Chronic pain management in veterans

Chronic pain in veterans has been linked to mental health conditions and high use of healthcare resources.
Chronic pain in veterans has been linked to mental health conditions and high use of healthcare resources.

Several recent articles published on Clinical Pain Advisor covered presentations by Sean Mackey, MD, PhD, at the 35th Annual Meeting of the American Pain Society (APS) in Austin, TX, outlining the National Pain Strategy1 (NPS) and some of its large-scale applications in the Bay Area.

Here, we will focus on the work of Robert Kerns, PhD, professor of psychiatry, neurology, and psychology at Yale University, who recently retired from the Veteran's Affairs (VA) Connecticut Healthcare System. Dr Kerns, who is involved in the Federal Pain Research Strategy,2 was one of the early actors of the NPS and talked about his efforts within the VA system to address chronic pain and, in particular, back pain care at the APS conference.

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Over the past decades, ongoing efforts to develop, report, and integrate a comprehensive approach to pain management in the VA — the largest integrated healthcare system in the United States — have taken place. In 1998, the former Under-Secretary for Health in the Department of Veterans Affairs, Kenneth Kizer, MD, MPH, and whom Dr Kerns dubs a visionary, launched a “National Pain Management Strategy” (NPMS).3

Dr Kerns was involved in the earliest foundational efforts to enact this strategy, which was informed by a plethora of data available at the time, but also largely by a white paper produced by nursing assistants who had identified 2 systematic review gaps in care as well as inconsistencies in care across the VA. According to Dr Kerns, such inconsistencies persist to this day, as would be expected in a large integrated healthcare system, but he also points to major systematic improvements that have occurred over the last couple of decades.

The NPMS was also informed by the high prevalence of pain. Data from Dr Kerns' and other groups suggest that as many as 50% of male veterans and 75% of female veterans experience chronic pain. This chronic pain issue, largely consisting of back pain, was identified relatively early on and continues to be noted as one of the costliest medical conditions in the United States.

Chronic pain in veterans is associated with numerous other negative factors such as mental health conditions, high use of healthcare resources, low social support, high levels of emotional distress, and particularly among women, higher rates of military sexual trauma.4 The Public Healthcare Strategy group publishes quarterly reports on healthcare data, which include pain data. These reports provide a snapshot of the variety of factors that contribute to chronic pain in military personnel returning from recent conflicts in Iraq and Afghanistan. Of note, each report shows that the largest cluster of medical conditions and diagnoses among veterans falls under the category of musculoskeletal and connective tissue disorders. These conditions surpass mental health disorders (specifically traumatic brain injury and posttraumatic stress disorder [PTSD]), which have long been considered signature injuries of those 2 wars. 

Dr Kerns next emphasized the large and robust nature of the VA's research program. In FY2015, more than 100 pain-related research projects were funded by the VA's Office of Research and Development, and with each passing year the portion of the VA's budget supporting research increases. The VA pain research community is supported by the National Pain Research Working Group, which was chartered in the context of the launching of the NPMS in 1998, started in 2000, and has thrived ever since. This group comprises approximately 80 VA investigators who have an interest in pain and pain management. Every couple of years, group members publish a special topic issue in Pain Medicine, Clinical Journal of Pain, or Journal of Rehabilitation Research and Development (JRDD). Most recently, Dr Kerns and his colleague Alicia Heapy, PhD, associate director of the Pain Research, Informatics, Medical co-morbidities and Education (PRIME) Center at Yale University, in Connecticut, published a special topic issue in JRDD showcasing noteworthy pain research conducted at the VA.5

To further expand its focus on research, the VA Office of Research and Development funded the aforementioned PRIME Center, the mission of which is to study interactions between pain and associated chronic conditions, as well as behavioral health factors, in order to develop and implement effective interventions aimed at reducing pain, its negative impact on emotional and physical functioning, and on overall disease burden. The PRIME Center addresses these goals by employing principles of medical informatics, behavioral sciences, and health services research.

References

  1. National Institutes of Health. The National Pain Strategy. March 18, 2016. Available at: https://iprcc.nih.gov/National_Pain_Strategy/NPS_Main.htm. Accessed June 8, 2016.
  2. National Institutes of Health. The Federal Pain Research Strategy. Available at: https://iprcc.nih.gov/FPRS/FPRS.htm. Accessed June 8, 2016.
  3. Kerns RD, Philip EJ, Lee AW, Rosenberger PH. Implementation of the veterans health administration national pain management strategy. Transl Behav Med. 2011;1(4):635-643.
  4. Kerns RD, Otis J, Rosenberg R, Reid MC. Veterans' reports of pain and associations with ratings of health, health-risk behaviors, affective distress, and use of the healthcare system. J Rehabil Res Dev. 2003;40(5):371-379.
  5. Kerns RD, Heapy A. Advances in pain management for veterans: current status of research and future directions. J Rehabil Res Dev. 2016;53(1):vii-x.
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