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Military Pain Management: A Cultural Change for the 21st Century
The management of combat trauma pain with morphine and other opioid medications and the introduction of battlefield anesthesia was a tremendous medical breakthrough for wounded warriors and military medicine. The first American use of battlefield anesthesia is thought to have been in 1847 during the Mexican-American War, and the use of opioid medication during the Civil War was not uncommon. These advancements in analgesia and the effectiveness of opioid-based medications in treating pain led the American military and civilian medical communities to focus almost exclusively on opioid-based pain management.
Medical progress in battlefield surgery and trauma resuscitation has been remarkable since the Civil War, resulting in a greater than 90% survival rate following wounding in the present conflicts. Notwithstanding this impressive accomplishment, since the 1860s, the evolution of pain management in our wounded has been far less dramatic. Morphine and other opioid-based medications continue to be used as the primary treatment option.
Although the success of opioids in managing pain is without question, the side effects associated with these medications can contribute to increased morbidity and mortality as patients recover from wounds. While the side-effect profile of opioids is a challenging issue for health-care providers in modern American medical systems, these issues are only magnified in the austere and often chaotic environment of the modern battlefield. The potential harm that opioid-based pain management can have on warriors and families was highlighted by the recent account by Lt. Gen. David Fridovich, regarding his difficulties with opioid pain medications (Army Times – Feb. 7, 2011). He noted that his use of prescription opioids for pain, “altered his personality, darkened his mood and management style and strained his 35-year marriage.”
Significant improvements in the past two decades in our understanding of pain mechanisms and the detrimental effects that poorly managed pain can have on recovery from trauma or surgery has resulted in a re-evaluation of pain management in the military. This coincided with a number of technological improvements in pain care, such as improved needle systems, epidural and continuous peripheral nerve blocks, microprocessor controlled infusion systems and ultrasound imaging. These advancements have greatly increased treatment options for health-care providers managing pain in wounded warriors.
Initial efforts to improve pain care in the wounded returning from the Afghanistan and Iraq conflicts focused on enhancements to pain management during evacuation from the battlefield. Novel pain-treatment innovations applied during the current conflicts include the fielding of a military pain-infusion system approved for evacuation flights, the use of non-opioid pain medications such as ketamine and local anesthetics, and the use of epidural and continuous peripheral nerve blocks in combat support hospitals and on evacuation flights. Additionally, the first deployment of medical personnel to establish acute pain services at a combat support hospital and the first battlefield clinical practice guideline for pain care within theater have been established.
While these enhancements to pain care were important for combat casualties, they were not necessarily impacting on the larger issues of pain management within the greater military community. Additionally, it was recognized that pain issues were having a detrimental effect on wounded warrior recovery and on the health of the entire military community. Despite pain complaints being the most frequent reason for patients to seek physician care and the cost of chronic pain in the U.S. topping $100 billion annually in health-care expenses, lost income and lost productivity, the U.S. health-care system has considerable variability in standards of pain care.
The inconsistency in American pain care seen in both civilian and military care systems is rooted in our medical educational systems. There is wide variability in physician training in pain management. That training is often influenced by the physician’s chosen specialty, cultural beliefs and personal experiences. Because, historically, pain has been thought of as a symptom of other disease processes, emphasis on, and funding for, education and research into pain mechanisms and treatments has been sluggish. Finally, there is no clear “ownership” of the disease process of pain among the accepted medical specialties and “pain medicine” as an accepted medical specialty is only now being seriously considered as a legitimate member of the medical hierarchy.
Recognizing these inconsistencies in pain management within the military community, Army Surgeon General Lt. Gen. Eric B. Schoomaker chartered the Army Pain Management Task Force (PTF) in August 2009 with Brig. Gen. Richard Thomas, Assistant Surgeon General for Force Projection, as the PTF Chairperson. The PTF membership included a variety of pain specialists, medical disciplines and health-care administrators drawn from all three services, the VHA and civilian medicine. The PTF mission was to develop, “recommendations for a MEDCOM comprehensive pain-management strategy that was holistic, multidisciplinary and multimodal in its approach, utilizes state of the art/science modalities and technologies, and provides optimal quality of life for soldiers and other patients with acute and chronic pain.”1
The need for this historic effort was validated with section 711 of the National Defense Authorization Act for fiscal year 2010 which tasked the Secretary of Defense to develop and implement a comprehensive policy on pain management for the military health care system by March 31, 2011.
From October 2009 until January 2010, the PTF conducted 28 site visits at Air Force, Army, Navy, VHA and civilian hospitals and clinics to gauge the state of pain care in American medicine. Strengths, weaknesses and best practices for pain care were assessed during these visits. This information was consolidated into the Pain Management Task Force – Final Report May 2010. Three overarching findings from the PTF included: 1) Army Medicine was meeting current accepted standards of pain care in its medical-treatment facilities. 2) There were best practices identified in many DoD treatment facilities that warranted replication throughout the organization. 3) There was an ‘unwarranted variation’ in pain-management practice, capabilities, and orientation across the DoD health-care system.
This PTF Report contains 109 recommendations for a comprehensive pain-management strategy for the U.S. Army Medical Command (MEDCOM) and DoD. Perhaps one of the most important recommendations from the PTF was the requirement to develop a clinical information database designed to enhance patient screening and the delivery of pain care while simultaneously providing outcomes evidence to drive pain-management resource decisions. The PTF labeled this concept/capability as the Pain Assessment Screening Tool and Outcomes Registry (PASTOR).
After a thorough review and analysis of the PTF report, the Army Surgeon General directed MEDCOM staff to operationalize the Task Force recommendations into a Comprehensive Pain Management Campaign Plan (CPMCP). The CPMCP was published in September 2010.
With the publication of the CPMCP, each Army Regional Medical Command (Figure 1) has been required to establish an Interdisciplinary Pain Management Center (IPMC). The IPMC in each region will serve as a model of interdisciplinary pain management and as a consultant on regional pain management. The IPMC will also act as a base from which changes to pain management standards can be disseminated across the region in order to standardize and optimize pain care.
Recognizing that pain management in the military is a continuum that begins from point of injury (whether on the battlefield or in garrison) throughout the DoD and into VHA partners and civilian communities, the PTF has continued building upon field-medicine successes. In December 2010, a new field-medic pain curriculum was introduced at the annual Special Operations Medical Conference in Tampa. This curriculum expands upon current training for this vital link in casualty care by enhancing the special-operation medic’s pain-management capabilities to include basic regional-anesthesia blocks (axillary, femoral, sciatic and popliteal blocks), basic acupuncture techniques, osteopathic manipulation and relaxation techniques, and enhanced pain medication training that reorients providers to favor non-opioid pain-medication alternatives as part of a multimodal plan.
Other completed actions include integration of pain-question content into the Warrior Transition Command Satisfaction Survey that was completed in August 2010. In addition, working with the Joint Improvised Explosive Device Defeat Organization (JIEDDO), advanced acute-pain equipment chests with ultrasound technology have been fielded to Level 3 facilities in Afghanistan and Iraq. In order to improve pain-management communication for the safe application of advanced pain-care modalities during evacuation, a pain-medicine module, called the Joint Regional Anesthesia and Analgesia Tracking System (JRAATS), has been added to the Theater Medical Data Store (TMDS). The JRAATS system allows real-time tracking of patients from a pain-management perspective from point of injury back to the U.S. This dynamic record of a warrior’s pain care allows providers at all levels to intervene, when required, with confidence anywhere along the evacuation chain.
With the publication of the CPMCP, the transformation of MEDCOM from a pain-management perspective has begun. Capitalizing on the expertise in pain management that already exists, and building out from the RMC IPMC’s, the military is developing regional pain consortiums that combine the pain expertise from DoD with local VHA and civilian academic medical centers. The first of many of these relationships has been established in Washington State between Madigan Army Medical Center, VA Puget Sound Health Care System, and University of Washington Center for Pain Relief with assistance from Alex Cahana, MD, Chief, Division of Pain Medicine at the University of Washington. Some of the largest research projects dealing with wounded-warrior pain have been facilitated through partnerships with VHA research leaders such as Rollin Gallagher, MD, deputy national program director for Pain Management, VA Central Office. Collaborations of this type will ensure the latest, evidence-based pain-care techniques and protocols are available to patients.
Pain research in direct support of military requirements will also be facilitated by these federal and civilian partnerships. Other partnerships include working with organizations such as the Bravewell Collaborative and the Samuelli Institute, both of whom provide DoD with expertise in building mature integrative medicine capabilities to compliment and improve our existing pain medicine resources.
Coordination of effort across the care continuum (on the battlefield and at home) is vital for successful implementation of CPMCP goals. The PTF leadership recognized from the onset of the project that the significance and extent of change recommended by the PTF would require a central pain management advisory organization to synchronize regional efforts and provide necessary policy, curriculum and research recommendations. This pain-advisory organization will be the liaison between the Uniformed Services and the VHA.
This “central point of contact” is required to maintain and update pain care clinical standards, manage provider and patient pain-education programs, and provide research priority recommendations based on individual service and VHA needs and requirements It is imperative that the DoD establish an enduring organization to serve as the conduit to integratively link PTF efforts with established warrior health-care initiatives such as Patient Centered Medical Home, Health Promotion Risk Reduction Task Force and the Warrior Transition Command’s Comprehensive Transition Plan. Currently, although pain is a component of post-traumatic stress, suicide and other mental and physical health issues, no current DoD program is tasked with pain-management responsibility.
The PTF leadership has no illusions concerning the difficulties and challenges that will accompany an effort of this magnitude and scope. In effect, the DoD is undertaking a culture change within its health-care staff that is historic in proportion and unique in military medical history. Regional Medical Commands will need to realign their variable existing pain assets and team them with other disciplines to form interdisciplinary pain teams. Many of these assets have philosophical and methodological differences that have precluded integration in the past. This has resulted in redundancy of effort, inconsistency of care, poor communication and less-optimal outcomes for pain patients.
Concerned over a perceived loss of authority or status within their respective specialties, some established pain programs within our system are resistant to this reorganization. From the pain patient’s perspective, these concerns are so much nonsense. Perhaps this concept was best articulated by one of its most senior patients, Lt. Gen. Fridovich.
During his briefing on PTF activities at the Pentagon in January 2011, he expressed his own frustration with traditional opioid based pain care and the lack of integration among pain specialists. He noted that his recovery from his back injury required the surgeon, the acupuncturist and everything in between for success. From the general’s viewpoint, no one specialty was superior or more important in his recuperation. They were all equally vital to his eventual recovery. Integration of these diverse pain-care services, working together to deliver patient-centered care, is the overarching goal of the PTF and the Army CPMCP.
In an era of shrinking health-care budgets, Campaign Plan goals will require ongoing refinement in order to survive funding realities. Implementation of the PTF recommendations will reduce inefficiencies in pain-care delivery and will likely avoid greater costs that are incurred when pain is poorly managed. Outcomes tracking throughout the pain-care continuum are essential to establish the most beneficial and cost-effective treatment standards throughout the military and VHA system. Novel metrics and methods for measuring outcomes that are sufficiently rigorous to avoid exclusion of non-traditional pain-management methods must be adopted. Whether spinal cord stimulators or acupuncture needles, the adoption of any technology or method for pain management must be grounded in patient outcomes data.
The military health care system, which includes providers, administrators, resource managers and patients, must be re-educated on the management of pain as well as the consequences of failure to treat this disease. This re-orientation to pain will require a robust education and training curriculum that impacts all service members and their dependents.
Finally, the magnitude of change in medical culture and methods demands a coordinating organization to be successful. Military medicine has a tradition of leading the country in times of conflict to new and exciting change that benefits the larger American community as a whole. The Comprehensive Pain Management Campaign Plan is certainly a part of this fine tradition. The goals are lofty, the task is difficult, but the effort will enhance wounded-warrior care which is reason enough to move out.
- Pain Management Task Force – Final Report May 2010, http://www.armymedicine.army.mil/reports/reports.html.
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