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Nonpharmacological Treatment of Army Service Members with Chronic Pain Is Associated with Fewer Adverse Outcomes After Transition to the Veterans Health Administration



Potential protective effects of nonpharmacological treatments (NPT) against long-term pain-related adverse outcomes have not been examined.


To compare active duty U.S. Army service members with chronic pain who did/did not receive NPT in the Military Health System (MHS) and describe the association between receiving NPT and adverse outcomes after transitioning to the Veterans Health Administration (VHA).

Design and Participants

A longitudinal cohort study of active duty Army service members whose MHS healthcare records indicated presence of chronic pain after an index deployment to Iraq or Afghanistan in the years 2008–2014 (N = 142,539). Propensity score-weighted multivariable Cox proportional hazard models tested for differences in adverse outcomes between the NPT group and No-NPT group.


NPT received in the MHS included acupuncture/dry needling, biofeedback, chiropractic care, massage, exercise therapy, cold laser therapy, osteopathic spinal manipulation, transcutaneous electrical nerve stimulation and other electrical manipulation, ultrasonography, superficial heat treatment, traction, and lumbar supports.

Main Measures

Primary outcomes were propensity score-weighted proportional hazards for the following adverse outcomes: (a) diagnoses of alcohol and/or drug disorders; (b) poisoning with opioids, related narcotics, barbiturates, or sedatives; (c) suicide ideation; and (d) self-inflicted injuries including suicide attempts. Outcomes were determined based on ICD-9 and ICD-10 diagnoses recorded in VHA healthcare records from the start of utilization until fiscal year 2018.

Key Results

The propensity score-weighted proportional hazards for the NPT group compared to the No-NPT group were 0.92 (95% CI 0.90–0.94, P < 0.001) for alcohol and/or drug use disorders; 0.65 (95% CI 0.51–0.83, P < 0.001) for accidental poisoning with opioids, related narcotics, barbiturates, or sedatives; 0.88 (95% CI 0.84–0.91, P < 0.001) for suicide ideation; and 0.83 (95% CI 0.77–0.90, P < 0.001) for self-inflicted injuries including suicide attempts.


NPT provided in the MHS to service members with chronic pain may reduce risk of long-term adverse outcomes.

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We thank Richard Gromadzki and Andrea Linton with AXIOM Resource Management, Inc., who compiled the DoD data used in these analyses, and the Defense Health Agency’s Privacy and Civil Liberties Office, which provided access to the DoD data.


This research was supported by grants NIDA R01DA030150 and NCCIH R01AT008404 from the National Institutes of Health (M.J. Larson) and a Research Career Scientist Award RCS-14-232 from the Veterans Health Administration Health Services Research and Development Service (A.H. Harris).

Author information

Correspondence to Esther L. Meerwijk PhD, MSN.

Ethics declarations

Approval for this study was granted by the Brandeis University Committee for Protection of Human Subjects, the Stanford University and VA Palo Alto Health Care System Institutional Review Boards, and the Human Research Protection Program at the Office of the Assistant Secretary of Defense for Health Affairs/ Defense Health Agency (OASD/DHA).

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The authors declare that they do not have a conflict of interest.


The opinions and assertions herein are those of the authors and do not necessarily reflect the official views of the DoD, VA, or NIH.

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Meerwijk, E.L., Larson, M.J., Schmidt, E.M. et al. Nonpharmacological Treatment of Army Service Members with Chronic Pain Is Associated with Fewer Adverse Outcomes After Transition to the Veterans Health Administration. J GEN INTERN MED (2019). https://doi.org/10.1007/s11606-019-05450-4

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  • chronic pain
  • veterans
  • nonpharmacological treatment
  • adverse outcomes
  • opioids