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11 Articles in Volume 18, Issue #8
Challenges & Opportunities for Pain Management In Veterans
Chronic Pain and Psychopathology in the Veteran and Disadvantaged Populations
ESIs: Worth the Benefits?
Letters to the Editor: Recovery Centers Reject MAT, Cannabis for Chronic Headaches, Central Pain
Medication Management in the Aging
Pain Management in the Elderly
Pharmacists as Essential Team Members in Pain Management
Photobiomodulation for the Treatment of Fibromyalgia
Plantar Fasciitis: Diagnosis and Management
Slipping Rib Syndrome: A Case Report
What types of risk screening tests are available to clinicians prescribing opioid therapy?

Challenges & Opportunities for Pain Management In Veterans

Pain practitioners may consider the resources made available to them by the VA when assessing and treating Veterans.

A Guest Editorial

As PPM readers are well aware, the number of people experiencing chronic pain in the United States is considerable, with some reports estimating the prevalence at 11.2% of the adult population. Chronic untreated pain is associated with significant individual and societal consequences. Physical and mental health consequences may include reduced physical functioning and mobility, disturbed sleep, fatigue, altered mood, depression, anxiety, anger, and irritability. The socioeconomic consequences grow to incorporate diminished social relationships and work income, decreased sexual function, increased healthcare utilization, disability, and substance abuse.

The latter has serious implications for our nation’s opioid epidemic; the National Institute on Drug Abuse and the CDC reported a 4.1-fold increase in the total number of deaths involving an opioid between 2002 and 2017. Among the 72,000 drug overdose deaths estimated in 2017, the sharpest increase occurred in deaths related to fentanyl and fentanyl analogs. Interestingly, the 2017 National Survey on Drug Abuse and Health demonstrated that 53% of people who misuse prescription painkillers either purchased them, took or got them for free from a friend or relative; only 34.6% received the medications from one doctor, while 1.5% obtained them from multiple doctors. According to the nonprofit health systems research and consulting organization Altarum, the country’s opioid crisis is projected to cost an additional $500 billion by 2020, largely due to lost wages and productivity, as well as healthcare costs.

In the Veteran population, pain management today is particularly challenging given the higher prevalence rates of chronic pain, and of mental health and substance abuse disorders compared to the general US population. Veterans with comorbid mental health disorders, particularly post-traumatic stress disorder, are more likely to be prescribed opioids at higher doses and to receive opioids and sedative hypnotics (including benzodiazepines) concurrently.

Chronic Pain Management for Veterans(Source: 123RF)

Opioid use in Veterans with comorbid mental health illness is associated with higher rates of opioid, alcohol, and non-opioid related accidents and overdoses. The rate of accidental poisoning mortality among Veterans is nearly twice that of the general US population. As a healthcare system, the Veterans Health Administration (VHA) has been proactive and vigilant about providing safe and effective pain care to Veterans while closely monitoring for risks and implementing system-wide risk mitigation strategies. As psychological distress may lead to the inappropriate use of opioid medications, it is also important to identify those who are seeking relief from psychological pain.

In response, the VHA has implemented several programs and developed provider and patient-related resources to optimize pain management. For example, the VHA Office of Primary Care, in collaboration with other pain care team members and stakeholders, has created the PACT Roadmap for Managing Pain, to assist Patient Aligned Care Teams (PACTs) in establishing the processes and relationships needed to provide safe and effective team-based, stepped pain care. The agency’s Pharmacy Benefits Management (PBM) Academic Detailing service has developed many provider and patient resources for pain management. The recently issued PBM Chronic Pain Provider’s Guide emphasizes a stepwise approach to chronic pain management starting with self-management and optimized treatment of comorbidities, followed by the addition of non-pharmacologic therapies, non-opioid pharmacotherapy, intensive interdisciplinary pain rehabilitation, and finally, the intermittent use of opioids for limited conditions.

In addition, the Departments of Veterans Affairs and Justice released in 2016 a Clinical Practice Guideline for Opioid Therapy for Chronic Pain, offering 14 evidenced-based recommendations on opioid initiation and continuation and risk mitigation. The guideline goes into detail about the type, dose, follow-up, and taper of opioid therapy. The guideline may be used by general clinicians or specialists as they consider the latest information on opioid prescribing and how or whether to incorporate these evolving recommendations into their practice. With specific information on patient encounters, such as looking up the dosing of a medication used less frequently or the meaning of a urine drug test result, the guide further provides resources for practitioners so they can continue to provide compassionate, effective, safe, and culturally sensitive evaluations and care.

The VA has achieved measurable improvements in this area, largely as a result of the 2013 Opioid Safety Initiative, which aimed to reduce the use of opioid medications, improve the safety of opioid prescribing, and expand alternative pain therapies. By 2016, the number of Veterans dispensed an opioid was reduced by 25%, while the number receiving morphine equivalent daily doses greater than 100 mg was reduced by 36%, and the number receiving concomitant opioids and benzodiazepines was reduced by 47%.

Instrumental to the success of the pain management programs within the VA is the agency’s collaborative, interdisciplinary approach to pain management. Primary and Specialty Care pain teams tend to include primary care providers, pain management and interventional pain specialists, nurses, clinical pharmacy specialists, mental health providers, physical and occupational therapists, acupuncturists, chiropractors, and others. Given the detrimental consequences of untreated pain in the quality of lives of those who suffer it, as well as the adverse consequences of inappropriate pain management, it is our obligation as healthcare providers to offer the most optimal, safe, and effective pain care, and to minimize the risks associated with such care, to those who served our country.

The opinions and views expressed herein do not necessarily represent those of the VA or any government agency.

Last updated on: November 12, 2018
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Chronic Pain and Psychopathology in the Veteran and Disadvantaged Populations
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