By Col. Chester “Trip” Buckenmaier III, MD, program director, Defense and Veterans Center for Integrative Pain Management
In August 2009, the Pain Management Task Force (PMTF) was chartered by retired Lt. Gen. Eric B. Schoomaker as the Army Surgeon General. The PMTF membership included pain experts with diverse medical backgrounds from the Air Force, Army, Navy, TRICARE Management Activity and the Veterans Health Administration (VHA). The PMTF mission was to review the status of existing pain-management services and provide recommendations for a “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 results of this review, along with specific recommendations for enhancements to military pain care were provided in the Pain Management Task Force — Final Report, May 2010. Soon after publication of the PMTF Final Report, the Institute of Medicine released its report, “Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education and Research” in June 2011. Perhaps most interesting and intriguing about these two efforts at defining areas for pain-management improvement, was the high amount of correlation between the two documents in terms of the identified major issues and suggested solutions. Both documents recognized the tremendous national economic burden associated with chronic pain, both recognized that chronic pain could be a disease itself, and both efforts established the need for better pain data and research. With the call to action established by these two important federal documents, considerable effort and investment into federal pain medicine improvements has been under way during the last few years. This article will introduce some of the larger and more influential changes undertaken by the Department of Defense (DoD) that providers may see in the near future.
Defense and Veterans Center for Integrative Pain Management (DVCIPM)
The PMTF recognized that the scope and magnitude of change recommended in the final report would require a tri-service advisory board to ensure effective implementation of Task Force recommendations and a central point of contact on pain-management issues affecting the varied organizations within the DoD. This goal will be achieved with the establishment of a Military Pain Medicine Board of Directors for the DVCIPM consisting of Air Force, Army, Navy, VHA and civilian senior expert pain clinicians and researchers with diverse backgrounds in the management of acute and chronic pain.
The organization is tasked with providing clinical advice to the services on the best, evidence-based, integrative clinical pain-management practices. Additionally, the DVCIPM seeks to standardize military pain education for providers and patients and serve as a pain research and outcomes focal point (Fig. 1). Much of the available published and ongoing research into military pain issues during the current conflicts has come from or been directly influenced by the DVCIPM.
The DVCIPM has excelled as a resource for enhanced collaboration and cooperation for the services and the VHA. The DVCIPM has played a major leadership role within the PMTF and the major initiatives highlighted in this article.Defense and Veterans Pain Rating Scale (DVPRS)
The most commonly used pain-rating scale in the military is the standard, 0-10, numeric rating scale (NRS). This scale is easily administered, well-known throughout the military care community and has been extensively validated as a clinical research tool to monitor and track a patient’s pain. One of the findings from the PMTF Final Report was the general negative feedback expressed about the clinical utility of the NRS by physicians, nurses and other clinicians. Common issues with the NRS included inconsistencies in its clinical use, its subjective nature with no functional anchors and the perceived minimal value of recorded NRS values actually observed in the clinical management of patients.
In response to these criticisms, the PMTF was tasked with developing a new pain-rating scale that would measure pain intensity, as well as pain’s impact on mood, stress and bio-psychosocial and physical function. The result was the Defense and Veterans Pain Rating Scale (DVPRS — Figure 1, Available at: www.DVCIPM.org/training.html).
This scale was designed to be useful in a variety of clinical environments and diverse patient encounter situations. The DVPRS faces, for example, can be used for pediatric or non-English speaking patients. The red-yellow-green colored bars should be useful for medics interested primarily in the need to treat pain (red), need to provide supplement treatment (yellow) or need to move on if the patient is “good to go” (green). The ascending bars work for the colorblind and those not culturally tuned to red-yellow-green symbolism.
Most importantly, the functional language provides anchors to the NRS numbers and a common definition useful for treatment comparisons. Finally, the four supplemental questions about the impact of pain on a patient’s general activity, sleep, mood and level of stress provide the clinician insight into the often-overlooked psychosocial aspects of pain.
The scale has been integrated into daily acute-pain medicine rounds at Walter Reed National Military Medical Center, Bethesda, MD, and already has enhanced quality of care. DVPRS data now are collected as a routine part of clinical rounds, and the information informs patient, family and caregiver discussions. In the first validation study of the DVPRS, a convenience sample of 350 veterans identified both functional-language statements and pain ratings to describe their pain. Excellent alignment was obtained between the functional language anchors by respondents matching the language correctly with pain scores.2
The tool is open source and available for clinical or research purposes.Interdisciplinary Pain Management Centers (IPMC)
All pain-management programs noted thus far directly support the Interdisciplinary Pain Management Centers (IPMC) being established at major Army medical centers throughout the DoD. The Navy is building similar centers termed R4s (Readiness, Restoration of Function, Relief of Pain and Research). These pain-management centers are designed to be interdisciplinary and patient-centered in their approach. One important goal of these centers is the amalgamation of interventional pain medicine with selected integrative medicine therapies such as acupuncture, yoga, medical massage and biofeedback. Not only are patients increasingly demanding the availability of these options, but evidence continues to mount that these less invasive and less-expensive approaches can be effective for a variety of pain conditions. Coupled with the new standards for data collection and utilization exemplified by the DVPRS and PASTOR/PROMIS, along with new, mutually supportive, specialist/primary-care knowledge networks, the next decade is set for unprecedented advancement in the field of pain management for warriors and their families.
Look for these changes in the coming months within your federal healthcare facilities. Because pain management crosses all medical specialty boundaries, these enhancements to care will be far reaching in scope and meaningful to all manner of providers.
1Pain Management Task Force – Final Report. May 2010 (http://www.armymedicine.army.mil/reports/reports.html— accessed Oct. 19, 2012.
2Buckenmaier CC III, Galloway KT, Polomano RC, McDuffie M, Kwon N, Gallagher RM. Preliminary validation of the defense and veterans’ pain rating scale (DVPRS) with a military population. Pain Medicine – Accepted for publication October 2012.
3http://echo.unm.edu/ – accessed 29 October 2012
4Arora S, Thornton K, Murata G, Deming P, Kalishman S, Dion D, Parish B, Burke T, Pak W, Dunkelberg J, Kistin M, Brown J, Jenkusky S, Komaromy M, Qualls C. Outcomes of treatment for hepatitis C virus infection by primary-care providers. N Engl J Med. 2011 Jun 9;364(23):2199-207.
5http://www.mss.northwestern.edu/Grants%20and%20Research/PROMIS%20Pain.html – accessed Oct. 29, 2012. Fig. 1. Defense and Veterans Center for Integrative Pain Management.Extensions for Community Health Outcomes (ECHO)
Both the DoD and VHA are actively adopting the Extensions for Community Health Outcomes (ECHO) telemedicine initiative developed at The University of New Mexico under the direction of Sanjeev Arora, MD. Unlike more-traditional applications of telemedicine technology that link specialist providers with patients separated by distance using video telecommunications, the ECHO project focuses this communication technology on building knowledge networks between specialists at medical centers and primary-care providers at rural or underserved locations. The intent of the project is “to develop the capacity to safely and effectively treat chronic, common and complex diseases in rural and underserved areas and to monitor outcomes of this treatment.”3
Arora, et al.4 demonstrated that rural primary-care providers, when part of the ECHO network, could manage complex hepatitis C patients diagnostically and therapeutically as successfully as specialists. The New Mexico team has successfully empowered primary-care providers in managing a variety of chronic health problems including management of chronic pain and headache,diabetes and cardiovascular disease, HIV/AIDS, rheumatology and others. Both the Army and Navy are in the process of establishing ECHO networks, modeled after The University of New Mexico project, throughout the DoD.
Pain Assessment Screening Tool and Outcomes Registry (PASTOR) and Patient Reported Outcomes Measurement Information System (PROMIS)
Early in the PMTF effort, it was recognized that a common problem for pain management in the United States was lack of data to support many current pain-management procedures and techniques. Additionally, it was noted that effective pain management required extensive inquiry into the many psychosocial aspects of the chronic pain condition. This information can be exceedingly difficult to obtain in the characteristically limited time allotted for clinical interaction between provider and patient in modern medical practice.
The lack of a common data registry within the DoD and VHA also has impeded responsible, data-driven decision-making on the myriad possible treatment possibilities available for pain management. This issue is particularly poignant today as integrative medicine techniques are being evaluated as possible alternatives or supplements to more standard pain-management techniques.
The Task Force agreed that the DoD and VHA require a Pain Assessment Screening Tool and Outcomes Registry (PASTOR) to collect needed clinical information from the patient about all aspects of their pain. The PASTOR system would summarize this information for clinicians, leaders and medical resource managers, providing the needed data for diagnostic and decision support. A key feature of the PASTOR system is that patients can complete the PASTOR questions online prior to their clinical appointments and in the privacy of their own home. Patients will be able to provide the needed information on their schedule, and the clinic appointment time will not be burdened with data-collection tasks. This will permit the clinician to focus on the information and the patient.
In the process of defining the requirements of the PASTOR program, the Task Force was extremely pleased to learn of the National Institutes of Health (NIH) — Patient Reported Outcomes Measurement Information System (PROMIS —http://www.nihpromis.org). NIH has invested more than $90 million in PROMIS to develop a set of highly-researched, reliable tools that provide patient-reported health status for the psychosocial and physical functioning of the patient. While PROMIS tools are particularly suited for enhancing clinical pain medicine, they are equally appropriate for many other chronic health conditions. In fact, they were developed specifically to be appropriate for measuring symptoms and outcomes across a range of chronic conditions.
To reduce question burden for the patient, the PROMIS measures use computer-adaptive testing, with measures calibrated against the U.S. population. Therefore, responses have inherent normative meaning, because they can be directly compared to a U.S. general population sample that has been matched to the US 2000 census with respect to gender, race/ethnicity and age.
DVCIPM, in collaboration with NIH and Northwestern University’s Feinberg School of Medicine,5 Chicago, is actively researching and developing the PASTOR/PROMIS information system. Concurrently, the DoD is developing the information technology requirements documents with all three services to establish PASTOR/PROMIS as a key clinical information system for the near future.
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