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10 Articles in Volume 17, Issue #8
A Fresh Look at Opioid Antagonists in Chronic Pain Management
Addressing Chronic Pain in the United States Armed Forces
Are biosimilars as effective as their biologic counterparts?
Integrative Pain Care: When and How to Prescribe?
Lady Gaga, Fame, and Fibromyalgia
Letters to the Editor: An opportunity to learn what is on the minds of your colleagues and patients.
Must-Have Devices for Your Pain Practice
Obsessive-Compulsive Disorder & Chronic Pain
Theory of Motivated Information Management and Coping With Death
United Nations Says Untreated Pain Is “Inhumane and Cruel”

Addressing Chronic Pain in the United States Armed Forces

A look at the evolving approach to chronic pain in the armed forces and among our veterans since the Pain Management Task Force recommendations were issued in 2010.

Poorly managed pain in the general population is estimated to result in $560 billion annually in increased healthcare expenses, lost income, and lost productivity, as well as an increasing incidence of opioid misuse and abuse and deaths due to opioid overdose.1

This public health epidemic is also a critical issue for the Veterans Administration (VA) and Department of Defense (DoD). Recent findings indicated that as service members returned from deployments in Middle East operations, they experienced a higher prevalence of pain and a greater severity of pain than faced by civilians.2

Pain-related conditions commonly faced by returning service members included traumatic brain injuries, post-traumatic stress disorder (PTSD), and suicidal thoughts or behaviors, substance abuse disorders, among other associated comorbidities.

Alternative forms of pain relief, like yoga, are now recommended in the armed forces and among vets to help manage pain.

While pain management presents an ongoing challenge for many patients in the civilian section, the Military Health System (MHS) also has been expected to provide the highest level of care to those carrying wars’ heaviest burdens amidst a military culture that praises selflessness, toughness, and a willingness to accept pain.

To assess the current status of those serving, surveys were collected three months after their return from Afghanistan.3 In one of the first studies to quantify the impact of recent wars on the prevalence of pain and narcotic use among soldiers, a survey of one of the Army’s leading units showed that 44% of the deployed soldiers had chronic pain, and 15% of these soldiers reported regular use of opioids.3

Even accounting for the availability of full medical care, these rates are much higher than the estimates of 26% and 4%, respectively, than reported in the general population,4 and indicate an unmet need to offer better management strategies for chronic pain since functional impairment was a common impediment for active duty military personnel as well as among veterans.

Pain is the most common physical complaint affecting service members, with 50% of male and 75% of female veterans reporting chronic pain.5 In addition, more than 40% of returning service members with chronic pain also reported having PTSD and post-concussive symptoms.6 In the military, these conditions are considered components of trauma spectrum disorder, a mixture of war-related trauma and mind-brain injury that typically manifests with depression, anxiety, substance abuse disorders, and somatic dysfunction.8

Recognizing that the demands of war were overwhelming military personnel and their families, the concept of Total Force Fitness was developed to integrate the components of health and fitness into a biopsychosocial framework that would optimize the conditions for performance and resilience.3

In addition to medical care, this program encompasses physical, dietary, spiritual, mental health, behavioral, and social, as well as incorporating family into many of these areas, as a means of offering non-pharmacologic options to manage pain.

Moving Beyond Pain Relief to Better Function and Quality of Life

The Veterans Health Administration (VHA) had already established pain management as a national priority in 1998 under their National Pain Management Strategy, and in 2009 advocated for a multidisciplinary stepped-care approach to the treatment of acute and chronic pain that addressed not only adequate pain control but improved quality of life and function.8

That same year, the army surgeon general, Lieutenant General Eric B. Schoomaker, chartered the Pain Management Task Force (PMTF) under the leadership of the assistant surgeon general, Brigadier General Richard Thomas, to review current military pain practice and make recommendations for a US Army Medical Command (MEDCOM) comprehensive, evidence-based pain management strategy that would provide optimal quality of life for soldiers and others dealing with pain. The PMTF also included representatives from the VHA, Air Force, and Navy.

Released in May 2010, the PMTF Report described MHS pain management as lacking consistency and guidance as patients move from facility to facility, thereby contributing to opioid misuse and abuse, patient suicide, PTSD, and other issues.9

The recommendations highlighted the need for a MEDCOM comprehensive pain strategy that was “holistic, multidisciplinary, and multimodal in its approach, utilizing state of the art modalities and technologies, to provide optimal quality of life for soldiers and other patients with acute and chronic pain”.

The PMTF developed more than 100 recommendations that relied heavily on collaboration between the DoD and VHA to develop a comprehensive and standardized vision and approach to pain management to optimize care for Warriors and their families.9

The report offered recommendations to reduce polypharmacy risks, such as informed consent prior to prescribing opioids and delivery of care by a sole provider; limiting prescription drug use to six months; regular drug testing; education and training; take-back drug programs; exploring the use of nonpharmacological approaches to pain; and establishing an evidence base for self-management strategies such as yoga, Tai-chi, and music therapy.

Establishing a Coordinated Approach to Pain Care

The PMTF report clearly defined the need for a DoD and VHA central pain management advisory board to provide a coordinated platform for policy development, research, and curriculum development. Further, it was recommended that the Defense & Veterans Center for Integrative Pain Management (DVCIPM) take on an advisory role as well as to facilitate development of pain care clinical standards and pain management education and recommend priorities for pain research.9

Key PMTF recommendations were to:

  • Provide tools and infrastructure that support and encourage practice and research advancements in pain management
  • Build a full spectrum of best practices for the continuum of acute and chronic pain, based on a foundation of best available evidence
  • Focus on the warrior and family
  • Synchronize a culture of pain awareness, education, and proactive intervention  

Leveraging the work initiated by the DoD and VHA, the Institutes of Medicine published a groundbreaking report on Pain in America in 2011,11 which called for a coordinated, national effort to transform how the nation understands and approaches pain management and prevention.

This call to action led to an unprecedented collaboration between military and civilian health services and the establishment of a patient-centered, integrative approach to pain management that culminated in the National Pain Strategy of 2016.12 The strategy was the federal government’s first coordinated initiative aimed at reducing the burden of chronic pain in the United States.

During the same time period, a change in approach to pain management was underway in the VA, as traditional care was shifting to patient-centered care, requiring a massive cultural transformation through the entire organization. Tracy Gaudet, MD, who was responsible for starting the University of Arizona Center for Integrative Medicine program with Andrew Weill, MD, and an integrative medicine program at Duke University, joined the VA in 2011 as director of the Office of Patient-Centered Care and Cultural Transformation.

Under her direction, the office has made considerable progress toward the VA’s goal for personalized, proactive, and patient-driven healthcare for our nation’s veterans. This undertaking represents one of the largest evolutions in the philosophy and process for healthcare delivery ever undertaken by an organized healthcare system.

A 180-Degree Change in Direction for Healthcare Priorities

Lieutenant General Eric Schoomaker is currently serving as director of the Uniformed Service University of the Health Sciences (USU) LEAD program. Retired in 2012 from his role as the 42nd US Army Surgeon General and Commanding General of the US Army Medical Command, he put pain on the radar for the DoD, shifting from attention to disease management and focused healthcare to a program centered on the improvement and sustainment of health.

“What we really care about is how the individual is struggling to get back to being functional again and getting their lives back,” said Dr. Schoomaker.  

In a recent keynote presentation at the annual meeting of the Academy for Integrative Pain Management, he described the remarkable improvements in preparing for and performing battlefield care.13

With better equipment, enhanced training, and a single trauma system across three continents, for example, a critically injured warrior can be rapidly withdrawn from combat and flown home—a response that was not possible 15 years ago.

Ongoing field research has been prompting continual improvements in medical equipment and protocols that have saved thousands of lives. “Following survival of an initial wounding incident, a warrior’s probability of long-term survival now exceeds 95%, even as wounds get more and more grievous,” said Lt. Gen. Schoomaker.

While progress in physical medical care has been dramatic, mental health disorders and musculoskeletal complaints are two areas that have seen a significant rise from 2002 to 2012 while the incidence of other conditions remained consistent.1 In particular, the incidence of traumatic brain injuries soared. “What was the consequence of this?” asked Lt. Gen Schoomaker. “Unintentional drug overdose deaths.”

Incorporating Emotional & Behavioral Components

Several major changes in clinical practice came to fruition in the years after the task force made their recommendations. One key improvement in pain assessment came with the introduction of a new pain scale, the Defense and Veterans Pain Rating Scale (Figure 1),14 that no longer focused on pain intensity alone, but expanded to include an assessment of how physical function and emotional well-being contributes to the soldier’s pain. 

Employing supplemental questions with the DVPRS was intended to allow the conversation to move beyond pain intensity but still anchor the patient’s level of pain with the level of function. Use of this tool has helped to standardize communication among pain providers and enhances insight into how pain and its treatment can be expected to affect activities of daily living, sleep, mood, and stress level.

The Joint Pain Education Program (JPEP) is a collaborative effort between the DoD and VA to develop a standardized pain management curriculum intended to improve complex patient-provider education and training.15

One element of the program is instituting the Opioid Informed Consent, a tool to foster clearer communication between provider and patient as well as to solidify the patient’s commitment to appropriate self-pain care. The document provides information on the risks associated with taking opioid medications, alternatives to opioids, safe opioid prescribing practices, and responsible pain control.

The consent form reinforces the need for a single opioid provider and provides patients with individualized information on their pain condition and recommended treatment, as well as the risks associated with opioid therapy.

The Pain Assessment Screening Tool and Outcomes Registry (PASTOR) was created to facilitate pain research and provide clinical outcomes data to inform evidence-based decision-making by providers.16 PASTOR uses instruments developed by the National Institutes of Health, collectively known as the Patient Reported Outcomes Measurement Information System (PROMIS), to administer select questions as part of a survey covering a wide range of pain-related areas.

PROMIS instruments use Computer Adaptive Testing (CAT) technology to obtain scores in areas such as sleep disturbance or physical function. PASTOR also incorporated the DVPRS and other pain-related questions specific to the military, which are compiled into a report for the clinician.16

The Army also has developed its own pain management network, a series of community clinics that are linked to interdisciplinary pain management centers and include Project ECHO clinics, in which primary care providers in multiple locations present cases to a multidisciplinary team of specialists who offer suggested treatment strategies.

Future Emphasis on Non-Pharma Alternatives

In addition, the DVCIPM offers an array of resources, such as the Military Advanced Regional Anesthesia and Analgesia Handbook for managing the pain of battlefield trauma,17 and a training program on battlefield acupuncture, which has led to more than 2,800 providers capable of employing this technique.

Several pain management professional organizations have established Shared Interest Groups, or SIGs, for their members who are part of the MHS, VHA, and other areas of the federal medical care system. These groups encourage members to share information on best practices, research, national initiatives, and other opportunities for participation.

Finally, the VA/DoD Evidence-Based Practice Work Group recently convened to revise the 2010 guidelines for the management of opioid therapy for chronic pain, determined to meet the specific needs of the VA/DoD and incorporating new evidence regarding pain prescribing.18 The group was co-chaired by Jack M. Rosenberg, MD, of the Department of Veteran’s Affairs, and Christopher Spevak, MD, MPH, JD, of the Department of Defense. Dr. Rosenberg said “this guideline focused on data and the findings really changed the minds of those on the panel.”18

Based on the data, the guidelines strongly recommend that opioids not be used for long-term therapy, particularly in patients younger than 30 years because of their higher risk for opioid use disorder and overdose. In addition, the panel recommended that opioid use be restricted to a maximum of 90 days.17

The National Center for Complementary and Integrative Health (NCCIH) has made pain research in military and veteran populations a priority.18 Together with the National Institute on Drug Abuse and the VA, NCCIH funded 13 research projects in 2014 that over the next five years would explore nonpharmacologic approaches to managing pain and such related conditions as PTSD, drug abuse, and sleep disorders.

Earlier this year, this partnership expanded to include the DoD and additional NIH agencies in a collaborative initiative to implement more cost-effective, large-scale clinical research programs in military and veteran healthcare delivery organizations focusing on alternative approaches to control pain and related comorbid conditions. In addition, as part of their commitment to expanding research and resources on health issues that affect the military, NCCIH has been hosting live and online programs that focus on complementary and integrative health approaches to pain management.19

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Lady Gaga, Fame, and Fibromyalgia

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