Treating a patient’s chronic pain is a complex issue, especially for those with service-connected healthcare complexities. The regular and consistent prescribing of opioids is particularly sensitive within the Department of Veterans Affairs (VA) as it is viewed as an incomplete solution to the patient’s problem. The VA is at the forefront of reducing opioid prescribing volume while still meeting the challenge of how to meaningfully address an individual’s chronic pain through a personalized treatment plan of non-opioid medications (whenever possible) and alternative therapy techniques.
While chronic pain doesn’t have a universally accepted definition, it is usually a criteria-based diagnosis based on the duration and impact of consistent pain. The VA, generally, defines chronic pain as pain lasting 6 months or longer and interfering with the daily activities of life. Worth noting, duration is not a hard-and-fast rule in the VA but, rather, a guideline for providers to consider.
The VA recognizes that there is not a singular cause of chronic pain. Based on a veteran’s role in the military or a veteran’s post-military medical diagnosis, chronic pain is acknowledged to arise from a variety of sources such as:
Combat injuries: Life-impacting physical injuries ranging from spinal cord injuries to scar formations.
Overuse injuries: Repetitive strain from military training or carrying heavy equipment can trigger chronic pain in muscles, tendons, and joints.
Degenerative conditions: Rheumatoid arthritis, multiple sclerosis, Parkinson’s disease, and other similar degenerative conditions.
Pain conditions: Complex Regional Pain Syndrome (CRPS), fibromyalgia, migraines and other non-specific pain-related diagnosis.
Illnesses: Conditions like cancer, chronic kidney disease, and HIV/AIDS can contribute to chronic pain.
Peripheral neuropathy: Nerve damage caused by injuries, exposure to toxins, or medical conditions (such as diabetes).
Traumatic brain injury (TBI): TBI can cause complex chronic pain syndromes, including headaches and facial pain.
Post-traumatic stress disorder (PTSD): PTSD can manifest as physical pain, including headaches, back pain, and muscle tension.
It is believed veterans experience chronic pain at a disproportionate rate than the general population. While approximately 20% of Americans report experience chronic pain, it is suggested 40% to 70% of veterans experience chronic pain and, generally, at a greater intensity. Since 2012, the VA has implemented significant changes to its opioid prescribing practices, including stricter guidelines and increased use of non-opioid pain management strategies through the employment of a multi-pronged “Whole Health” approach.
Addressing not just an individual’s chronic physical pain, the Whole Health approach also includes an individualized plan of action to address additional or underlying emotional, mental, and social factors that can impact an individual’s sensitivity to the pain. An individual’s team of specialists, including physicians, nurses, psychologists, physical therapists, occupational therapists, and social workers, work in concert to develop a personalized pain management plan that meets each individual’s needs where they are in the moment.
Under the Whole Health approach, providers focus on alleviating chronic pain symptoms through non-opioid medications including:
Antidepressants to improve mood and sleep
Anticonvulsants to manage neuropathic pain caused by nerve damage
Topical Medication (i.e., creams, gels, and patches) to provide localized pain relief
Muscle Relaxants to relieve muscle tension and spasms
Steroid Injections into joints or the spinal cord
Then, the patient’s individualized treatment plan incorporates non-pharmacological therapies. Depending on the patient’s needs, these interventions may include physical therapy and exercises such as yoga or tai chi. Equally important are the mental and emotional interventions such as formal cognitive-behavioral therapy and instruction in relaxation techniques.
The complex conditions faced by veterans have also motivated the VA into making investments into innovative, non-invasive, technology-based solutions for chronic pain treatment as well. Neuromodulation involves the electrical stimulation of specific neural pathways through implantable systems such as Spinal Cord Stimulation (SCS) and Peripheral Nerve Stimulation (PNS). Virtual reality is another non-pharmacological therapy example used in the VA. Research suggests these computer-generated environments can distract from the pain or even help an individual reframe the perception of pain by providing personalized engagement.
Chronic pain management is a complex issue for both patient and the provider. What works for one person, may require an alternative approach for another. While further research and refinement are necessary to support the on-going optimization of each treatment protocol, the VA's efforts position it as a transformative leader in chronic pain treatment.