Let’s Put Veterans in Charge of Their Pain Care

Nov 11, 2014, 9:00 AM, Posted by Erin Krebs

Erin Krebs, MD, MPH, is the women’s health medical director at the Minneapolis VA Health Care System and associate professor of medicine at the University of Minnesota Medical School. She is an alumna of the Robert Wood Johnson Foundation (RWJF) Physician Faculty Scholars program and the RWJF Clinical Scholars program.

How can we create a Culture of Health that effectively serves veterans? We can put veterans in charge of their pain care.

Chronic pain is an enormous public health problem and a leading cause of disability in the United States. Although 2000-2010 was the “decade of pain control and research” in the United States, plenty of evidence suggests that our usual approaches to managing chronic pain aren’t working. Veterans and other people with chronic pain see many health care providers, yet often describe feeling unheard, poorly understood, and disempowered by their interactions with the health care system.

Evidence supports the effectiveness of a variety of “low tech-high touch” non-pharmacological approaches to pain management, but these approaches are not well aligned with the structure of the U.S. health care system and are often too difficult for people with pain to access. Studies demonstrate that patients with chronic pain are subjected to too many unnecessary diagnostic tests, too many ineffective procedures, and too many high-risk medications.

Our treatment of chronic pain has been increasingly aggressive, but we have no evidence that chronic pain outcomes are improving. On the contrary, the prevalence of disabling chronic pain seems to be rising. In addition, we are experiencing an epidemic of opioid-related overdose and addiction as a serious unintended consequence of increased opioid prescribing for pain.

Although routine pain management in the U.S. Department of Veterans Affairs (VA) shares many problems with that in the U.S. health care system as a whole, the VA has already taken major steps toward improved chronic pain management. The VA’s national pain strategy emphasizes the central role of veterans in pain management and endorses evidence-based non-pharmacological approaches and team-based care for pain.

Recently, the VA has made major investments in establishing intensive multidisciplinary pain rehabilitation programs for veterans most severely affected by chronic pain.

The VA is well positioned to take the next step and fundamentally change the way pain is managed for the majority of veterans. To make this change, we should empower veterans to take charge of their pain care.

What would this mean in practice? It should include dramatically expanded access to evidence-based programs that teach pain management skills, as well as ongoing individualized support for the health behavior changes necessary to prevent pain-related disability.

It could be promoted by a public health campaign to spread the word that people can successfully manage their pain and prevent disability. It could break down the barriers between “conventional” and “alternative” medicine to provide a broad spectrum of active approaches with demonstrated effectiveness for pain, from group cognitive behavioral therapy to yoga.

For a veteran with new-onset back pain, it could mean same-day access to evidence-based pain education and advice. For a veteran with difficulty walking due to chronic knee pain, it could mean ongoing structured group exercise programs and personalized coaching to support progress toward health goals. A veteran empowerment approach to pain care would not eliminate the role of health care providers; rather, it would relocate the center of pain management activity and remove provider gate-keeping for access to low-risk, high-yield pain management programs.

A real shift toward veteran-centered pain care would require substantial investments in dedicated personnel and physical space, as well as shifts in how we think about delivering health care. The VA faces serious competing demands for its resources, but has good reason to invest in prevention of pain-related disability. As an integrated health system with strong educational and research infrastructure, the VA is uniquely positioned to lead this fundamental cultural change toward a truly patient-centered approach to pain.

This commentary originally appeared on the RWJF Human Capital Blog. The views and opinions expressed here are those of the authors.