There were 1,649,053 COVID-era patients with chronic pain who met inclusion criteria. Individuals included in the pre-COVID cohort were also included in the COVID-era cohort if they met inclusion criteria. Our cohorts were similar across all demographic variables, with differences not exceeding more than one percentage point in most cases (see Table 1). All patients were included in subsequent regressions.

Table 2 presents characteristics of individuals across cohorts who had any specialty pain care encounter. Across both cohorts, individuals who had any specialty pain care encounter were mostly White and non-Hispanic/Latinx men aged 60–69. Most individuals across both cohorts resided in an urban setting and were married or cohabiting. The top three pain diagnoses across cohorts were back pain, limb/extremity or joint pain, and other painful conditions. Both prior to and during COVID-19, most specialty pain care encounters were in-person, followed by telephone encounters, then video encounters (see Fig. 1).

Line graph indicating number of distinct Veteran-days of care per month during the pre-COVID and COVID eras by type of specialty pain care visit (i.e., any pain specialty care, in-person pain specialty care, pain specialty care via telehealth).

Results from quasi-Poisson models for telehealth specialty pain encounters are given in Table 3 and are visualized in Figs. 2 and 3. Prior to COVID-19, Black veterans were 36% less likely than White veterans to have a telehealth specialty pain encounter (pre-COVID adjusted RR = 0.64, 95% CI [0.62, 0.67]); Asian veterans were 37% less likely than White veterans to have a telehealth specialty pain encounter (pre-COVID adjusted RR = 0.63, 95% CI [0.54, 0.75]); and veterans identifying as NHOPI were 29% less likely than White veterans to have a telehealth specialty pain encounter (pre-COVID adjusted RR = 0.71, 95% CI [0.60, 0.83]). Veterans identifying as AI/AN were equally likely as White veterans to use specialty pain care via telehealth (pre-COVID adjusted RR = 0.98, 95% CI [0.85, 1.13]).

Line graph indicating number of distinct Veteran-days of care per month during the pre-COVID and COVID eras by type of telehealth specialty pain care visit (i.e., telephone vs. video encounters).

Bar chart indicating number of distinct Veteran-days of care per month during the pre-COVID and COVID eras by type of telehealth specialty pain care visit (i.e., telephone vs. video encounters).

Disparities improved during the start of the pandemic but did not disappear. In our adjusted model, Black veterans were 25% less likely than White veterans to use telehealth during the start of COVID-19 (RR = 0.75, 95% CI [0.73, 0.77]) and Asian veterans were 19% less likely to use telehealth (RR = 0.81, 95% CI [0.74, 0.89]). Whereas no AI/AN-White disparity in telehealth use existed prior to COVID-19, veterans identifying as AI/AN were 13% less likely to use telehealth compared to White veterans at the start of COVID-19 (RR = 0.87, 95% CI [0.79, 0.96]). In contrast, while veterans identifying as NHOPI were less likely to use telehealth compared to White veterans prior to COVID, this disparity disappeared when COVID-19 began (RR = 0.97, 95% CI [0.88, 1.06]).

Similarly, Hispanic/Latinx veterans were 30% less likely than non-Hispanic/Latinx veterans to use telehealth for pain care prior to COVID-19 (adjusted RR = 0.70, 95% CI [0.66, 0.75]). At the start of COVID-19, this trend reversed, and Hispanic/Latinx veterans were 6% more likely than non-Hispanic/Latinx veterans to use telehealth in our adjusted model (RR = 1.06, 95% CI [1.02, 1.09]).

Results from models for in-person pain care are given in Table 4. We found effects for both race and ethnicity in use of in-person care both prior and during the first months of COVID-19. Black veterans were 18% less likely than White veterans to receive in-person care prior to COVID-19, with disparities confounded by rurality, age, and gender (pre-COVID adjusted RR = 0.82, 95% CI [0.81, 0.83]). When COVID-19 began, Black veterans were 22% less likely than White Veterans to receive in-person care (COVID-era adjusted RR = 0.78, 95% CI [0.77, 0.80]). Similarly, Asian veterans were 7% less likely than White veterans to receive in-person pain care prior to COVID-19 in adjusted models (pre-COVID adjusted RR = 0.93, 95% CI [0.88, 0.99]) and 9% less likely at the beginning of COVID-19 (COVID-era adjusted RR = 0.91, 95% CI [0.84, 0.99]). While individuals who identify as NHOPI were equally likely as White veterans to receive in-person pain care prior to COVID-19 (pre-COVID adjusted RR = 0.96, 95% CI [0.90, 1.02]), they were 11% less likely to receive in-person care during the beginning of COVID-19 (COVID-era adjusted RR = 0.89, 95% CI [0.82, 0.97]).

Hispanic/Latinx veterans were more likely to receive in-person pain care relative to non-Hispanic/Latinx veterans prior to COVID-19 (pre-COVID adjusted RR = 1.06, 95% CI [1.04, 1.09]). Yet, at the start of COVID-19, Hispanic/Latinx veterans were 10% less likely than non-Hispanic/Latinx veterans to receive in-person care (COVID-era adjusted RR = 0.90, 95% CI [0.87, 0.93]).

There was an overall raw decrease of 17,481 specialty care encounters from the pre-COVID to COVID-era cohort. We found an effect for race on any specialty pain care for Black and Asian veterans (see Table 5). Prior to COVID-19, there was a small observed disparity in receipt of any specialty pain care between Black and White veterans, with Black veterans being 5% less likely to receive any specialty pain care compared to White veterans (unadjusted RR = 0.95, 95% CI [0.94, 0.97]). Once we adjusted for rurality, age, and gender, Black veterans were 19% less likely than White veterans to receive any specialty pain care pre-COVID-19 (adjusted RR = 0.81, 95% CI [0.80, 0.83]). The Black-White disparity in receipt of any specialty pain care was larger in COVID-era adjusted models (unadjusted RR = 0.92, 95% CI [0.90, 0.93]; adjusted RR = 0.79, 95% CI [0.77, 0.80]). Asian veterans were 9% less likely to receive any specialty pain care compared to White veterans in adjusted models during the pre-COVID era (adjusted RR = 0.91, 95% CI [0.86, 0.97]). This disparity was larger during COVID-19 onset, at 12% less likelihood (adjusted RR = 0.88, 95% CI [0.82, 0.94)].

Individuals of Hispanic/Latinx ethnicity utilized any specialty pain care at higher rates than non-Hispanic/Latinx individuals before COVID-19 (pre-COVID unadjusted RR = 1.11, 95% CI [1.08, 1.13]), but this difference was attenuated when adjusting for age, gender, and rurality (pre-COVID adjusted RR = 1.05, 95% CI [1.02, 1.07]). Following COVID-19 onset, Hispanic/Latinx veterans were equally likely to receive any specialty pain care as non-Hispanic/Latinx veterans (COVID-era adjusted RR = 0.97, 95% CI [0.95, 1.00]).