Providers Discuss Addressing Pain in Servicemembers

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WASHINGTON, DC—Not all pain is gain. Unmanaged chronic pain in injured servicemembers and veterans can lead to negative health effects that can last a lifetime, speakers said at an educational forum on pain management held at Walter Reed Army Medical Center (WRAMC). “Chronic pain is one of the primary reasons why people go see a doctor. It is the number one reason that people are out of work in our society,” said Sean Mackey, MD, PhD, chief of the Division of Pain Management in the Stanford School of Medicine.

At the “War on Pain” initiative held at WRAMC in September, speakers from DoD, VA, and the civilian sector discussed the latest research and developments in pain management.

The military and VA have been looking at how they can better ease chronic and acute pain in their patient populations. A Pain Management Task Force that was chartered by the Army, but included members from the Navy, Air Force, and Veterans Health Administration, developed 109 recommendations to improve pain management for patients and standardize care between DoD and VHA. The report, released in July, suggested that the military should expand the availability of pain management therapies for patients to reduce overmedication.

Brig Gen Richard Thomas, MD, assistant Army surgeon general for Force Protection, told participants at the forum that enhancing pain management is important, given the number of servicemembers returning from theater with injuries who deal with pain. “We have more than nine years of stress on the force and pain is a big part of that.”

Moving Forward with Task Force Recommendations

The task force’s report pointed to several areas where pain management needed to be improved. One area is the need for more uniformity in pain therapies offered across the system, Lt Col Scott Griffith, MD, the pain management consultant to the Army Surgeon General, said. “We need to standardize what is good and recognize the importance of innovation and not stifle that, but we need to do a better job of spreading what works well.”

The role of complimentary and alternative medicine (CAM) in treating servicemembers also needs to be better defined, the report suggested. One of the most important pieces of information to come from the task force is that pain treatment outcomes are not tracked well, Griffith explained. “It is hard to look back because we haven’t always tracked [them] very well. We do pretty well clinically tracking things on a paper form and having patients fill out information, but as far as a computer solution for this, that is something we need to move towards.”

Griffith said that a computerized system to track outcomes would allow better identification of which pain treatments are working and which are not. One software system that the Army is presently evaluating in a study is the Chronic Pain Impact Network (CPAIN). CPAIN is a multidimensional clinical patient profiler and data registry used to facilitate care for chronic pain patients.

Alex Cahana, MD, chief of the division of pain medicine in the department of anesthesiology and pain medicine at the University of Washington Medical Center, described CPAIN’s use there.

CPAIN works by having the patient complete a self-assessment online prior to the patient’s medical visit, he explained. The clinician is then provided with a Patient Profile Report that documents multiple pain characteristics and the interference that the pain has on the patient’s daily life. These reports help guide treatment decisions and to monitor the effectiveness of treatment.

One benefit for the clinician is that by having the patient’s profile report during the patient visit it allows the clinician and patient to have a more robust conversation about the pain they are experiencing. For example, Cahana said it allows a clinician to see the patient’s pain treatment history, concerns, and how pain is impacting the patient’s activities, among other things. “It improves communication,” said Cahana.

Data from the system can be used to evaluate the cost-effectiveness of specific treatments and identify what works for whom, under what circumstances.

Understanding Pain

Mackey, who described the neurobiology of pain, said pain is defined by the International Association for the Study of Pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. It is a subjective experience. “[Pain] is whatever it is our patients tell us it is. It doesn’t need to be tied directly one to one with any specific amount of tissue damage or problem, and you’ll find great variability in how people respond to a particular injury.”

Pain is related to depression and anxiety, and leads to poor sleep, among other things. Chronic pain, Mackey said, often requires long term management, much like diabetes, asthma, or cardiac disease.

Mackey said that a national survey conducted by Stanford University in conjunction with ABC and USA Today found that one in five Americans suffer from chronic pain.

Pain Task Force Urges More DoD/VHA Collaboration

Among the task force’s recommendations was the need for “enhancing standardization of pain care between the DoD and VHA.”

“There is currently a lack of coordination between DoD and VHA pain services at both the inpatient and outpatient levels of care. Better institutional patient coordination may lead to decreased medication use (particularly opioids) and transition to an effective pain treatment plan,” the report noted.

The task force stated in the report that presently there is no mechanism to communicate patient pain issues throughout the care continuum. “An electronic pain record of care is essential to provide DoD and VHA providers with a common communication tool that would assist physicians in the care of patients during the transition from the DoD system into the VHA healthcare system.”

The report suggested that one possible solution in development is the Joint Regional Anesthesia and Analgesia Tracking System (JRAATS). “The JRAATS electronic pain record would provide DoD and VHA clinicians with a detailed pain management history of the patient while that patient was under the federal healthcare system.”

The report also recommended establishing a uniform DoD and VHA formulary to maintain effective treatment plans during patient transitions to a new facility. “By implementing a standardized line of pain care for the DoD and VHA, patient rehabilitation, recovery, satisfaction, and pain control will likely be enhanced. Improved care standardization will lead to better opioid control and will minimize abuse. Improved care standardization will also lead to higher provider satisfaction,” the report stated.

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