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Pain Management and Post-Deployment Care

Emerging data document that painful musculoskeletal and connective tissue disorders are the most common cluster of diagnosed conditions of Veterans enrolled for care in VHA following deployment in Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND). At the same time, persistent pain is increasingly appreciated as only one of several highly co-prevalent clinically important problems or diagnosed disorders among this population of Veterans. Data document that a constellation of problems including chronic pain, persistent post-concussive symptoms, post-traumatic stress disorder (PTSD), depressive disorders, substance use disorders, and sleep disorders are particularly common. Walker and colleagues from the James Haley Veterans Hospital—a group that has served a particularly important role in documenting these comorbidities in this population of Veterans—have offered the label of "Post-Deployment Multi-Symptom Disorder" to best characterize this complex array of problems confronting a large proportion of OEF/OIF/OND Veterans.1 These VHA health services investigators have called for the development and evaluation of readily accessible and Veteran-centered approaches to assessment and treatment—novel approaches that emphasize interdisciplinary, integrative, and coordinated care.

VHA has established pain management as a high priority and has recently published policy guidance that calls for implementation of a stepped-care approach to pain management.2 The stepped-care model is an evidence-based and population-based approach that is consistent with OEF/OIF/OND Veterans' pain management needs and expectations. The model calls for most common pain conditions to be assessed and managed by interdisciplinary Patient Aligned Care Teams (PACTs). For Veterans with complex chronic pain conditions that cannot be managed in the PACT setting—including those with comorbid mental health and medical conditions and those identified as at greatest risk for disability, addiction, and suicide—timely access to secondary specialty care is required. Pain medicine, rehabilitation medicine, mental health and substance use disorders treatment, and specialty medical and surgical services are among those that must be readily available to support PACTs and Veterans who require this level of specialty care. Finally, the stepped model calls for building tertiary, interdisciplinary pain centers in each VISN by September 2014. These centers are expected to have the capacity to provide the highest level of advanced pain medicine diagnostics and interventions, chronic pain rehabilitation, and treatment for Veterans with comorbid complex chronic pain and substance use disorders, especially prescription opioid dependence and addiction.

PACTs are well suited to provide this kind of integrated and coordinated care due to the increasing availability of additional resources that can be brought to bear on addressing military-related issues and comorbid mental health and substance abuse problems. These resources include OEF/OIF/OND support teams, polytrauma support clinical teams, post-deployment clinics and teams, and mental health-primary care integration teams. Substantial efforts are underway to strengthen PACT members' competencies and to build PACT capacity for pain management. Simultaneously, health services investigators in conjunction with their service delivery and operations partners are developing and evaluating novel approaches to delivering efficient chronic pain assessment and management in these settings. Among these initiatives are those that incorporate the use of telehealth and other technological advances to promote safe and effective use of medications and delivery of non-pharmacological interventions. These include evidence-based psychotherapies, structured exercise and healthy living programs, and complementary and alternative medicine services such as acupuncture and meditation. In this context, research designed to promote the development and implementation of integrated interventions that target Veterans with chronic pain and comorbidities such as depression and PTSD—and that meet these Veterans' expectations for timely, efficient, and effective care—is a high priority.3

A new VHA initiative called PACT-SCAN (Specialty Care Access Network) will soon be implemented to further support the development of competencies of PACT teams for the assessment and management of chronic pain conditions, among other complex chronic diseases. The PACT-SCAN initiative will sponsor multidisciplinary specialty teams at regional hubs that will use advanced videoconferencing technologies to provide didactics and case-based learning opportunities for PACTs in rural areas and other settings where access to specialty care is lacking. A partnership with health services investigators is envisioned to provide high fidelity program evaluation that will be necessary to assure that the program functions optimally to build PACT members' competencies, to improve access to specialized care for Veterans, and to promote cost-efficiencies in this mode of delivering specialty care.

Meeting the expectations for pain management of Veterans returning from deployment in Iraq and Afghanistan represents a serious challenge to health care providers in VHA and to their health services investigator partners. Having recognized the challenge, there is reason for optimism that these partnerships will yield important advances in our knowledge about how best to assess and manage complex chronic pain and to rapidly implement improvements in effective Veteran-centered pain care.

  1. Walker RL, Clark ME, & Sanders SH. The "Postdeployment Multi-Symptom Disorder:" An Emerging Syndrome in Need of a New Treatment Paradigm. Psychological Services 2010; 7:136-47.
  2. Veterans Health Administration. VHA Pain Management Directive. Pain Management. Department of Veterans Affairs: Washington, D.C. 2009.
  3. Otis JD, Keane T, Kerns RD, Monson C, & Scioli E. The Development of an Integrated Treatment for Veterans with Comorbid Chronic Pain and Posttraumatic Stress Disorder. Pain Medicine 2009.10 (7), 1300-11.

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