Overview

The Centre of Excellence is the national leader in researching chronic pain in Veterans. The guiding principles for research include national and international collaboration, building upon existing strengths in Canada, and capitalizing on existing investments made by Veterans Affairs Canada (VAC). With the goal of improving Veterans’ well-being, our research findings will be used to promote evidence-based best practices that will inform our network of pain clinics, researchers, case managers, and the public.

Veteran Engagement

At the core of all Centre of Excellence activities is the principle of Veteran engagement. Consultation and engagement with Veterans, which includes an Advisory Council for Veterans (ACV) to advise on research priorities, began prior to establishing the organization and continues as a lasting priority. This ongoing engagement helps to develop a deeper and more thorough understanding of the day-to-day challenges that Veterans and their families face as a result of their experiences with chronic pain. That understanding is used to shape research to ensure that it will have a genuine, practical, and positive impact on the well-being of Veterans and their families.

Priorities

The Centre of Excellence conducted a qualitative study to better understand research priorities for Veterans. One-on-one interviews were conducted with Veterans across five Canadian provinces who reported living with chronic pain that began during their service. This research resulted in eight priorities, as listed below. A cross-sectional review to further define and rank these priorities is underway.

·        Pain care in the military

·        Post-operative care in the military

·        Coordination of services

·        Military to civilian transition

·        Primary care provider access outside the military

·        Knowledge of pain among civilian healthcare providers

·        Holistic care and patient knowledge

·        Effective strategies for chronic pain management

Foundational Research

Institution: McMaster University
Principal Investigator: Dr. Jason Busse, Associate Professor, Anesthesia& Health Research Methods, Evidence, and Impact, McMaster University
Summary: This project aims to lay important foundations for Veterans’ chronic pain research.
i) Rapid Recommendations
The MAGIC project has partnered with the British Medical Journal (BMJ) to create BMJ Rapid Recommendations (Rapid Recs) for areas in which there is a high potential of informing optimal clinical practice. The process begins by identifying an urgent clinical issue or new potentially practice-changing evidence, conducting systematic reviews of benefits, harms, and patients’ values and preferences, and using the findings to inform a focused clinical practice recommendation. To date, a Rapid Rec has been completed on medical cannabis and cannabinoids for chronic pain. Additionally, the CPCoE has embarked on a Rapid Rec for management of chronic pain from temporomandibular disorders (TMDs).

ii) Review of the Seven Domains of Well-being
VAC has established Seven Domains of Well-being that are important to facilitate understanding of Veterans’ well-being: (1) Health, (2) Life Skills& Preparedness, (3) Finances, (4) Social Integration, (5) Cultural & Social Environment, (6) Housing & Physical Environment, and (7) Employment or Other Meaningful Activity. To identify the optimal ways to measure each of these constructs, the CPCoE has committed to conducting further research on these Domains. In September 2020, the ACV participated in an exercise to rank the Domains in terms of order of importance for research. The Domain of Health was ranked number one. As such, an overview of reviews exploring measurement of well-being has been completed, and a systematic review of tools to measure the Domain of Health among community populations is underway.

iii) Review of Institute for Clinical Evaluative Sciences (ICES) Data
ICES data is a specific area of administrative health data research that tracks all healthcare utilization in the province of Ontario. Because Veterans access civilian healthcare services post-discharge from the Canadian Armed Forces(CAF), ICES data includes a Veteran identifier. The CPCoE has engaged with ICES to use their data to inform patters of care among Ontario Veterans living with chronic pain.

Evaluation of Online Pain Services

VAC has identified Seven Domains of Well-Being that are important to facilitate understanding of Veterans’ well-being: (1) health, (2) life skills & preparedness, (3) finances, (4) social integration, (5) cultural & social environment, (6) housing & physical environment, and (7) employment or other meaningful activity.
With the onset of COVID-19, many pain clinics have had to quickly shift their in-person programs to online delivery formats. Given the far-reaching implications of virtual care services, the CPCoE’s network of interdisciplinary pain clinics across Canada are being surveyed to understand the processes for setting up virtual appointments, ease of access, challenges/barriers, e-platforms used, resource implications, patient satisfaction, and clinical impact. Findings will be used to support the implementation of virtual pain care services for Veterans across Canada.

Evaluation of Community Pain Clinic Infrastructure

Institution: CHANGEpain Clinic Inc.
Principal Investigators: Dr. Brenda Lau, Founder and Medical Director, and Dr. Emmanuel Abreu, Research Director, CHANGEpain Clinic Inc.
Summary: This project aims to evaluate community-based pain clinic infrastructure that influences the care experience for Veterans living with chronic pain.
CPCoE recognizes the important role that community-based pain clinics play in the lives of Veterans. CHANGEpain Clinic Inc., a community-based pain clinic in Vancouver, British Columbia, is undertaking this research to evaluate community-based clinic infrastructure, resources, and processes, and the impact they have on overall patient satisfaction. Findings will be used to optimize the care experience for Veterans at community-based pain clinics across Canada.

Design of a Veteran Self-Education Platform

Institution: Healthcare Human Factors, University Health Network
Principal Investigator: Jennifer Rosart, Associate Director, Strategy and Design, Healthcare Human Factors
Summary: This project aims to design a self-managed education platform for Veterans living with chronic pain.
Self-education is an important component of chronic pain management. Committed to building an education platform that is truly impactful, CPCoE is giving Veterans an active voice in designing a platform that will deliver value to them and their families. Context labs have been held with Veterans and their families to gain insights into the Veteran support system. Content has been co-created through interviews with Veterans, their families, clinicians, and subject matter experts. Once complete, this education platform will help Veterans to understand, track, and manage their chronic pain.

Intergenerational Transmission of Chronic Pain in Canadian Veterans and their Children

Institution: University of Calgary
Principal Investigator: Dr. Melanie Noel, Associate Professor of Clinical Psychology, Department of Psychology, University of Calgary
Summary: This project aims to study the intergenerational transmission of chronic pain in children of Canadian Veterans.
Chronic pain and associated mental health issues are prevalent in the Veteran population, which places Veterans’ children at heightened risk for the development of pain problems that could potentially persist into adulthood. To date, only one empirical study (conducted in the United States) has examined pain in offspring of Veterans. Given this scarcity, there is a critical need for empirical research to understand the mechanisms underlying the intergenerational risk for chronic pain. This project will characterize and establish the prevalence of pain in Canadian Veterans and their children and provide an in-depth understanding of their pain experience. Findings will be used to help inform future generations on how to manage chronic pain transmission among Veterans and their children.

Identifying Differences in Chronic Pain Treatment Based on Sex and Gender in Canadian Veterans

Institution: Western University
Principal Investigator: Dr. Joy MacDermid, Associate Professor, School of Physical Therapy/Department of Psychiatry, Western University
Summary: This project aims to evaluate the impact of sex and gender on chronic pain management in Canadian Veterans.
Sex and gender influence the types of injuries that active-duty military personnel incur, their treatment needs, and responses. While some research on sex and gender differences in pain management is emerging for the general population, there has been little research specific to military personnel and Veterans. This research will examine to what extent current research on pain in Veterans considers sex and gender differences, understand the unique experiences of women Veterans, and analyze the differences in treatment responses between men and women Veterans. Findings will be used to support best practices for chronic pain management programs to be inclusive of the differences in needs and responses of men and women Veterans.

Veterans Cannabis Therapy Outcome Registry (VECTOR)

Institution: Hamilton Health Sciences
Principal Investigator: Dr. Vikas Parihar, Assistant Clinical Professor, Department of Anesthesia, McMaster University
Summary: This project aims to develop a registry focused on Canadian Veterans who use cannabis for medical purposes.
As reported by Veterans Affairs Canada statistics, from 2020 to 2021, a total of 15,369 Veterans were reimbursed for a total of 14,463,796 grams, or $119,264,105 worth, of cannabis. Given the prevalence of cannabis use among Canadian Veterans, it is imperative to study the usage of, and potential outcomes associated with, cannabis for Veterans living with chronic pain. This registry will feature Canadian Veterans using cannabis for medical purposes who are funded or seeking funding by VAC. It will identify the primary reason/indication for cannabis use; the types, forms, and quantities used; and the impact on pharmaceutical and/or non-pharmaceutical treatments already in place. Findings will be used to understand the potential outcomes associated with cannabis usage as it pertains to chronic pain and mental health comorbidities, which will help to inform Veterans and healthcare practitioners when considering cannabis as part of chronic pain management.

Characterization of the Landscape of Veteran Pain Clinics

Institution: The Pain and Wellness Centre
Principal Investigator: Dr. Angela Mailis, Director, The Pain and Wellness Centre
Summary: This project aims to characterize Veterans’ pain services nationally.
CPCoE provides research, training, and education for interdisciplinary teams to improve the delivery of evidence-based pain care across the country. An important component of this research, training, and education is understanding the pain services provided to Veterans nationally. Through this study, CPCoE’s network of interdisciplinary clinics are being surveyed to collect data about their organizational and clinical activities associated with treating Veterans. Findings will be used to understand the landscape of chronic pain management services and identify potential opportunities and/or barriers to improve those services across Canada.

Recent Publications

Recent articles published on the topic of chronic pain

Psychological Injury and Law

Chronic Pain: Evolution of Clinical Definitions and Implications for Practice
This paper reviews information regarding the evolution of definitions of pain terminology and pain syndromes as they relate to everyday practice for clinicians and those operating within the medicolegal judicial system, both trainees and seasoned professionals, with a focus on chronic pain.
View Article

Annals of Internal Medicine

Predictors of Prolonged Opioid Use After Initial Prescription for Acute Musculoskeletal Injuries in Adults
Opioids are frequently prescribed for acute musculoskeletal injuries and may result in long-term use and consequent harms.
View Article

Annals of Internal Medicine

Management of Acute Pain From Non–Low Back Musculoskeletal Injuries
Patients and clinicians can choose from several treatment options to address acute pain from non–low back musculoskeletal injuries.
View Article

Canadian Journal of Pain

Pain Management Program Outcomes in Veterans with Chronic Pain & Comparison with Nonveterans
This study presents evidence supporting the effectiveness of an interdisciplinary pain management program in addressing pain-related variables in Veterans and nonveterans and provides insight into how pain management is experienced differently by Veterans.
View Article

Veterans Affairs Canada

Post-traumatic stress disorder (PTSD) and war-related stress
View Article

Looking to Collaborate?

Should you wish to learn more or discuss collaboration on research projects, please e-mail research@vcp-vdc.ca.

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