Answering the call to address chronic pain in military service members and veterans: Progress in improving pain care and restoring health

doi:10.1016/j.outlook.2016.05.010

Nursing Outlook

Volume 64, Issue 5, September–October 2016, Pages 459-484

https://doi.org/10.1016/j.outlook.2016.05.010 Get rights and content

Abstract

Chronic noncancer pain (CNCP) in military and veteran populations mirrors the experience of chronic pain in America; however, these two populations have unique characteristics and comorbid conditions such as traumatic brain injuries, postconcussive syndrome, posttraumatic stress disorder, and behavioral health disorders that complicate the diagnosis and treatment of chronic pain. Military members and veterans may also be stigmatized about their conditions and experience problems with integration back into healthy lifestyles and society as a whole following deployments and after military service. The military and veteran health care systems have made chronic pain a priority and have made substantial strides in addressing this condition through advances in practice, education, research, and health policy. Despite this progress, significant challenges remain in responding to the wide-spread problem of chronic pain. The purpose of this article is to: (a) examine the state of CNCP in military and veteran populations; (b) discuss progress made in pain practice, education, research, and health policy; and (c) examine research, evidence-based practice guidelines, and expert consensus reports that are foundational to advancing pain care and improving health for military service members and veterans with CNCP. In addition, recommendations are proposed to address this widespread health problem through the expanded use of advanced practice registered nurses, the implementation of models of care, and use of national resources to educate health care providers, support practice, and promote effective pain care.

Section snippets

Pain in Military and Veteran Populations

Pain among military service members and veterans represents a wide span of pain-related issues. In 2006, 743,547 injury-related musculoskeletal conditions were recorded for military service members with 82% attributed to inflammation and pain from exertional overuse (Hauret, Jones, Bullock, Canham-Chervak, & Canada, 2010). The overall rate for chronic arm and shoulder pain from 2003 to 2012 reflected a 25% increase possibly explained by a greater incidence of joint pain and higher rates of pain

Prevention of Chronic Pain

As chronic pain originates from central sensitization, it is critically important to effectively treat acute pain in an effort to prevent, minimize, and even possibly reverse central sensitization thus reducing the likelihood for the development of chronic pain (Tighe et al., 2015). These approaches are outlined in a comprehensive expert consensus report on the state-of-the science on acute pain (Tighe et al., 2015). However, even with aggressive pain intervention, acute pain can transition

A Need for Improvements in Pain Assessment Practices and Standardization of Patient-Reported Pain Outcome Measures

For over a decade, the VHA's pain as the “5th Vital Sign” initiative, enacted in 1999, and later adopted in 2001 as a standard by The Joint Commission, focused national attention on the importance of regular assessments of pain intensity (Veterans Health Administration Memorandum, 1999). Unfortunately, this initiative fell short of achieving measurable improvements in pain outcomes as anticipated (Helfand and Freeman, 2009, Lorenz et al., 2009, Mularski et al., 2006). Some attribute the lack of

Treatment for Chronic Pain

Multimodal strategies that combine pharmacological and nonpharmacological therapies, spinal, epidural and peripheral interventional techniques, and pain-related patient education focused on self-management and holistic approaches to alleviating pain are recommended as an integrated approach to chronic pain management (American Association of Nurse Anesthetists, 2014). Integrated chronic pain care requires an interdisciplinary focus capitalizing on the expertise of physical therapists,

Evidence-Based Clinical Guidelines and Expert Consensus Reports

APRNs who prescribe opioids for CNCP and nurses who care for and monitor patients with CNCP receiving analgesics should align care with recommended practices from evidence-based guidelines. Table 3 provides a brief summary of published pain guidelines and expert reports including those generated by the military and VHA that highlight state-of-the-science and consensus recommendations for the treatment of CNCP. Most evidence-based guidelines and expert reports recommend that opioid analgesics

New Health Policy: Strategic Plan for Pain

The National Pain Strategy developed by the Interagency Pain Research Coordinating Committee (IPRCC) and released in early 2016 provides a comprehensive population health-level plan (National Pain Strategy: A Comprehensive Population Health-Level Strategy for Pain, 2016). The IPRCC was established by the National Institute of Health (NIH) to advance pain research, care, and education in response to the 2010 Patient Protection and Affordable Care Act. The national strategic initiatives outlined

Nursing and Interprofessional Pain Education

The National Defense Authorization Act of 2010 mandated the development and implementation of targeted efforts to address the crisis of pain treatment in military and veteran populations. This legislation drew attention to the inadequacy of formal education in chronic pain management in nursing and medical schools. Experts have called for the need to systematically integrate pain content into curriculum, conduct competency-based evaluations of learning, utilize interprofessional and interactive

Military and Veteran Health Systems Models for Pain Care

Several nurse driven and interdisciplinary models of care in military and VHA facilities demonstrate how structured and goal-oriented pain care can lead to optimal patient outcomes. For example, a randomized trial of an interdisciplinary functional restoration (FR) program for active duty military service members with chronic musculoskeletal pain was conducted at Wilford Hall Medical Center and Brooke Army Medical Center, San Antonio, Texas. Nurse supervision of FR interventions in

Discussion

Chronic pain places enormous demands on U.S. military health care and VHA systems not only in terms of health care resource utilization but also at a significant cost. The IOM projected that cost for the estimated 100 million Americans suffering from chronic pain is well over $600 billion (Institute of Medicine, 2011). Military and veteran populations share in the burden of suffering, and their unique experiences in military service can increase risks for CNCP and greater pain severity.

Conclusions

In summary, preparing and empowering qualified health care professionals across all transitions in military and veterans care and strengthening health systems to deliver comprehensive chronic pain care require both a nursing and interprofessional coordinated effort. Clearly, more nursing pain specialists are needed to not only implement aggressive acute pain care to prevent chronic pain but also to effectively treat chronic pain with evidence-based integrative therapies that include multimodal

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Influence of Primary Care Provider Type on Chronic Pain Management Among Veterans
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Citation Excerpt :
NPs in primary care increasingly provide chronic pain management among VHA patients (Bair et al., 2015; Schoneboom et al., 2016; Wiedemer et al., 2007).
Chronic pain disproportionately impacts veterans and is often treated in primary care, where physician shortages in the Veterans Health Administration (VHA) healthcare system are well documented. Nurse practitioners (NPs) may represent a solution to the care shortage; however, concerns of NP opioid overprescribing have led to NP practice and prescribing restrictions in individual VHA facilities and at the state level. Little is known regarding the prescribing patterns of NPs and physician assistants (PAs) for veterans with chronic pain in the VHA.
The purpose of this study was to compare opioid and non-opioid prescribing patterns of physicians, NPs, and PAs for chronic pain patients at VHA centers.
We used data from the U.S. Department of Veterans Affairs Survey of Healthcare Experience of Patients and Corporate Data Warehouse from October 2015 to September 2016. Patient medical records for the year were analyzed by provider type (physician, NP, or PA) for differences in providers’ rates of prescribing opioid and non-opioid medications, as well as characteristics of the opioid prescriptions (e.g., high daily morphine milligram equivalent [90 MME/day] dose, long-term opioid therapy [90 days]).
Medical records of a total of 39,936 patients were included. In FY 2016, 55% of patients received one opioid prescription, whereas 83.8% received one non-opioid prescription. Compared to patients of NPs and PAs, patients of physicians had higher odds of receiving opioid (vs. NPs: OR = 1.13, p < 0.01; vs. PAs: OR = 1.16, p < 0.01) and non-opioid prescriptions (vs. NPs: OR = 1.08, p = 0.02; vs. PAs: OR = 1.20, p < 0.01) after adjusting for patient characteristics. There were no differences in high MME/day dose (p = 0.59) or long-term opioid therapy (p = 0.99).
In a national sample of veterans with chronic pain, NPs and PAs did not have higher odds of opioid prescribing. Concerns of NP or PA opioid overprescribing may be addressed by considering evidence that patients of these providers are not at higher odds of receiving an opioid prescription.
Population-Focused Approaches for Proactive Chronic Pain Management in Older Adults
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Chronic pain, and the ethical management thereof, is the single most imperative health issue of this decade. Although a growing majority of individuals with chronic pain are middle-aged, the largest proportion of sufferers are older adults. Shifting tides in practice and research have led to population-focused approaches to pain management; however, the practice of many healthcare providers remains reactive and individualistic, limiting the discovery and implementation of long-term solutions for pain management in older adults. Yet, nurses and other health professionals have an opportune position to provide expert pain care by proactively providing evidence-based care for patients systematically. The purpose of this article is to stimulate discussion on three paradigms important to population-focused pain management: (1) prevention; (2) restoration and rehabilitation; and (3) palliation, which are in line with current national policy initiatives for improving patients’ care experience, improving overall health and quality of life, and reducing associated health care costs.
Evaluating Suicide Risk Using the Reasons for Dying-Reasons for Living (RFD-RFL) Index in a Military Psychiatric Inpatient Setting
2021, Psychiatry Research
Citation Excerpt :
Accordingly, when military personnel struggle to manage stressors on their own, they may interpret difficulties with coping as personal failures, which may in turn contribute to more frequent reporting of negative self-descriptors as their primary RFD. Further, with regard to escaping pain, chronic pain following deployments is common within the military (Schoneboom et al., 2016), and is positively linked to suicide ideation and behaviors (Blakey et al., 2018; Legarreta et al., 2018). This may partially explain why escaping pain was ranked as the second most important RFD in the current sample.
The present study aimed to explore reasons for dying (RFD) and reasons for living (RFL) among suicidal inpatients, conceptualize the RFD-RFL index, and examine whether suicide risk indicators were associated with the RFD-RFL index scores. Participants were military personnel (N = 167) psychiatrically hospitalized following a suicide-related crisis who provided baseline data as part of a randomized controlled trial. Family was the most commonly reported RFL (39.7%) and was the top ranked RFL for 65.9% of participants. The most frequently endorsed RFD categories included general descriptors of self (26.9%), general statements about escape (19.7%), and others/relationships (19.1%). Greater RFD-RFL index scores were associated with a greater wish to die relative to wish to live, greater hopelessness, and with a history of lifetime multiple suicide attempts. Endorsing more RFD relative to RFL may indicate heightened suicide risk. Results of this study identify the characteristics of RFD and RFL among a high-risk, military sample, and provide preliminary support for the clinical utility of evaluating the quantities of RFD and RFL. Clinicians are encouraged to explore RFD and RFL when working with suicidal patients. Future research may explore military-specific RFD and evaluate the validity of the proposed RFD-RFL index.
Relationships between chronic pain and mood symptoms among veterans with bipolar disorder
2020, Journal of Affective Disorders
Citation Excerpt :
Individuals with comorbid chronic pain and bipolar disorder experience increased pain interference and sensitivity, increased prevalence of multisite pain, increased suicidal ideation, and worse disability and quality of life relative to general adult, pain, and other mental health populations (Abdin et al., 2016; Cerimele et al., 2014; Cook et al., 2015; Failde et al., 2013; Goldstein et al., 2009; Nicholl et al., 2014). At the same time, chronic pain negatively affects mood, physical activity, and sleep in ways that are detrimental to functioning (Failde et al., 2013; Schoneboom et al., 2016; Travaglini et al., 2019). Studies have revealed factors common to both chronic pain and negative mood states (i.e., depression), including shared genetic vulnerability, brain regions implicated in both pain experiences and negative affect, and psychosocial risk factors such as life stress, trauma, and lower socioeconomic status (Adler-Neal et al., 2019; Crofford, 2015; Humo et al., 2019).
Chronic pain is highly prevalent among individuals with mood disorders. While much is known about the relationship between pain and unipolar depression, little is known about pain experiences among people with bipolar disorder. This pilot study addresses this gap by examining pain and its relationship to mood and functioning in a sample of US military veterans with bipolar disorder.
Qualitative interviews were conducted with 15 veterans with bipolar disorder and chronic pain who were recruited from outpatient services within a Veterans Affairs medical center.
Veterans reported a bidirectional relationship between pain and bipolar depression. When discussing manic episodes, individuals’ experiences varied between notable reductions in pain (usually in euphoric states), increases in pain (usually in angry/irritable states), and feeling disconnected from pain. Many reported that increased activity when manic contributed to worse pain after an episode. Veterans clearly articulated how these connections negatively affected their functioning and quality of life.
This was a small, retrospective study that included a non-random sample of veteran participants from one VA medical center. All veterans were engaged in outpatient mental health care, so the majority reported that their mood has been well-stabilized through medications and/or psychotherapy.
Chronic pain experiences appear to be related to depressive and manic mood states and significantly affects functioning and quality of life in Veterans with bipolar disorder. This study highlights the need to assess chronic pain among veterans with bipolar disorder, as changes in mood could have significant implications for functioning and pain management.
Parameter-specific analgesic effects of electroacupuncture mediated by degree of regulation TRPV1 and P2X3 in inflammatory pain in rats
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Citation Excerpt :
Pain that is induced by inflammation remains a serious health problem with significant social and economic consequences [1].
Observing the parameter-specific anti-hyperalgesic effects of EA with different stimulation times and frequencies on painful hyperalgesia mediated by the level of TRPV1 and P2X3 expression in DRG after CFA injection.
The model was induced by the injection of CFA in each rat's right hind paw. EA treatment was applied to the bilateral ST36 and BL60. Paw withdrawal threshold (PWT) and paw withdrawal latency (PWL) were tested with Von Frey filaments and the radiant heat source of the test instrument, respectively. TRPV1 and P2X3 expressions were measured by immunofluorescence and western blot. αβ-meATP and capsaicine combined with EA were further utilized to investigate the change in PWL.
Different stimulation times (20, 30, 45 min) combined with different frequencies (2 Hz, 100 Hz, 2/100 Hz) of EA have analgesic effects on the PWT and PWL; however, the level of the hypoalgesic efficacy of EA was primarily associated with EA frequency. The analgesic effect of EA was better at 100 Hz than at 2 Hz. The level of regulation of 100 Hz EA on TRPV1 and P2X3 in DRG was greater than that of 2 Hz. Furthermore, both TRPV1 agonist and P2X3 agonist may impair the level of EA analgesia.
EA has a parameter-specific effect on chronic inflammatory pain relief, which primarily depend on the stimulation frequency and not on the stimulation time at a certain stimulation time. The parameter-specific analgesic effect of EA is at least partially related to mediation of the protein level of TRPV1 and P2X3 expression in DRG of CFA rats.
TelePain: Primary care chronic pain management through weekly didactic and case‐based telementoring
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Pain due to injuries, sustained both on and off the battlefield, is a leading cause of short- and long-term disability among military personnel [2–4]. Diagnosis and treatment of pain among the military population can be challenging due to common comorbid conditions such as traumatic brain injuries, pre-concussive syndrome, post-traumatic stress disorder, and behavioral health disorders [5]. To address this problem, the Military Health System has made chronic pain management a priority.
Chronic pain is a significant problem among military personnel and a priority of the military health system. The U.S. Army Surgeon General's Pain Management Task Force recommends using telehealth capabilities to enhance pain management. This article describes the development and evaluation of a telehealth intervention (TelePain) designed to improve access to pain specialist consultation in the military health system. The study uses a wait-list cluster controlled clinical trial to test: 1) effectiveness of the intervention, and 2) interviews to assess barriers and facilitators of the intervention implementation. The intervention involves a didactic presentation based on the Joint Pain Education Curriculum followed by patient case presentations and multi-disciplinary discussion via videoconference by clinicians working in the military health system. A panel of pain specialists representing pain medicine, internal medicine, anesthesiology, rehabilitation medicine, psychiatry, addiction medicine, health psychology, pharmacology, nursing, and complementary and integrative pain management provide pain management recommendations for each patient case. We use the Pain Assessment Screening Tool and Outcomes Registry (PASTOR) to measure patient outcomes, including pain, sleep, fatigue, anxiety, and depression. This article reports some of the challenges and lessons learned during early implementation of the TelePain intervention. Weekly telephone meetings among the multisite research team were instrumental in problem solving, identifying problem areas, and developing solutions. Solutions for recruitment challenges included additional outreach and networking to military health providers, both building on existing relationships and new relationships.

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Special Issue: Military and Veteran HealthAnswering the call to address chronic pain in military service members and veterans: Progress in improving pain care and restoring health

Abstract

Section snippets

Pain in Military and Veteran Populations

Prevention of Chronic Pain

A Need for Improvements in Pain Assessment Practices and Standardization of Patient-Reported Pain Outcome Measures

Treatment for Chronic Pain

Evidence-Based Clinical Guidelines and Expert Consensus Reports

New Health Policy: Strategic Plan for Pain

Nursing and Interprofessional Pain Education

Military and Veteran Health Systems Models for Pain Care

Discussion

Conclusions

Journal of Pain

Spine Journal

Spine Journal

Pain

Journal of Pain

American Journal of Preventative Medicine

Journal of Professional Nursing

Journal of Pain

Journal of Pain

Journal of Pain

Clinical Therapeutics

Nursing Outlook

Pain

Journal of Pain

Support joining forces [web page]

Chronic pain management guidelines

Arm and shoulder conditions, active component, U.S. Armed Forces, 2003-2012

MSMR

Managing chronic pain with opioids: A call for change. A white paper by the Nurse Practitioner Healthcare Foundation

Implementing a paradigm shift: Incorporating pain management competencies into pre-licensure curricula

Pain Medicine

Evaluation of Stepped Care for Chronic Pain (ESCAPE) in veterans of the Iraq and Afghanistan conflicts: A randomized clinical trial

JAMA Internal Medicine

Non-pharmacological intervention for chronic pain in veterans: A pilot study of heart rate variability biofeedback

Global Advances in Health and Medicine

Non-pharmacological interventions for chronic pain in people with spinal cord injury

Cochrane Database of Systematic Reviews

Conceptualizing and treating comorbid chronic pain and PTSD

Pain Research and Treatment

Sleep and military members: Emerging issues and nonpharmacological intervention

Sleep Disorders

Pain phenotypes and associated clinical risk factors following traumatic amputation: Results from Veterans Integrated Pain Evaluation Research (VIPER)

Pain Medicine

Preliminary validation of the Defense and Veterans Pain Rating Scale (DVPRS) in a military population

Pain Medicine

Impact of an acute pain service on pain outcomes with combat-injured soldiers at Camp Bastion, Afghanistan

Pain Medicine

A national study of racial differences in pain screening rates in the VA health care system

Clinical Journal of Pain

Managing pain in high-risk patients within a patient-centered medical home

Translation Behavioral Medicine

Mindfulness-based interventions for chronic pain: A systematic review of the evidence

Journal of Alternative and Complementary Medicine

Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain

Journal of Pain

Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: An evidence-based clinical practice guideline from the American Pain Society

Spine (Phila Pa 1976)

Traumatic brain injury, posttraumatic stress disorder, and pain diagnoses in OIF/OEF/OND Veterans

Journal of Rehabilitation Research and Development

Comparison of pain and emotional symptoms in soldiers with polytrauma: Unique aspects of blast exposure

Pain Medicine

The future of nursing: Leading change, advancing health

A systematic review of ketamine for complex regional pain syndrome

Pain Medicine

Economic benefits of less restrictive regulation of advanced practice registered nurses in North Carolina: An analysis of local and statewide effects on business activity

PASTOR/PROMIS® pain outcomes system: What does it mean to pain specialists?

Pain Management

Standards for accreditation of nurse anesthesia programs - practice doctorate

Physically oriented therapies for the self-management of chronic pain symptoms

Pain Medicine

Healthcare inspection - VA patterns of dispensing take-home opioids and monitoring patients on opioid therapy

Integrating interdisciplinary pain management into primary care: Development and implementation of a novel clinical program

Pain Medicine

Draft CDC guideline for prescribing opioids for chronic pain — United States, 2016

Core competencies for pain management: Results of an interprofessional consensus summit

Pain Medicine

Randomized controlled trials of acupuncture for neck pain: Systematic review and meta-analysis

Special Issue: Military and Veteran Health
Answering the call to address chronic pain in military service members and veterans: Progress in improving pain care and restoring health