 2015 at the p < .001 level in 2015, except for posttraumatic stress disorder, depressive disorder, anxiety disorder, and psychotic disorder.
All urban versus rural comparisons were significantly different in 2022 at the p < 0.001 level in 2022, except for posttraumatic stress disorder.
Among 31,599 rural veterans with an initial pain clinic visit in 2015, over half, 53.6% (n = 20,858) had at least one follow‐up visit within the following year. This was significantly lower than the rate of 58.1% (37,180/63,950) observed among urban veterans (odds ratio [OR]: 0.83; 95% confidence interval [CI]: 0.81–0.86) and remained significant after statistical adjustment (adjusted odds ratio [aOR]: 0.85; 95% CI: 0.82–0.87; Table 2). This gap in pain clinic follow‐up rates narrowed in 2022, where 59.8% of rural veterans (20,858/34,855) and 61.6% of urban veterans (50,649/82,189) had at least one follow‐up pain clinic visit. While diminished in magnitude, this difference was statistically significant in both unadjusted (OR: 0.93; 95% CI: 0.90–0.95) and adjusted analyses: (aOR: 0.92; 95% CI: 0.90–0.95; Table 2). In a sensitivity analysis, pain clinic follow‐up visits were also analyzed in an adjusted negative binomial regression model (Table S1), which also demonstrated a similar narrowing of the rural/urban gap between 2015 (adjusted incidence rate ratio [aIRR]: 0.81; 95% CI: 0.80–0.83) and 2022 (aIRR: 0.94; 95% CI: 0.92–0.96). A diminishing rural/urban gap was also noted for the discrete count of visits, where rural veterans in 2015 had a mean of 3.0 follow‐up pain clinic visits, compared to 3.5 among urban veterans (Wilcoxon Z = 18.1; p < 0.001). In 2022, rural veterans had a mean of 3.8 follow‐up visits compared to 3.9 among urban veterans (Wilcoxon Z = 5.4; p < 0.001).
TABLE 2.
The associations of rurality with receipt of at least one follow‐up pain clinic visit within 1 year among those receiving an initial visit in 2022 or 2015.
| 2015 | 2022 | |
|---|---|---|
| Characteristic | Logistic regression, aOR (95% CI) | Logistic regression, aOR (95% CI) |
| Rurality | 0.85 (0.82, 0.87) | 0.92 (0.90, 0.95) |
| Age (per 10 years) | 0.94 (0.93, 0.94) | 0.98 (0.97, 0.99) |
| Female | 1.15 (1.10, 1.20) | 1.10 (1.06, 1.14) |
| Race (ref: White American) | ||
| Asian American | 0.99 (0.87, 1.15) | 1.15 (1.03, 1.27) |
| Black or African American | 0.91 (0.88, 0.95) | 0.90 (0.87, 0.93) |
| Other | 0.91 (0.83, 0.99) | 0.97 (0.89, 1.05) |
| Unknown | 0.90 (0.84, 0.95) | 1.01 (0.96, 1.07) |
| Hispanic or Latino | 1.09 (1.03, 1.15) | 1.03 (0.98, 1.07) |
| Mean pain severity score | 1.08 (1.08, 1.09) | 1.09 (1.09, 1.10) |
| Posttraumatic stress disorder | 1.03 (0.99, 1.06) | 1.01 (0.98, 1.04) |
| Substance use disorder | 0.91 (0.88, 0.95) | 0.72 (0.69, 0.74) |
| Depressive disorder | 1.04 (1.01, 1.07) | 0.93 (0.91, 0.96) |
| Psychotic disorder | 0.93 (0.88, 0.99) | 0.68 (0.63, 0.74) |
| Anxiety disorder | 1.08 (1.02, 1.14) | 0.97 (0.93, 1.01) |
| Bipolar disorder | 0.90 (0.85, 0.96) | 0.76 (0.72, 0.81) |
| Sleep disorder | 1.15 (1.12, 1.19) | 1.13 (1.10, 1.16) |
Abbreviation: aOR, adjusted odds ratio; CI, confidence interval.
Bold indicates statistical significance.
Among 95,549 veterans with an initial pain clinic visit in 2015, 12.0% (n = 11,488) were also seen by pain psychology, compared to 10.8% (12,667/117,044) in 2022. Of note, the raw number of veterans with a pain psychology visit increased from 2015 to 2022. For the 11,488 veterans who received pain psychology care in 2015, 47.7% (n = 5,480) had at least one follow‐up pain psychology visit within 1 year of the index pain clinic visit (i.e., additional pain psychology session/s following the first session). This frequency increased by 3.3% overall to 51.0% (6459/12,667) in 2022. Notably, this change was most pronounced among rural veterans, increasing by 8.5%, from 43.4% (1331/3069) in 2015 to 51.9% (1820/3506) in 2022. Analyzed as a discrete count of follow‐up pain psychology visits, the mean number of visits for the 2015 cohort was 2.2 for rural veterans and 2.6 for urban veterans, and in 2022 was 2.5 for rural veterans and 2.6 for urban veterans. After adjustment for confounding factors, rural veterans were significantly less likely (aIRR: 0.88; 95% CI: 0.81–0.95) to receive each additional pain psychology follow‐up visit in the 2015 cohort, but equally likely in the 2022 cohort (aIRR: 1.00; 95% CI: 0.93–1.08; Table 3). In a sensitivity analysis, pain psychology follow‐up visits were also analyzed as a dichotomous variable for whether veterans did or did not receive a minimum dose of at least three pain psychology follow‐up visits (Table S2). 18 Findings were consistent with the primary analysis, where rural veterans were significantly less likely to receive a minimum dose of pain psychology treatment in the 2015 cohort (24.3% vs. 29.1%), but equally likely in the 2022 cohort (29.9% vs. 31.2%).
TABLE 3.
The associations of rurality with receipt of follow‐up pain clinic psychology visits within 1 year among those receiving an initial visit in 2022 or 2015.
| 2015 | 2022 | |
|---|---|---|
| Characteristic | Negative binomial regression, aIRR (95% CI) | Negative binomial regression, aIRR (95% CI) |
| Rurality | 0.88 (0.81, 0.95) | 1.00 (0.93, 1.08) |
| Age (per 10 years) | 1.04 (1.01, 1.07) | 0.94 (0.92, 0.97) |
| Female | 1.19 (1.08, 1.31) | 1.17 (1.08, 1.27) |
| Race (ref: White American) | ||
| Asian American | 1.26 (0.81, 1.94) | 1.31 (1.02, 1.70) |
| Black or African American | 1.22 (1.12, 1.33) | 1.22 (1.13, 1.33) |
| Other | 0.85 (0.67, 1.09) | 0.91 (0.74, 1.11) |
| Unknown | 1.25 (1.04, 1.51) | 0.97 (0.85, 1.10) |
| Hispanic or Latino | 1.33 (1.15, 1.54) | 1.06 (0.96, 1.18) |
| Mean pain severity score | 0.98 (0.96, 0.99) | 0.99 (0.97, 0.99) |
| Posttraumatic stress disorder | 1.08 (1.00, 1.18) | 1.07 (0.99, 1.15) |
| Substance use disorder | 0.78 (0.71, 0.86) | 0.80 (0.73, 0.88) |
| Depressive disorder | 1.18 (1.09, 1.28) | 1.19 (1.11, 1.27) |
| Psychotic disorder | 1.07 (0.92, 1.24) | 0.78 (0.61, 0.99) |
| Anxiety disorder | 0.96 (0.84, 1.10) | 1.07 (0.96, 1.20) |
| Bipolar disorder | 0.97 (0.82, 1.13) | 1.02 (0.87, 1.20) |
| Sleep disorder | 1.17 (1.08, 1.26) | 1.04 (0.97, 1.11) |
Abbreviation: aIRR, adjusted incidence rate ratio; CI, confidence interval.
Bold indicates statistical significance.
DISCUSSION
With recent expansion of multidisciplinary pain clinic offerings across the VA, the rural/urban gap in follow‐up pain clinic care has narrowed. With pain psychology specifically, rates of follow‐up are now equivalent between rural and urban‐dwelling veterans. Other pain care metrics have historically demonstrated differences for rural veterans, such as higher rates of long‐term opioid use 6 and lower rates of initial pain specialty care visits among rural veterans. 5 Additional analyses are needed to determine if these other metrics have also improved in recent years for rural veterans.
Among both rural and urban veterans, over one third with an initial pain clinic visit did not have a follow‐up within 1 year in the current analysis. Although there was some decrease across time, there remained a substantial proportion with only one pain clinic visit. These single pain clinic visits may reflect a range of possibilities: veterans may be offered follow‐up and decline that care, or they may be referred back to primary care or other multidisciplinary care (e.g., physical therapy; complementary and integrative health approaches) either within the VA or through VA paid care in the community. Of note, pain clinics across the VA vary in the composition of their multidisciplinary pain care teams; for example, some include interventional pain management while others offer rehabilitation programs. 21 The variability in number of pain clinic visits received may reflect, at least in part, different offerings available across the VA. Also, of note, prior work has demonstrated that the subset of veterans who receive pain clinic care 22 are more likely to have psychiatric comorbidities and widespread pain (i.e., fibromyalgia). 23 These characteristics suggest that veterans receiving specialty pain clinic care may present with higher complexity which may also impact continuity of care metrics. Future work is needed to fully elucidate the meaning of single pain clinic visits; whether these are serving as planned assessments with referrals to other services, or whether these reflect patients who become lost to follow‐up, and if so which subsets of veterans are becoming lost to follow‐up.
Among the veterans who received pain clinic psychology services, by 2022 rural veterans received follow‐up services at equitable rates to urban veterans. While it was hypothesized that continuity of pain psychology may be more likely to be disrupted for rural veterans, due to challenges such as transportation and distance from the medical center, this was not found. Overall, however, pain psychology services were only utilized by about one in every nine veterans with an initial pain clinic appointment in 2022. It is not clear whether these relatively low rates reflect patient receptivity, 24 provider referrals, availability of pain psychology services in pain clinics, and/or referral to similar services outside of the pain clinic setting, such as brief CBT‐CP in primary care. 25 , 26 In addition, the rates of pain clinic patients who engage with pain psychology services may increase in the future, as the VA has hired dozens of additional pain psychology providers since 2022, through the Active Management of Pain initiative. 27 Further research is needed here.
This study was not without limitations. While we were able to examine rates of follow‐up services, we were not able to determine from these data what occurred in each session. For example, in pain psychology sessions, we do not know whether the clinician was providing empirically supported interventions, such as CBT‐CP or acceptance and commitment therapy (ACT) for chronic pain 14 versus interventions such as lifestyle management, supportive psychotherapy, or general counseling. The minimum dose of psychotherapy utilized for this study was based on prior work with CBT‐CP. 18 In addition, many studies of CBT and ACT for chronic pain include many more than three sessions and examining a higher threshold for a minimum dose could impact the sensitivity analyses. Also, we looked at group and individual pain psychology sessions collectively, so results may vary by looking at these separately. Finally, the pain psychology interventions captured in the current analyses were circumscribed to those provided via specialty pain clinics; this work should not be interpreted as a survey of pain psychology services provided in other settings across the VA. Further work is needed to capture the ways in which specialty pain care services interact with pain psychology services provided in primary care or mental health settings.
In conclusion, the rural gap in continuity of specialty pain clinic services for veterans has narrowed, during a time when the VA has increased multidisciplinary pain clinic staffing. Future work is still needed to elucidate the function of single session pain clinic visits and to determine whether a greater proportion of veterans with chronic pain would benefit from pain clinic psychology services.
CONFLICT OF INTEREST STATEMENT
The authors declare no conflicts of interest.
Supporting information
Supporting Information
ACKNOWLEDGMENTS
This material is based upon work supported by the Department of Veterans Affairs, Veterans Health Administration, Office of Rural Health, Veterans Rural Health Resource Center—Iowa City (Award # 03857). The work reported here was also supported by the US Department of Veterans Affairs Health Services Research and Development (HSR&D) Service through the Center for Access and Delivery Research and Evaluation (CADRE) Center (CIN 13‐412), and with the use of resources and facilities of the Salem VA HCS, and a VISN 6 Career Development Award. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the US Department of Veterans Affairs or the United States Government.
Hadlandsmyth K, Courtney RE, Adamowicz JL, Driscoll MA, Murphy JL, Lund BC. Continuity of pain clinic care among rural and urban veterans. J Rural Health. 2025;41:e70031. 10.1111/jrh.70031
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from Veterans Health Administration. Restrictions apply to the availability of these data, which were used under license for this study. Data are available from the author(s) with the permission of Veterans Health Administration.
REFERENCES
- 1. Nahin R. Severe pain in veterans: the effect of age and sex, and comparisons with the general population. J Pain. 2017;18(3):247‐254. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2. Elbers S, Wittink H, Konings S, et al. Longitudinal outcome evaluations of interdisciplinary multimodal pain treatment programmes for patients with chronic primary musculoskeletal pain: a systematic review and meta‐analysis. Eur J Pain. 2022;26(2):310‐335. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3. Bujak BK, Regan E, Beattie PF, Harrington S. The effectiveness of interdisciplinary intensive outpatient programs in a population with diverse chronic pain conditions: a systematic review and meta‐analysis. Pain Manag. 2019;9(4):417‐429. [DOI] [PubMed] [Google Scholar]
- 4. Institute of Medicine (US) Committee on Advancing Pain Research, Care, and Education . A Blueprint for Transforming Prevention, Care, Education, and Research. The National Academies Press; 2011. [PubMed] [Google Scholar]
- 5. Hadlandsmyth K, Driscoll MA, Mares JG, Au V, Miell KR, Lund BC. Rurality impacts pain care for female veterans similarly to male veterans. J Rural Health. 2022;39(2):313‐319. [DOI] [PubMed] [Google Scholar]
- 6. Lund BC, Ohl ME, Hadlandsmyth K, Mosher HJ. Regional and rural‐urban variation in opioid prescribing in the Veterans Health Administration. Mil Med. 2019;184(11‐12):894‐900. [DOI] [PubMed] [Google Scholar]
- 7. Ohl ME, Carrell M, Thurman A, et al. Availability of healthcare providers for rural veterans eligible for purchased care under the veterans choice act. BMC Health Serv Res. 2018;18(1):315. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8. Leonard C, Ayele R, Ladebue A, et al. Barriers to and facilitators of multimodal chronic pain care for veterans: a national qualitative study. Pain Med. 2021;22(5):1167‐1173. [DOI] [PubMed] [Google Scholar]
- 9. Baker MB, Liu EC, Bully MA, et al. Overcoming barriers: a comprehensive review of chronic pain management and accessibility challenges in rural America. Healthcare (Basel). 2024;12(17):1765. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10. Murphy JL, Palyo SA, Schmidt ZS, et al. The resurrection of interdisciplinary pain rehabilitation: outcomes across a Veterans Affairs collaborative. Pain Med. 2021;22(2):430‐443. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11. Courtney R, Schadegg M. Chronic, noncancer pain care in the veterans administration: current trends and future directions. Anesthesiol Clin. 2023;41(2):519‐529. [DOI] [PubMed] [Google Scholar]
- 12. How internal audit helped VA leaders enhance their support of pain management. US Department of Veterans Affairs. 2022. https://www.va.gov/VHAoversight/internal‐audit/case‐study/pain‐management.asp
- 13. Martinez‐Calderon J, García‐Muñoz C, Rufo‐Barbero C, Matias‐Soto J, Cano‐García FJ. Acceptance and commitment therapy for chronic pain: an overview of systematic reviews with meta‐analysis of randomized clinical trials. J Pain. 2024;25(3):595‐617. [DOI] [PubMed] [Google Scholar]
- 14. Williams A, Fisher E, Hearn L, Eccleston C. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst Rev. 2020;8(8):CD007407. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15. Ehde D, Dillworth T, Turner J. Cognitive‐behavioral therapy for individuals with chronic pain: efficacy, innovations, and directions for research. Am Psychol. 2014;69(2):153‐166. [DOI] [PubMed] [Google Scholar]
- 16. Driscoll MA, Edwards RR, Becker WC, Kaptchuk TJ, Kerns RD. Psychological interventions for the treatment of chronic pain in adults. Psychol Sci Public Interest. 2021;22(2):52‐95. [DOI] [PubMed] [Google Scholar]
- 17. Murphy J, Cordova M, Dedert E. Cognitive behavioral therapy for chronic pain in veterans: evidence for clinical effectiveness in a model program. Psychol Serv. 2022;19(1):95‐102. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18. Heapy AA, Higgins DM, Goulet JL, et al. Interactive voice response‐based self‐management for chronic back pain: the COPES noninferiority randomized trial. JAMA Intern Med. 2017;177(6):765‐773. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19. Rural‐urban commuting area codes. U.S. Department of Agriculture. September 6, 2024. https://www.ers.usda.gov/data‐products/rural‐urban‐commuting‐area‐codes/rural‐urban‐commuting‐area‐codes/
- 20. Hadlandsmyth K, Bernardy N, Lund B. Gender differences in medication prescribing patterns for veterans with posttraumatic stress disorder: a 10‐year follow‐up study. J Trauma Stress. 2022;35(6):1586‐1597. [DOI] [PubMed] [Google Scholar]
- 21. Sandbrink F. What is special about veterans in pain specialty care? Pain Med. 2017;18(4):623‐625. [DOI] [PubMed] [Google Scholar]
- 22. Blevins CA, Weathers FW, Davis MT, Witte TK, Domino JL. The posttraumatic stress disorder checklist for DSM‐5 (PCL‐5): development and initial psychometric evaluation. J Trauma Stress. 2015;28(6):489‐498. [DOI] [PubMed] [Google Scholar]
- 23. Arout C, Sofuoglu M, Rosenheck R. Rates and correlates of pain specialty clinic use nationally in the Veterans Health Administration. Pain Med. 2017;18(4):702‐710. [DOI] [PubMed] [Google Scholar]
- 24. Silvestrini M, Indresano J, Zeliadt SB, Chen JA. “There's a huge benefit just to know that someone cares:” a qualitative examination of rural veterans' experiences with TelePain. BMC Health Serv Res. 2021;21(1):1111. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25. Beehler GP, Loughran TA, King PR, et al. Patients' perspectives of brief cognitive behavioral therapy for chronic pain: treatment satisfaction, perceived utility, and global assessment of change. Fam Syst Health. 2021;39(2):351‐357. [DOI] [PubMed] [Google Scholar]
- 26. Beehler GP, Murphy JL, King PR, et al. Brief cognitive behavioral therapy for chronic pain: results from a clinical demonstration project in primary care behavioral health. Clin J Pain. 2019;35(10):809‐817. [DOI] [PubMed] [Google Scholar]
- 27. Murphy J, Craine M. Update to VA's pain management program. AVAPL Newslett, 2023:(1). [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supporting Information
Data Availability Statement
The data that support the findings of this study are available from Veterans Health Administration. Restrictions apply to the availability of these data, which were used under license for this study. Data are available from the author(s) with the permission of Veterans Health Administration.