Restoring Function in Veterans With Complex Chronic Pain

According to the International Association for the Study of Pain (IASP), pain is “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”¹ Chronic pain (pain lasting more than 3 months) has a high prevalence in the U.S. veteran population. In a recently published article by Richard Nahin, PhD, of the National Institutes of Health, 65.5% of U.S. veterans reported pain in the previous 3 months with 9.1% classified as having severe pain (defined as “which occurs most days or every day and bothers the individual a lot”) compared with 6.4% among nonveterans.² In addition, male veterans were more likely to report severe pain, 9%, compared with male nonveterans, 4.7%.² Veterans make up about 6.2% of the U.S. population; therefore, the number of veterans negatively impacted by pain is substantial.^3,4 Compared with individuals with other chronic diseases, such as heart disease, chronic obstructive pulmonary disease, or diabetes mellitus, a recent population-based, matched cohort study reported that only patients with Alzheimer disease have a poorer quality of life (QOL) than do those with chronic pain.⁵

Background

When comparing veterans to nonveterans, Nahin also reported that younger veterans aged 18 to 39 years had significantly higher rates for severe pain, compared with similarly aged nonveterans, 7.8% vs 3.2%, respectively. The prevalence of severe pain was significantly higher among veterans than it was for nonveterans experiencing the following: back pain, 21.6% vs 16.7% among nonveterans; jaw pain, 37.5% vs 22.9%, respectively; severe migraine and headaches, 26.4% vs 15.9%, respectively; and neck pain, 27.7% vs 21.9%, respectively. The veterans also were more likely than were nonveterans to have joint pain, 43.6% vs 31.5% , respectively.²

A study by Kerns and colleagues noted that almost 50% of older veterans (mean age 65.6 years) experience chronic pain regularly.⁶ Based on responses of 685 veterans to the Health-Risk Behavior Screening Questionnaire (HRBSQ), this study also found that the presence of pain was strongly associated with patient reports of worsening health and emotional distress. Rollin Gallagher, MD, of the Philadelphia VAMC, reported that veterans who experienced pain tended to have more personal problems due to higher rates of psychiatric and social comorbidities, such as substance abuse, depression, posttraumatic stress syndrome, and early work disabilities.⁷ Gallagher also has noted that the number of veterans seeking pain treatment has grown steadily over the past 2 decades due to the aging veteran population retiring and seeking VA care for chronic illness management.

In January 2017, the VA released an analysis of health care use among recent Operation Iraqi Freedom (OIF), Operation Enduring Freedom (OEF), and Operation New Dawn (OND) veterans from October 2001 through June 2015.⁸ The VA noted that 1,965,534 veterans have become eligible for VA health care since fiscal year 2002. Of the 1,218,857 OIF/OEF/OND veterans treated during this period, 62.3% (759,850) were treated for diseases of the musculoskeletal system and connective tissue, 58.1% (708,062) were treated for mental disorders, and 58.7% (715,263) were treated for “symptoms, signs and ill-defined conditions.”

According to the VA, “the ICD-9-CM diagnostic category ‘Symptoms, Signs and Ill-Defined Conditions’ is a diverse, catch-all category that consists of 160 sub-categories and includes primarily symptoms that do not yet have an identified cause and clinical findings that are not coded elsewhere.” The most frequently reported codes in this category, in order of magnitude are General Symptoms (ICD-9-CM 780), Symptoms Involving Respiratory System and Other Chest Symptoms (ICD-9-CM 786), and Symptoms Involving Head and Neck (ICD-9-CM 784).

Musculoskeletal ailments (ie, joint and back disorders), mental health disorders and symptoms, signs, and ill-defined conditions are the 3 most frequently coded diagnoses related to medical treatment in OEF/OIF/OND veterans. This demonstrates the high rate of pain-related conditions with comorbid mental health diagnoses.

Public Health Challenge

Recognizing that pain is a public health challenge, the National Academy of Sciences published the landmark study Relieving Pain in America.⁹ The study reported that pain affects at least 100 million Americans, greatly reducing quality of life. In addition, annual financial costs to society are estimated at $560 to $635 billion, with federal and state costs almost $100 billion annually. Given the challenges of addressing chronic pain, especially in the U.S. veteran population, the VHA has likewise outlined 6 recommendations for transforming VA pain care:

1. Educate veterans/families to promote self-efficacy and shared decision making, provide access to all relevant sources;
2. Educate/train all team members to their discipline-specific competencies, including team-based care;
3. Develop and integrate nonpharmacologic modalities into care plans;
4. Institute evidence-based medication prescribing, use of pain procedures, and safe opioid use (universal precautions);
5. Implement approaches for bringing the veteran’s whole team together, such as virtual pain consulting (SCAN-ECHO, e-consults, telehealth, clinical video teleconsultation and education) and for maintaining ongoing communication between team members; and
6. Establish metrics to monitor pain care and outcomes at both the individual level and population level.¹⁰

The American Pain Society (APS) differentiates multidisciplinary care vs interdisciplinary pain care.¹¹ Multidisciplinary pain care is provided by several disciplines that may not be coordinated. Treatment may occur with different goals and in parallel rather than with an integrated approach. The APS suggests that professional identities are clearly defined, team membership is a secondary consideration in multidisciplinary care, and the leadership is typically hierarchical with a physician in charge. In this model of care, each team member has a “clearly defined place in the overall care of the patient, contributing their expertise in relative isolation from one another.”¹¹

In contrast, according to APS, interdisciplinary teams have complementary roles that enhance patient care. Each discipline has valuable knowledge and a set of skills that complement other team members who are collaborative partners. The interdisciplinary approach encourages complementary roles and responsibilities, conjoint problem solving, and shared accountability. Treatment decisions are consensus based.