Open Access Open Access  Restricted Access Subscription or Fee Access

Examining the relationship between pain interference, pain intensity, and mental health symptoms among veterans receiving long-term opioid therapy for chronic noncancer pain in primary care

Amanda Kutz, PhD, Amber Martinson, PhD, Katherine Stratton, PsyD, Clayton Hamilton, PharmD, Julie Carney, RN, William Jacobson, RN, Katherine Sadler, RN, Tauna Thomas, RN, William Marchand, MD, Jamie Clinton-Lont, MS, CNP


Objective: As part of the evaluation of the Whole Health Primary Care Pain Education and Opioid Monitoring Program (PC-POP), we examined the relationship between pain intensity, pain interference, and mental health symptoms among PC-POP enrollees.

Design/methods: Retrospective cohort study examining self-reported symptoms of pain intensity, pain interference, anxiety, depression, substance use, and quality of life. Data were retrieved through a combination of chart review and data extracted from the VA Informatics and Computing Infrastructure.

Setting: Veterans Health Administration Health Care System Primary Care service.

Subjects: Adult veterans with chronic noncancer pain receiving opioid therapy >3 months being managed in primary care and enrolled in PC-POP between August 1, 2018 and April 1, 2019.

Results: A total of 439 participants were included in the final analysis. Results showed that anxiety has a unique relationship to pain intensity and that depression and quality of life have unique relationships to pain interference when relevant covariates, eg, gender, age, pain diagnosis, and predictors are examined among this unique sample of veterans enrolled in a pain and opioid education and monitoring program.

Conclusions: Given that primary care is the dominant healthcare setting in which opioids are prescribed for chronic noncancer pain, further research is needed to examine factors that influence pain management in this setting. This study examined the role mental health factors have on pain intensity and pain interference among patients enrolled in an opioid monitoring program and found that anxiety and depression appear to uniquely predict how intensely and impactful these veterans experience their pain. This study extends the literature by examining such factors among a unique population that has yet to be studied and offers some recommendations for monitoring and practice.


anxiety, depression, pain intensity, pain interference, chronic pain, opioid therapy, primary care, Veterans Affairs

Full Text:



Breuer B, Cruciani R, Portenoy RK: Pain management by primary care physicians, pain physicians, chiropractors, and acupuncturists: A national survey. South Med J. 2010; 103(8): 738-747.

Smith BH, Elliott AM, Hannaford PC, et al.: Is chronic pain a distinct diagnosis in primary care? Evidence arising from the Royal College of General Practitioners’ Oral Contraception study. Fam Pract. 2004; 21(1): 66-74.

American Academy of Family Physicians: Primary care. Available at Accessed March 1, 2021.

Johnson M, Collett B, Castro-Lopes JM: The challenges of pain management in primary care: A pan-European survey. J Pain Res. 2013; 6: 393-401.

Kaur S, Stechuchak KM, Coffman CJ, et al.: Gender differences in health care utilization among veterans with chronic pain. J Gen Intern Med. 2007; 22(2): 228-233.

Otis JD, Gregor K, Hardway C, et al.: An examination of the co-morbidity between chronic pain and posttraumatic stress disorder on US veterans. Psychol Serv. 2010; 7: 126-135.

Bohnert AS, Ilgen MA, Galea S, et al.: Accidental poisoning mortality among patients in the Department of Veterans Affairs Health System. Med Care. 2011; 49(4): 393-396.

Kerns RD, Otis JD, Wise E: Treating families of chronic pain patients: Application of a cognitive-behavioral transactional model. In Gatchel RJTD (ed.): Psychological Approaches to Pain Management. 2nd ed. New York: Guilford Press, 2002: 256-275.

Gallagher RM: Advancing the pain agenda in the veteran population. Anesthesiol Clin. 2016; 34(2): 357-378. 10. Nahin RL: Severe pain in veterans: The effect of age and sex, and comparisons with the general population. J Pain. 2017; 18(3): 247-254.

Commission on Combating Drug Addiction and the Opioid Crisis: Interim draft report to the President. 12. Comprehensive Addiction and Recovery Act (CARA): 2016.

Department of Veterans Affairs/Department of Defense (VA/DoD): VA/DoD clinical practice guidelines for opioid therapy for chronic pain. 2017. Available at 2017. Accessed November 10, 2020.

Sekhon R, Aminjavahery N, Davis CN Jr, et al.: Compliance with opioid treatment guidelines for chronic non-cancer pain (CNCP) in primary care at a Veterans Affairs Medical Center (VAMC). Pain Med. 2013; 14(10): 1548-1556.

Wu PC, Lang C, Hasson N, et al.: Opioid use in young veterans. J Opioid Manag. 2010; 14(10): 1548-1556.

Lockett TL, Hickman KL, Fils-Guerrier BJ, et al.: Opioid overdose and naloxone kit distribution: A quality assurance educational program in the primary care setting. J Addict Nurs. 2018; 29(3): 157-162.

Gaudet T, Kligler B: Whole health in the whole system of the Veterans Administration: How will we know we have reached this future state? J Altern Complement Med. 2019; 25(S1): S7-S11.

Clinton-Lont JKC, Martinson A: A primary care approach to managing chronic noncancer pain. Federal Pract. 2016; 33(12): 65-71.

Marszalek D, Martinson A, Smith A, et al.: Examining the effect of a whole health primary care pain education and opioid monitoring program on implementation of VA/DoD-recommended guidelines for long-term opioid therapy in a primary care chronic pain population. Pain Med. 2020; 21(10): 2146-2153.

Knaster P, Karlsson H, Estlander AM, et al.: Psychiatric disorders as assessed with SCID in chronic pain patients: The anxiety disorders precede the onset of pain. Gen Hosp Psychiatry. 2012; 34(1): 46-52.

Blackburn-Munro G, Blackburn-Munro RE: Chronic pain, chronic stress and depression: Coincidence or consequence? J Neuroendocrinol. 2001; 13(12): 1009-1023.

Fishbain DA, Cutler R, Rosomoff HL, et al.: Chronic pain-associated depression: Antecedent or consequence of chronic pain? A review. Clin J Pain. 1997; 13(2): 116-137.

Foley C, Lipman AG: Current and emerging issues in cancer pain: Research and practice. Am J Hosp Pharm. 1994; 51(3): 422.

McGorry RW, Webster BS, Snook SH, et al.: The relation between pain intensity, disability, and the episodic nature of chronic and recurrent low back pain. Spine (Phila Pa 1976). 2000; 25(7): 834-841.

Gaston-Johansson F, Ohly KV, Fall-Dickson JM, et al.: Pain, psychological distress, health status, and coping in patients with breast cancer scheduled for autotransplantation. Oncol Nurs Forum. 1999; 26(8): 1337-1345.

Amtmann D, Cook KF, Jensen MP, et al.: Development of a PROMIS item bank to measure pain interference. Pain. 2010; 150(1): 173-182.

Teh CF, Morone NE, Karp JF, et al.: Pain interference impacts response to treatment for anxiety disorders. Depress Anxiety. 2009; 26(3): 222-228.

Kroenke K, Shen J, Oxman TE, et al.: Impact of pain on the outcomes of depression treatment: Results from the RESPECT trial. Pain. 2008; 134(1-2): 209-215.

Osborne TL, Turner AP, Williams RM, et al.: Correlates of pain interference in multiple sclerosis. Rehabil Psychol. 2006; 51(2): 166.

Tan G, Jensen MP, Thornby J, et al.: Negative emotions, pain, and functioning. Psychol Serv. 2008; 5(1): 26.

de Heer EW, Gerrits MM, Beekman AT, et al.: The association of depression and anxiety with pain: A study from NESDA. PLoS One. 2014; 9(10): e106907.

Mok LC, Lee IF: Anxiety, depression and pain intensity in patients with low back pain who are admitted to acute care hospitals. J Clin Nurs. 2008; 17(11): 1471-1480.

Gerrits MM, van Marwijk HW, van Oppen P, et al.: Longitudinal association between pain, and depression and anxiety over four years. J Psychosom Res. 2015; 78(1): 64-70.

Arola HM, Nicholls E, Mallen C, et al.: Self-reported pain interference and symptoms of anxiety and depression in community-dwelling older adults: Can a temporal relationship be determined? Eur J Pain. 2010; 14(9): 966-971.

Tang J, Gibson SJ: A psychophysical evaluation of the relationship between trait anxiety, pain perception, and induced state anxiety. J Pain. 2005; 6(9): 612-619.

Granot M, Ferber SG: The roles of pain catastrophizing and anxiety in the prediction of postoperative pain intensity: A prospective study. Clin J Pain. 2005; 21(5): 439-445.

Bair MJ, Robinson RL, Katon W, et al.: Depression and pain comorbidity: A literature review. Arch Intern Med. 2003; 163(20): 2433-2445.

Palacios-Cena M, Fernandez-Munoz JJ, Castaldo M, et al.: The association of headache frequency with pain interference and the burden of disease is mediated by depression and sleep quality, but not anxiety, in chronic tension type headache. J Headache Pain. 2017; 18(1): 19.

Day MA, Thorn BE: The relationship of demographic and psychosocial variables to pain-related outcomes in a rural chronic pain population. Pain. 2010; 151(2): 467-474.

Cuff L, Fann JR, Bombardier CH, et al.: Depression, pain intensity, and interference in acute spinal cord injury. Top Spinal Cord Inj Rehabil. 2014; 20(1): 32-39.

Putzke JD, Richards JS, Hicken BL, et al.: Interference due to pain following spinal cord injury: Important predictors and impact on quality of life. Pain. 2002; 100(3): 231-242.

Barry DT, Pilver CE, Hoff RA, et al.: Pain interference and incident mood, anxiety, and substance-use disorders: Findings from a representative sample of men and women in the general population. J Psychiatr Res. 2013; 47(11): 1658-1664.

Goldstein BI, Houck PR, Karp JF: Factors associated with pain interference in an epidemiologic sample of adults with bipolar I disorder. J Affect Disord. 2009; 117(3): 151-156.

Martinson A, Kutz A, Marchand W, et al.: Factors associated with participation and nonparticipation in a VA Whole Health Primary Care Pain Education and Opioid Monitoring Program (PC-POP). J Opioid Manag. 2020; 16(3): 179-188.

Cella D, Yount S, Rothrock N, et al.: The Patient-Reported Outcomes Measurement Information System (PROMIS): Progress of an NIH Roadmap cooperative group during its first two years. Med Care. 2007; 45(5 Suppl. 1): S3-S11.

Reeve BB, Hays RD, Bjorner JB, et al.: Psychometric evaluation and calibration of health-related quality of life item banks: Plans for the Patient-Reported Outcomes Measurement Information System (PROMIS). Med Care. 2007; 45(5 Suppl. 1): S22-S31.

Cella D, Riley W, Stone A, et al.: The Patient-Reported Outcomes Measurement Information System (PROMIS) developed and tested its first wave of adult self-reported health outcome item banks: 2005-2008. J Clin Epidemiol. 2010; 63(11): 1179-1194.

Spitzer RL, Kroenke K, Williams JB, et al.: A brief measure for assessing generalized anxiety disorder: The GAD-7. Arch Intern Med. 2006; 166(10): 1092-1097.

Löwe B, Decker O, Müller S, et al.: A brief measure for assessing of the Generalized Anxiety Disorder Screener (GAD-7) in the general population. Med Care. 2008; 46(3): 266-274.

Kroenke K, Strine TW, Spitzer RL, et al.: The PHQ-8 as a measure of current depression in the general population. J Affect Disord. 2009; 114(1-3): 163-173.

Shin C, Lee SH, Han KM, et al.: Comparison of the usefulness of the PHQ-8 and PHQ-9 for screening for major depressive disorder: Analysis of psychiatric outpatient data. Psychiatry Investig. 2019; 16(4): 300-305.

Kelly C: American Chronic Pain Association. 2003. Available at Accessed March 1, 2021.

Skinner HA: Guide for using the drug abuse screening test. Addictive Behav. 1982; 7(4): 363-371.

Yudko E, Lozhkina O, Fouts A: A comprehensive review of the psychometric properties of the Drug Abuse Screening Test. J Subst Abuse Treat. 2007; 32(2): 189-198.

Evans MC, Bazargan M, Cobb S, et al.: Pain intensity among community-dwelling African American older adults in an economically disadvantaged area of Los Angeles: Social, behavioral, and health determinants. Int J Environ Res Public Health. 2019; 16(20): 3894.

Edlund MJ, Steffick D, Hudson T, et al.: Risk factors for clinically recognized opioid abuse and dependence among veterans using opioids for chronic non-cancer pain. Pain. 2007; 129(3): 355-362.

Rhee TG, Rosenheck RA: Comparison of opioid use disorder among male veterans and non-veterans: Disorder rates, sociodemographics, co-morbidities, and quality of life. Am J Addict. 2019; 28(2): 92-100.

Iheanacho T, Stefanovics E, Rosenheck R: Opioid use disorder and homelessness in the Veterans Health Administration: The challenge of multimorbidity. J Opioid Manag. 2018; 14(3): 171-182.

Manhapra A, Stefanovics E, Rosenheck R: Initiating opioid agonist treatment for opioid use disorder nationally in the Veterans Health Administration: Who gets what? Subst Abuse. 2020; 41(1): 110-120.

Murphy JL, McKellar JD, Raffa SD, et al.: Cognitive Behavioral Therapy for Chronic Pain Among Veterans: Therapist Manual. Washington, DC: US Department of Veterans Affairs, 2014.

Lewinsohn PM, Libet J: Pleasant events, activity schedules, and depressions. J Abnorm Psychol. 1972; 79(3): 291-295.

Vowles KE, McEntee ML, Julnes PS, et al.: Rates of opioid misuse, abuse, and addiction in chronic pain: A systematic review and data synthesis. Pain. 2015; 156(4): 569-576.



  • There are currently no refbacks.