Chester “Trip” Buckenmaier III, MD,
COL (ret.), MC, USA

This past week, I attended the Uniformed Services Academy of Family Physicians (USAFP) annual meeting in Seattle. I was there representing the Defense and Veterans Center for Integrative Pain Management (DVCIPM.org) as the organization director on behest of Maj. Gen. Jeffery Clark the current director, Operations Directorate Defense Health Agency (DHA), and a family physician. Maj. Gen. Clark has made pain a priority topic for DHA and wanted DVCIPM, the Center of Excellence for Pain in the DOD, to be on hand exchanging ideas and leveraging our pain management products with primary care docs.

Since most pain in healthcare is first managed in the primary care environment, this effort not only makes sense but probably is long overdue. Perhaps that is why Maj. Gen. Clark is a general.

The meeting went well, and we had the opportunity to expose federal primary care physicians from across the nation to new ways of thinking about and managing pain in their patients. For the pain discussion, the highlight of the meeting was an afternoon session on primary care pain management co-chaired by Maj. Gen. Clark and Dr. Diane Flynn, who serves as the Madigan Army Medical Center primary care pain management adviser. This session was a refreshing exchange about new ideas concerning nonpharmacologic approaches to managing pain.

Frustratingly, despite general agreement that integrative medicine approaches to pain were critically needed, there was considerable discussion about the overall lack of these services, because many treatment approaches such as acupuncture or massage are not covered by TRICARE. This discussion was particularly disturbing to me because of what I had observed on my short walk to the meeting conference center that morning.

Our DVCIPM team was staying at a hotel near the USAFP meeting. The walk to the meeting venue took us past McGraw Square in downtown Seattle. As we passed the square, we were shocked to see drug use paraphernalia casually scattered on a stone bench. A colleague took a cellphone photograph of the appalling scene (Figure 1). To be clear, this is not an indictment of the fine city of Seattle which I have always enjoyed visiting. Based on the growing death rate from illicit opioid use, I am sure the scene I witnessed is a common sight in many American cities today. What struck me was the juxtaposition of this public display of the tragedy of addiction being played out next to a conference filled with physicians struggling with the challenges of managing pain with anything other than pills. Sadly, with the exception of our interest, the local Seattle passersby barely even noticed the occurrence as extraordinary.

Figure 1. Drug use materials scattered in a public park in downtown Seattle, Washington.

The opioid epidemic, so graphically on display in the photograph, is inextricably linked to the challenges healthcare providers are facing in managing pain in this country. Perhaps even more frustrating is that plans to address the opioid issue, which is devastating American lives at an ever-increasing rate, have been available for some time.

The VA and DOD developed recommendations for improvements in pain management that de-emphasized opioids and recommended expansion of nonpharmacologic approaches to pain management with the Pain Management Task Force Report in 2010.1 This was followed a year later with the Institute of Medicine (IoM) Report on Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research.2 The IoM report was very similar to the federal medicine pain report and also called for more reliance on integrative health care approaches for pain management. More recently the National Pain Strategy was released and contains a blueprint for implementing the changes called for in the IoM report.3 As if we needed more compelling reasons to act, the American College of Physicians updated the organization’s back pain (the most common pain complaint of patients) guidelines this month recommending nonpharmacologic approaches to pain first.4 In short, we are not for want of ideas on what to do about this problem, but we seem paralyzed to act.

The history of substance abuse in this country is not subtle and goes back many decades. The causes for our present difficulties with opioid pharmaceuticals are many, and there is plenty of blame for the country’s present opioid predicament that rests squarely on the medical community’s shoulders. History and our own national statistics clearly indicate business as usual for pain management is not serving our patients. Failure to act on this history is, and will continue to translate into death, despair and ruined families for growing thousands of Americans.

The people that provide for our nation’s defense are drawn from the communities that are being devastated by the opioid epidemic. For this reason, I personally see the opioid epidemic as a threat to our national security. Radical change in how we respond to pain in our patients to include a general acceptance and funding through TRICARE of integrative health modalities (acupuncture, massage, manipulative therapy, biofeedback, yoga) needs to occur soonest. As federal medicine providers, we all must demand this change with one voice and the call from each individual cannot happen soon enough. Federal medicine cannot afford for George Shaw to be correct in his assessment of our response to history.

1 http://www.dvcipm.org/clinical-resources/pain-management-task-force. Accessed March 11, 2017.

2 http://www.nationalacademies.org/hmd/Reports/2011/Relieving-Pain-in-America-A-Blueprint-  for-Transforming-Prevention-Care-Education-Research.aspx. Accessed March 11, 2017.

3 https://iprcc.nih.gov/National_Pain_Strategy/NPS_Main.htm. Accessed March 11, 2017.

4 https://www.nytimes.com/2017/02/13/health/lower-back-pain-surgery-guidelines.html. Accessed March 11, 2017.