Pain in Women Veterans Veterans

Sally G. Haskell, MD

Acting Director, Comprehensive Women’s Health,

Women Veteran’s Health Strategic Healthcare Group,

VA Central Office

Associate Professor of Medicine, Yale University School of

Medicine
Disclosure Statement

• No conflicts conflicts of interest interest to disclose disclose
Outline

• Cag g h n ing wo e m n Vete a s eterans Popu at o opulation• Pain in Women (non‐Veteran studies)

• Risks for pain in Women Veterans Veterans

• Women Veteran’s Pain Studies• Pain in women Veterans Veterans of OEF‐OIF• Specific Pain syndromes, including

musculoskeletal p , ain pain in TBI,

• Are there differences in pain treatment an

outcomes?
Population of Women Vetera

Source data supplied 7/9/10 by the Office of the Actuary, Office of Policy and Planning, Department of Veterans Affairs
Expanding Population

• The number of women veterans is growing

rapidly.

• Because of the large number of women on 

duty and entering military service, the perc

of female veterans is projected to increase:

• from 7.7 percent in 2008

• to 10.0 percent in 2018• to 14.3 percent in 2033
Women Veterans and the VA

Number oVeterans 

VA plans

Number thealthcar

Source data supplied 7/9/10 by the Office of the Actuary, Office of Policy and Planning, 

Department of Veterans Affairs
A New Generation Generation of Women V

V

 Young – 47.3% less than 30;

78% less than 40 

 49.7% received VA health care  47 8% of outpatients seen for 11 or more 47.8% of outpatients seen for 11 or more

visits
Age distributions distributions of women Veteran Veteran VHA

patients, FY00 and FY09
Civilian Civilian studies, studies, pain more common in w

• Chronic pain is more common among women 

men

• WHO study—women were found to have ele

rates of persistent pain relative to men acros

societies.

• Specific Specific pain syndromes syndromes including including headaches headaches

facial pain, musculoskeletal pain, and abdom

have all been demonstrated to have a higher

prevalence in women.

• Gureje O, Von Korff, M, Simon GE, Gater R, Persistent Persistent pain and well‐being: A World Health Organization Organization study in primary primary care
Women Veterans Veterans are at risk of 

• Are women Veterans Veterans at higher risk than • Maybe,• S l evera factors may place women Veter

a population) at high risk of pain.

• 1‐Pain is more common in Women

• 2‐Women Veterans, as a pp , o ulation, m

particularly at risk because of high rates 

mental health conditions and trauma.
Risks for Pain in Women Vete

Vete

• High injury rates in basic training training and ac

duty

• Higher prevalence prevalence of depression depression, anxiet

anxiet

adjustment disorders

• C b om at trauma

• Sexual Trauma –18% screen positive
Women are excluded from “direct combat” 

serve in a variety of support positions wher

come under direct fire

• Women soldiers carry heavy loads and

participating in strenuous strenuous physical physical train

train

• have higher injury rates than men in ini

entry trai i n ng in military service.

• are particularly prone to specific injurie

as stress fracture.



DOD studies studies risk factors factors for injur

injur

• DOD studies have identified specific risk fact

injury (low aerobic fitness and previous injury

history) and targeted strategies to strengthen 

and reduce risk of stress fracture fracture in basic trai

trai

• In addition addition, other DOD studies studies of physical physical str

str

demands have led to new helmet design, evaof spine load lifting tolerance, and further tes

whether strength deficiencies are associated 

injury risk.

• Friedl KE. Biomedical research on health and performance of military women: Accomplishments of the Defense Women’s Hea

Wom Health 2005, 14(9): 764‐80.
One Study of Disease and Nonbattle Inj

sustained sustained by a U.S. Army Brigade Brigade Comba

during OEF/OIF

• Historically DNBI has resulted in significantly more hospit

and time l t os than b ttl a e ij i n ur es as a result of the h til os e 

environment.

• In a study of one Army brigade (3,797 males, 325 female

deployed deployed to Iraq for 15 months: months:

• Females had significantly higher rates of DNBI (accounted 

of population and 12.5% of DNBI)...However, 74% of the f

receiving MEDEVAC had pregnancy related issues.

• Musculoskeletal injuries were the most common body sy

involved (50%)

• In this study there was no significant difference in rates o

f l/ l emale/male soldiers recei i v ng MEDEVAC MEDEVAC for muscul k

os e

injuries.

• Belmont PJ, Goodman GP, Waterman B, Dezee K, Burks R, Owens BD. Military Medicine, 175,7:469,2010
Depression Depression and risks for Chronic Chronic 

• Depression is twice as common in women Ve

compared to men.

• Pain and depression depression frequently frequently co‐exist (30‐5

occurrence) and have additive effect on adve

health outcomes and treatment responsiven

one another *

• The presence presence of depressive depressive symptoms symptoms is a str

independent, and highly prevalent risk factor 

occurrence of disabling back pain **

* Bair, MJ, Robinson RL, Katon W, Kroenke K. Depression and Pain Co‐morbidity: a literature review. Arch Intern Med 

** Reid MC, Depressive symptoms as a risk factor for disabling back pain Am Geriatr Soc. 2000 Dec;51(12):1710‐7.
Mental Health Diagnoses of Iraq and Afghanistan V

Seeking VA Health Care by Gender: April 2002‐Marc

Maguen S, Ren L, Bosch J, Marmar C, Seal K. AJPA, Dec. 2010

Mental health diagnosis Women (n=40,701) Men (n=288,3Depression 23% 17%PTSD 17% 22%Substance Use 2% 3%Adjustment Disorder 11% 11%Anxiety 12% 10%Alcohol Use 3% 8%Eating Disorder 0 6%. 0 1%.
Sexual trauma may increase increase risk of 

• High rates of sexual trauma• Some studies have found women with s

trauma have higher rates of pain syndro

syndro

such as:

• Pli e v c pain

• Gastrointestinal disorders

• Headache• Back pain
MST Support Team

Screening Report

Females Male

% Screened 21.9% 1.1%

Positive 17.9% 0.8

# Screened

Positive

53,295

5,590

46,8

1,6

All Veteran Data, OEF/OIF Veteran Data, FY2009
Sexual Trauma Associated with Pain

I t it n ensity and P i a n It f n er erence

• Study of Women VA CT Primary Primary Care Patient

Patient

• 78% reported ongoing pain problem

• 36% reported reported any sexual trauma

• In multivariate multivariate linear regression regression that included included 

those who reported pain, the presence of se

trauma was associated with higher levels of p

intensity, and higher levels of pain interferen

• Haskell, et al. Pain Medicine 2008
Studies Studies of Pain in Women Vete

Vet
Prevalence and Age‐Related Characteristics 

in a Sample of Women Veterans Receiving P

Care

• 213 Women Primary Care Patients• Mean age 52

• 78% reported ongoing pain problem

• Mean duration duration of pain 6 years

• Average pain intensity 6.3 (range 1‐10)

• Commonly endorsed pain sites included:

• Lo er w e tremit extremity (68%), Low back (63%), Sho lder Shoulder (4

• Highest prevalence in age 36‐50 (89%), and 51‐65(83

• Haskell Haskell SG, Heapy A, Reid MC, Papas R, Kerns RD. J Women s Women’s Health, 15 (7); 864‐871
Health Related Quality of Life in VA Pat

wi ht M l enta Illness

• Another Another study of health related related quality quality 

in over 18,000 veterans with mental illn

found females females had lower scores on the 

physical component summary (indicatin

worse symptoms) symptoms), were more likely to r

that they were limited "a lot" in activiti

daily living, and had more pain than ma

• Teh CF, Kilbourne AM, McCarthy JF, Welsh D. Blow FC. Gender differences in health related quality of life for Veterans w

Illness. Psychiatri Serv 2008; 59( ) 6 :663‐9
Painful Conditions in OEF/OIF Veteran

G d en er (unpublished WVCS data)
Painful Conditions in Homel

OEF/OIF Veterans (WVCS, Blackstock, et al, Unpubli

• Chronic Chronic Pain Conditions Conditions defined defined as having at 

one or more of the following ICD‐9 codes for 

inpatient visit or two outpatient visits:

• Headache, tension headache, migraine, back 

fibromyalgia, IBS, TMJ, peripheral neuropathy

malignancy, arthritis.

• N = 9,170 Homeless Veterans

• Women with Pain: 39.9%• Men with Pain: 31.3%
Pain in OEF‐OIF Veterans‐Are th

Gender Differences?

• Because Because of the high prevalence prevalence of pain 

women, and the risks of pain in Women

Veterans Veterans, we evaluated evaluated pain scores in O

O

Veterans who use VA in the first year af

deployment.

• We hypothesized that women Veterans 

have more pain, more moderate moderate to sev

pain, and more persistent pain than me

Veterans.
Women Veteran s Veteran’s Cohort St

Study of gender differences in

healthcare costs, utilization

VA CT/VA Indiana

Cynthia Brandt, MD, 

and medical and mental

health outcomes (including

pain) after service in

Cynthia Brandt, MD, Sally G. Haskell, MDAmy Justice, MD, PhD pain) after service in

OEF/OIF.

Links OEF/OIF Roster to VA

Kristin Mattocks, PhD

Patty Rosenberger, Ph

Electronic Medical Record

Includes prospective survey

component

Joe Goulet, PhDBob Kerns, PhDOthers component
Methods

• Study p po ulation from VA’s OEF/OIF roster

– Roster contains information on U.S. Military personn

discharged from 10/1/2001‐11/30/2007

– Who enrolled for VA services before January 1, 2008– N=406,802 at the time of this analysis

• Sample limited to:

– Veterans Veterans who had at least 1 visit to a VA clinic likely t

obtain pain scores (e.g. primary care, women’s clinic)

– And at least one year of observation after enrollment
Data Sources

• Roster includes includes information information on Veteran Veteran s’ sex, DO

race, education, marital status, rank, branch of

service, and deployment start and end dates.

• Data on eligible visits, ICD‐9 codes, and pain sco

ascertained from VA Corporate Data Warehouse(CDW).
Pain numeric rating scale

• At each vi it s , V t e erans are ask de to rate th 

current pain intensity on a scale of 0–10, w

is no pain and 10 is the worst possible possible pai

• The score is recorded recorded along with vital sign• We retained retained only scores recorded recorded at outp

outp

visits.

• We retained the highest scores on a day.
Definitions

• Pain was defined as assessed if the Veteran had a va

pain score in the 1 year observation period.

• Among Veterans who were assessed, Any P i a n was

defined as a score ≥ 1.

• Among those with Any Pain, Moderate‐Severe pain 

defined as a score ≥ 4.

• Persistent pain was defined as 3 or more scores ≥4

recorded recorded in at least 3 different different months.
Gender Differences in OEF/OIF Populat

D hi emographics

Female Male P‐valu

Age mean (SD) 30 (8.8) 32 (9.7) <.0001

Race <.0001

White 53% 69%Black 30% 15%Hispanic 11% 10%Other/unknown 6% 6%Married 32% 49% <.0001
Clinical Diagnoses in first year aft

deployment (Top 6)

Diagnosis Female Male OR (95%CI) P

value

Adjusted O(95% CI)

Back Problems 9.4% 10.3% .95(0.86,0.95) <.0001 0.97(0.92,1.0Joint Di d sor ers 9 2%. 9 %.5 0 9 (0 92 02) 0.97(0.92,1.02) 0 90 .1 4 1.00(0 9 0 

00(0.95,1.0

PTSD 8.4% 9.7% 0.86(0.81,0.90) <.0001 0.95(0.89,1.0Female GenitalDisorders

6.2%

Mild Depression Depression 6.8% 4.1% 1.72(1.62,1.83) 1.72(1.62,1.83) <.0001 1.81(1.70,1.9

1.81(1.70,1.9

MusculoskeletalDisorders

4.6% 4.1% 1.13(1.05,1.21) .0011 1.22(1.13,1.3
Pain Assessment and Pain

Characteristics by Sex

Female 

n=18,481

Male 

n=134,731

P va

Pain Assessment Pain Assessment 60.1% 59.6% 

Any pain Any pain 38.1% 44.0% <

<

Moderate pain Moderate pain 68.0% 62.6% <

<

Persistent pain Persistent pain 18 0%. 21 2%. <

<
Results Results of regression regression models (relative (relative 

Variable Variable Assessed Assessed

RR 95% CI)

Any pain

RR (95%CI)

Moderate Pain

RR (95%CI)

Per

RR 95% CI) RR (95%CI) RR (95%CI) R

R

Female 0.98 (0.96, 1.00) 0.89 (0.86, 0.92) 1.05 (1.01, 1.09) 0.90 Male Ref. Ref. Ref. Age 1.00 (1.00, 1.00) 1.00 (1.00, 1.00) 1.00 (1.00, 1.00) 1.

Divorced 1.05 (1.02, 1.08) 1.00 (0.96, 1.04) 1.00 (0.95, 1.06) 0.Never married 1.10 (1.08, 1.12) 0.88 (0.86, 0.90) 0.98 (0.95, 1.01) 0.

Married Ref. Ref. Ref. Black 1.00 (.098, 1.02) 0.97 (0.94, 1.00) 1.22 (1.18, 1.26) 1.Hispanic 1 07 (1 05 1 10) 1.07 (1.05, 1.10) 0 92 (0 90 0 95) 0.92 (0.90, 0.95) 1 01 (0 97 1 05) 1.01 (0.97, 1.05) 0 

0.

Other 1.05 (1.01, 1.09) 0.97 (0.91, 1.03) 1.09 (1.01, 1.17) 0.

Unknown 0.92 (0.88, 0.96) 0.97 (0.90, 1.03) 1.16 (1.07, 1.25) 1.

White Ref. Ref. Ref. 

Also controlled for education, branch, and rank
Limitations:

• Accuracy of Pain Scores? Scores?• In one study, that compared Pain Scores to B

Inventory, the Pain Score misses nearly 1/3 o

patients with clinically important pain.

• In a second study the Pain Score underestima

pain in 33% of cases and overestimated in 12

cases.

• Does inaccuracy vary by Gender?• Krebs EE, et al. Accuracy of the pain numeric rating scale as a screening test in primary care. J Gen Intern 

1453‐8)

• Lorenz KA et al How reliable is pain as the 5th Lorenz KA, et al. How reliable is pain as the 5 vital sign. J Am board Fam Med 2009;22(3):291 2009;22(3):291‐8.
Specific Painful Conditions in OEF/OIF W

Veterans

• Because Because of concern concern for risk of

musculoskeletal injury in female Vetera

examined the prevalence prevalence of Painful Painful

Musculoskeletal Conditions and the

trajectory trajectory of these conditions conditions over 7 ye

after return from deployment.

• Haskell, et al. Clinical Journal of Pain, 2011, In press
Methods

• Used VA administrative administrative and clinical clinical data base

OEF/OIF Veterans who had enrolled in and us

care.

• The prevalence of back problems, musculosk

problems and joint disorders was determined 

years 1 through 7 after deployment for fema

male Veterans using ICD‐9 code groupings fo

conditions.
Results

• For both female and male Veterans the preva

painful musculoskeletal conditions increased 

year after deployment.

• After adjustment for demographic difference

Women Veterans Veterans were more likely than men 

have back problems, musculoskeletal proble

joint problems, and the odds of having these

conditions increased each year for women

compared to men in years 1‐7 after deploym
The prevalence of back problems in female and male 

Veterans Veterans in years 1‐7 after end of last deployme

deployme

Year Female Male OR

(95% CI)

Pvalue

Adjusted OR(95%CI)

(95% CI) value (95%CI) 

1 3.89 4.27 0.91(0.87,0.95) <.001 1.06(1.01,1.12 8.25 8.7 0.94(0.91,0.98) 0.001 1.10(1.06,1.13 13.07 13.3 0.98(0.95,1.01) 0.23 1.15(1.11,1.14 16.9 16.92 1.00(0.96,1.03) 0.91 1.17(1.13,1.25 19.43 18.77 1.04(1.00,1.09) 0.04 1.22(1.17,1.26 20.53 19.59 1.06(1.01,1.12) 0.03 1.25(1.18,1.37 19.63 17.19 1.18(1.05,1.31) .0004 1.38(1.23,1.5
The prevalence of musculoskeletal conditions in female 

OEF/OIF OEF/OIF V t e erans in years 1‐7 after end of l t as dl 

ep o

year Female Male OR P Adjusted OR 

(95%CI) value (95% CI) 

1 2.23 2.05 1.09(0.87,0.95) <.001 1.32(1.10,1.1

2 4 88 . 4 34 . 1 13(1 08 1 19) 1.13(1.08,1.19) < 001 . 1 36(1 30 1 4

1.36(1.30,1.4

3 8.03 6.94 1.17(1.12,1.22) <.001 1.40(1.34,1.44 10.87 9.27 1.19(1.15,1.25) <.001 1.42(1.36,1.45 12.84 10.68 1.23(1.17,1.33) <.001 1.47(1.39,1.56 13.52 11.15 1.25(1.17,1.33) <.001 1.50(1.40,1.67 12 42 . 9 58 . 1 34(1 17 1 53) 1.34(1.17,1.53) < 001 . 1 60(1 39 1 8

1.60(1.39,1.8
The prevalence of joint problems in female and male 

V t e erans in years 1‐7 after end of l t as dl 

ep oyme

Year Female Male OR(95%CI) P Adjusted OR 

value (95%CI) 

1 4.23 4.42 0.95(0.91,0.99) 0.03 1.13(1.08,1.

2 8 66 . 8 8. 0 98(0 95 1 02) 0.98(0.95,1.02) 0 33 . 1 16(1 12 1 

1.16(1.12,1.

3 13.59 13.4 1.02(0.98,1.05) 0.009 1.21(1.17,1.4 17.64 16.99 1.05(1.01,1.08) <.001 1.24(1.20,1.5 20.32 18.87 1.10(1.05,1.14) <.001 1.29(1.24,1.6 21.18 19.52 1.11(1.05,1.17) <.001 1.31(1.24,1.7 19 47 . 16 66 . 1 21(1 08 1 35) 1.21(1.08,1.35) < 001 . 1 36(1 21 1 

1.36(1.21,1.
Limitations

• Findings Findings can t’ be generalized generalized to all Veterans, Veterans, 

only those who enrolled in and sought care in 

• Large sample size, g p rou comparisons reach

statistical significance and are not necessarily 

clinical importance.

• Analysis each year is based on those Veteran

continue care for that period of time. While m

Veterans have compl d ete one year of care, fa

have completed up to 7 years of care and att

may disproportionately disproportionately affect those with or w

w

certain conditions.
Gender Differences in Symptoms in OE

Veterans wi ht D l ep oyment Rl d e ate T

• Iverson, K. M., et al, ( July,2010). Oral presentation a

annual HSR&D National Meeting on Building the Evid

Base to Improve Heal ht care Outcomes for Women V

Arlington, VA.
Inclusion Criteria

OEF/OIF Screened Veterans

N = 327,633 

Females

N = 40,448

Males

N = 287,185

Had Comprehensive 

TBI Evaluation

N = 1 912

Had Comprehe

TBI Evaluati

N = 1,912 N = 31 873 ,

Confirmed Deployment-related Confirmed Deploym

mTBI

N = 654

mTBI

N = 11,95
Percentages of Veterans Who Report “Severe” an

Severe” Sy p m toms on the Four NSI‐22 Scales by Ge

12,605)

%
Sex Differences in Pain and Pain‐Relat

Disability (Stubbs et al, Pain Medicine, 2010;11:232‐239)

• Study analyzed analyzed baseline baseline data collected collected 

Stepped Care for Affective Disorders an

Musculoskeletal Pain (SCAMP) (SCAMP) study, a

randomized clinical trial of pain and

depression depression care management management. (Kroenke (Kroenke et al, G

Psychiatry 2007;29:506‐17)

• SCAMP enrolled 500 patients with chro

musculoskeletal pain, 250 had comorbidepression.
Sex Differences in Pain and P

Related Disability

• 259 Women, 249 Men• Women reported greater pain intensity

• BPI Severity Severity 6 2. vs. 5 2. (P< 001) (P<.001)

• Greater pain specific disability• BPI interference interference 6 47 . vs. 5 27 . (P< 001) (P<.001)• More pain related disability days• 32 5. vs. 23 4. (P< 001) .• More likely to acknowledge emotional aspe

pain and expressed expressed a greater greater need for empa

empa
Differences in Pain Treatme

Treatme

• Women seek care for musculoskeletal musculoskeletal p

more often than men.

• Women may face challenges challenges in pain

treatment such as stigmatization,

misunderstanding and gender bias.

• Women may respond differently to pain

treatment programs.

• 1. Wijnhoven HA, Sex differences in Consequences of Musculoskeletal Pain. Spine 2007;32:1360‐7)

• 2. Frantsve LM, et al. Patient‐provider interactions in the management of chronic pain: current findings w

shared medical decision making. Pain Medicine 2007,8:10:25‐35

• 3. Keogh E et al. Do men and women differ in their response to interdisciplinary chronic pain manageme

2005:14:1:37‐46.
Are there gender differences in p

treatment in VA? (unpublished WVCS data)

Gender Distribution of Pain Clinic Stop Code (420)Gender N %Male 8449 1.94%Female 1049 1 82% .
Summary and Conclusion

• Women Veterans Veterans who use VA have a high pre

pre

of pain.

• With rising numbers of female military servic

members and female Veterans, it will be imp

for VHA to develop prevention and treatmen

programs that focus on issues of particular

importance to women, including patient‐prov

communication and prevention prevention of functional functional

disability.