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Response to Commentary

Meeting the Challenge of Chronic Pain as a Public Health Problem

In his commentary, Dr. Gallagher emphasizes the public health importance of chronic pain. We could not agree more. Back pain is the leading cause of disability in the United States and worldwide—a fact worth restating—and the other top five conditions are closely related: neck pain, other musculoskeletal disorders, depression, and anxiety. Given its immense public health burden, our approach to chronic pain must extend beyond interventions focused solely on symptom alleviation. At both population and individual levels, prevention of chronic pain disability is a critical target for interventions. For patients already affected by disability, promotion of recovery should be a primary goal.

A key recommendation of the recently published National Pain Strategy is to “define and evaluate integrated, multimodal, and interdisciplinary care” for pain.¹ Similarly, acknowledging that improved management of pain is key to prevention of opioidrelated injuries, the first recommendation in the new CDC guideline for opioid prescribing focuses on non-opioid pain management: “non-pharmacologic therapy and non-opioid pharmacologic therapy are preferred for chronic pain.”² We see numerous opportunities for health services research to reduce the burden of chronic pain and disability among Veterans.

VA Research Progress

Consistent with these recommendations, VA’s investment in research related to pain and pain management is substantial and continues to grow.³ This growth is particularly true in some of the key scientific knowledge gaps and challenges highlighted by Dr. Gallagher in his commentary. As he suggests, growing evidence points to the role of mental health comorbidities in the perpetuation, if not development, of chronic pain, or the process of “chronification.” A variety of research methods are relevant to this central issue, including use of existing databases to identify key factors that may moderate or mediate the development of chronic pain. HSR&D-funded projects, including the Musculoskeletal Diagnosis Cohort and Women Veterans Cohort Study by Drs. Cynthia Brandt, Joe Goulet, Sally Haskell, Robert Kerns, and colleagues have already contributed important findings in this domain.

Randomized effectiveness trials of innovative collaborative interventions targeting chronic pain and important mental health comorbidities, particularly depression, have led to identification of a growing number of effective pain care delivery approaches. Trials by Drs. Matthew Bair, Steve Dobscha, and Kurt Kroenke on primary care-based collaborative care and telecare management are particularly noteworthy in this regard. Other projects are specifically relevant to the dual public health crises of pain and prescription opioid harms. For example, Dr. Erin Krebs and colleagues are in the final year of the HSR&D-funded Strategies for Prescribing Analgesics Comparative Effectiveness trial, which is comparing opioids vs. non-opioid medications over 12 months for back and osteoarthritis pain.

Dr. Gallagher also highlights a widely acknowledged challenge to the field of pain management that’s far from unique to this field—dissemination and implementation of empirically supported interventions across VA facilities. It is exciting that the Quality Enhancement Research Initiative (QUERI) continues to make investments in pain, most recently by funding Drs. William Becker, Alicia Heapy, and Amanda Midboe’s Improving Pain Related Outcomes for Veterans (IMPROVE) QUERI program. A related challenge from Dr. Gallagher is to conduct high fidelity evaluations of important VA initiatives. In this regard, a QUERI study led by Dr. Mark Ilgen is assessing effects of the Opioid Safety Initiative (OSI) on opioid prescribing practices and an HSR&D study led by Dr. Krebs is assessing OSI effects on patient-reported outcomes.

One area not specifically highlighted by Dr. Gallagher that is garnering considerable attention is the study of complementary and integrative health (CIH). HSR&D recently commissioned an Evidence Synthesis Program review of selected CIH approaches for pain. Also, in 2014, HSR&D partnered with the National Center for Complementary and Integrative Health in an initiative that funded several ongoing studies of CIH for pain among Veterans.

Future Directions

We see numerous opportunities for HSR&D researchers to continue to lead the way with patient-centered comparative effectiveness, implementation, and partnered health services research. First, we should continue to address critical gaps in pain management evidence, such as those identified in the CIH review, as well as those related to therapies with established efficacy. For example, although multiple exercise programs have demonstrated effectiveness in chronic pain, uncertainties about key components, dosing, and maintenance strategies are barriers to their broader implementation. Second, we should target implementation research to advance the spread of pain care delivery strategies, such as telephone-based pain care management, that have demonstrated effectiveness in VA settings. Finally, to meet the public health challenges of chronic pain, we should be thinking about populationand organizational-level methods to realign services toward Veteran-empowered pain self-management.

References

1. U.S. Department of Health and Human Services. National Pain Strategy. Available at: www.iprcc.nih.gov/docs/HHSNational_Pain_Strategy.pdf.

2. Dowell D., Haegerich T.M., and Chou R. “CDC Guideline for Prescribing Opioids for Chronic Pain,” Morbidity and Mortality Weekly Report, Recommendations and Reports 2016; 65:1–49.

3. Kusiak A.N. “Department of Veterans Affairs Office of Research and Development’s Pain Portfolio,” Journal of Rehabilitation Research and Development 2016; 53(1):xi-xiv.