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Commentary

Chronification of Pain and the Science of Pain Management

Pain hurts. Without good care, pain removes the joy and love of life that our Veterans deserve. Even in the most resilient Veterans with strong family and community support, inadequately managed pain can lead to depression, substance misuse, and suicide. The biospsychosocial epiphenomena of chronic pain, such as disability, obesity, social distress, and isolation further exacerbate pain's burden on Veterans, their families, and their communities. The importance of pain research in VHA has never been higher.

The 2011 Institute of Medicine study of pain's public health impact, Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research, made a compelling argument for major changes in education and health policy.¹ The increasing rate of drug overdose deaths, often involving opioid analgesics prescribed for pain is a second, related, public health challenge and a consequence of the 'pain disability epidemic.' Together, these challenges raise the stakes for our pain management enterprise nationally, compelling us to improve access to cost-effective, evidence-based treatment approaches.

Such approaches are urgently needed across VHA. The exposure of Middle East troops to repetitive physical and psychological stress of combat in multiple deployments explains the higher rates of painful musculoskeletal (>60 percent) and mental health (>50 percent) diagnoses in Veterans than in the general population. Older Veteran cohorts, many retired from employment and turning to VA for care, face painful disease and illness as consequences of earlier service-related physical and psychological injuries, as well as from those associated with aging, such as arthritis or cancer.

Ironically, the well-meaning effort to control pain with opioids and their subsequent over-use helped galvanize societal attention on the need for more pain research and better pain care: lives shortened by pain-related deaths from suicide or unintended drug overdose as well as the consequences of chronic exposure to living with pain, such as disability, obesity, depression, social distress, and substance abuse. Defining pain as a public health problem invites an understanding of its phenomenology and an examination of opportunities for HSR&D research.

Pain as a Public Health Problem

As medicine and society consider the vast domain of human pain and its burden, how do we find our focus for producing meaningful research, particularly for our Veterans? I find it helpful to consider this question through the lens of an illness construct—pain chronification—describing the progression from acute pain to persistent pain to "complex chronic pain" with its sociomedical consequences.³ We know co-morbidities, such as catastrophizing, depression, PTSD, and substance use disorder are key indicators of risk for chronification and poor outcomes—no matter the initiating cause of pain. How does the VA healthcare system, at Veterans' first encounter for pain in primary care or hospital, incorporate practical methods for ensuring screening and immediate clinical attention for them?

HSR&D researchers have a complex array of pressing questions to consider. Does VHA implement interventions to identify and manage co-morbidities, to prevent chronification? Can we do more than just screen for pain intensity at hospital admission or during recovery by identifying risk factors that portend higher suffering and costs (e.g., catastrophizing, depression, obesity)? Are VHA behavioral health and pain consultation teams able to respond with evidence-based interventions to prevent chronification? Can we measure the cost-effectiveness of such clinical process improvements, and then implement these widely? Can we measure the impact of process improvement across our health system?

Role of VHA's Research Enterprise

VHA's research enterprise is poised to provide national leadership to these research challenges. Our electronic medical record (EMR) already informs VHA about risky opioid prescribing, and by providing feedback and education, lowers these risks in our Veterans. Two clinical support tools, the Opioid Therapy Risk Report (OTRR) and the Stratification Tool for Opioid Risk Management (STORM), use EMR-derived reports to help front-line clinicians identify overall overdose risk level for individual Veterans and specific risks that become targets of intervention. Are these data improving Veterans' quality of life by helping them join the work force, maintain stable family relationships, or achieve other markers of successful return to a healthy and fulfilling life? Are rates of suicide positively impacted when we coalesce our skills and attention to pain? When and how can we develop models of combining medical and nonmedical treatments to interrupt the cascade to chronification?

Our VHA pain research enterprise is poised to take advantage of new developments in pain research. Our "Million Veteran" project will collect a database of sufficient size to understand more about the "pain genome" in well-defined phenotypes, helped by data registries such as CHOIR and PASTOR PROMIS, which will propel pain management toward evidence-based, personalized medicine. For example, what are the clinical and genetic factors contributing to catastrophizing or depression in response to persistent pain conditions, thereby increasing chronification risk? Who is susceptible to opioid over-use and misuse when treated for acute pain or a chronic pain condition? What factors shift the trajectory towards recovery of function and quality of life?

How do we change the vital equations involving the sequential and simultaneous neurobehavioral processing of persistent somatic pain signals in the context of an individual's lived environment and experience? A well-funded pain research portfolio has great potential for affecting this trajectory so that Veterans hurt less and have a better quality of life and that VHA and its clinicians feel rewarded for their dedication to good pain care.

References

1. The National Academies Press. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research (2011). Available at www.nap.edu/read/13172/chapter/2.

2. Carr D.B. "'Pain is a public health problem'—what does that mean and why should we care?" Pain Medicine 2016; 17(4):626-27.

3. Gallagher R.M. "Chronification to maldynia: Biopsychosocial failure of pain homeostatis," Pain Medicine 2011; 12(7):993-5